1999 Ukraine Reproductive Health Survey Final Report

Publication date: 2001

KI EV INT ERNATlOI" AL INSTITUT E OF SOClO LO (; v SA r I:R · HEALTH IER · PEOPLE: " DEPARTl\I ENT OF HEALTH Al\'D HUl\IA l\' SERV IC ES Ce nte rs for Disea se Control a nd Prevention r**ttt', '.•. ' U.S. Agency for Int ernati onal Development 1999 UKRAINE REPRODUCTIVE HEALTH SURVEY FINAL REPORT 1999 UKRAINE REPRODUCTIVE HEALTH SURVEY FINAL REPORT Kiev International Institute of Sociology Centers for Disease Control and Prevention, Division of Reproductive Health, USA United States Agency for International Development September, 2001 -i- ACKNOWLEDGMENTS This report describes the 1999 Ukraine Reproductive Health Survey and its major findings. This undertaking could not have taken place successfully without the participation, support, and cooperation of a large number of individuals and organizations, both in Ukraine and the United States. Funding for the survey was provided by the United States Agency for International Development (USAID) mission in Kiev, which was also the motivating force behind the activity. The survey was capably directed by Dr. Vladimir Paniotto, president of the Kiev International Institute of Sociology (KIIS). KIIS staff members in Kiev and elsewhere in Ukraine, particularly Elena Buslayeva and Victoria Zakhozha, did an outstanding job coordinating and implementing all survey activities. Dr. Howard Goldberg coordinated technical assistance from the United States Centers for Disease Control and Prevention’s Division of Reproductive Health, which provided consultation in survey design, planning, questionnaire development,fieldwork implementation, data analysis, and report preparation. Important contributions were also made by many others working in the area of reproductive health in Ukraine, most notably at the Ukraine Ministry of Health and Johns Hopkins University/Population Communications Services. Finally, thanks go to the KIIS interviewing staff, who did an excellent job collecting the survey data, and to the many women across Ukraine who willing gave their time and cooperation to provide the information that will be so valuable to improving the health of women and children in their country. -ii- Contributors This report was prepared by Howard Goldberg, Natalia Melnikova, Elena Buslayeva, and Victoria Zakhozha. The following organizations and individuals made important contributions to the 1999 Ukraine Women=s Reproductive Health Survey and the preparation of this report: Kiev International Institute of Sociology (KIIS) Vladimir Paniotto, President, Survey Director Elena Buslayeva, Assistant Director, KIIS Victoria Zakhozha, Project Manager Centers for Disease Control and Prevention (USA) Howard Goldberg, Deputy Chief, Behavioral Epidemiology and Demographic Research Branch (BEDRB), Division of Reproductive Health (DRH) Natalya Melnikova, Visiting Fellow, BEDRB, DRH Jay Friedman, Program Analyst, BEDRB, DRH Leo Morris, Chief, BEDRB, DRH David Gilbertz, Computer Programmer, DRH J. Timothy Johnson, Chief, Program Services Evaluation Section, DRH United States Agency for International Development/Kiev Teresa Ingham, Women=s Health Advisor (former), Office of Democratic and Social Transition (ODST) Marilynn Schmidt, Director, ODST Catherine Fischer, Senior Health Advisor (former), ODST Pamela Mandel, Deputy Director, ODST Alina Yurova, Health Program Coordinator, ODST Eliot Pearlman, Senior Health Advisor, ODST Boris Uspensky, Women’s Health Advisor, ODST Johns Hopkins University/Population Communications Services (JHU/PCS) Laurie Liskin, Chief, Division of Europe and New Independent States (DENIS) Paul Nary, Program Officer, DENIS Anne Sochan, Project Officer, DENIS The Futures Group, Inc. Monica Medrek, Country manager, POLICY Project Karen Foreit, Evaluation Coordinator, POLICY Project -iii- Others Petr Velebil, Institute for the Care of Mother and Child, Prague, Czech Republic Naomi Blumberg, Fellow, Office of Population, USAID/Washington Tamara K. Irkina, Deputy Head of Administration, Head of Department of Maternal and Child Health, Ukraine Ministry of Health -iv- -v- TABLE OF CONTENTS PAGE ACKNOWLEDGMENTS.i CONTRIBUTORS.ii LIST OF TABLES.viii LIST OF FIGURES.xv SUMMARY OF FINDINGS.1 CHAPTER I. INTRODUCTION.11 Background The Ukraine Women’s Reproductive Health Initiative The 1999 Ukraine Reproductive Health Survey CHAPTER II. SURVEY METHODOLOGY.15 Organizational Structure Questionnaire content Survey design Data collection Response rates CHAPTER III. CHARACTERISTICS OF THE RESPONDENTS.19 Demographic and social characteristics Economic characteristics Marriage CHAPTER IV. PREGNANCY AND CHILDBEARING.31 Fertility and pregnancy levels and patterns Pregnancy outcomes Planning status of pregnancies Pregnancy intentions CHAPTER V. INDUCED ABORTION.55 Proportions of women with any abortions Current incidence of abortion Types of abortion, complications, cost -vi- CHAPTER VI. INFERTILITY.71 Prevalence of infertility Treatment of infertility CHAPTER VII. CONTRACEPTION.79 Knowledge and ever use of contraceptive methods Current contraceptive prevalence Recent trends in contraceptive prevalence Source of contraceptive methods Reasons for not using contraception Unmet need for contraception Preference for other methods/Problems with current method Contraceptive failure and discontinuation Opinions about fertility control methods Use of non-supplied methods IUD use Oral contraceptive use Contraceptive sterilization CHAPTER VIII. CONTRACEPTIVE COUNSELING.127 Post-abortion/Post-partum counseling Content of counseling/Method selection Partner involvement in reproductive health decisions CHAPTER IX. INFORMATION, EDUCATION, AND COMMUNICATION .135 Television viewing habits Radio listening habits Newspaper readership Exposure to and attitudes about health messages in the media CHAPTER X. SEXUAL EXPERIENCE.149 Sexual experience of all women First sexual experience of young adults CHAPTER XI. MATERNAL AND CHILD HEALTH / WOMEN’S HEALTH.165 Prenatal care Hospitalization during pregnancy Labor and delivery Cigarette smoking during pregnancy Breastfeeding Women’s health behaviors -vii- CHAPTER XII. SEXUALLY TRANSMITTED INFECTIONS.187 Awareness of STI’s and lifetime history of STI diagnosis Treatment for possible symptoms of STIs Knowledge about prevention/Perceived risk of acquiring STIs CHAPTER XII. DOMESTIC VIOLENCE.199 CHAPTER XIII. CONCLUSIONS.207 REFERENCES.211 APPENDIX. Survey Questionnaire.215 -viii- LIST OF TABLES Chapter II 2.1 Percentage distribution of household and individual final interview status, by residence Chapter III 3.1 Percentage distributions of socio-demographic characteristics of respondents, by residence 3.2 Percentage distributions of socio-demographic characteristics of respondents, by region of residence 3.3 Percentage distributions of current employment status and percent of women who live in homes with selected possessions, by residence 3.4 Percentage distributions of current marital status by age of respondent, by residence 3.5 Percent of respondents who have ever been in union and who are currently in union, by current age 3.6 Percent of women who were married or in a consensual union before selected ages by current age Chapter IV 4.1 Percentage of respondents who have had one or more live births and mean number of live births, by age at interview, by residence 4.2 Percentage of respondents who have had one or more pregnancies and mean number of pregnancies, by age at interview, by residence 4.3 Age-specific and total fertility rates, by residence, region, and education 4.4 Age-specific and total pregnancy rates, by residence, region, and education 4.5 Percent of women ever in union with any live births and percent ever pregnant, by years since first union and residence 4.6 Percentage distribution of number of live births, by current age and residence 4.7 Percentage distribution of number of live births, by number of years since first union, by residence 4.8 Percentage of women who had a live birth before selected age, by current age 4.9 Percentage distribution of number of pregnancies, by current age, by residence 4.10 Percentage distributions of outcomes of pregnancies ending since January 1996, by selected characteristics 4.11 Percentage distribution of planning status of pregnancies ending since January 1996, by selected characteristics 4.12 Percentage distribution of outcomes of pregnancies ending since January 1996, 4.13 Number of additional children desired, by number of living children, by residence among fecund women currently in union 4.14 Percentage distribution of total number of children desired, by number desired at time of first marriage, by residence, fecund women currently in union -ix- Chapter V 5.1 Percentage of respondents who have had any induced abortions or two or more induced abortions and mean number of induced abortions, by age at interview, by residence 5.2 Percentage of respondents who have had any induced abortions or two or more induced abortions and mean number of induced abortions, by selected characteristics 5.3 Percentage distribution of number of abortions, by current age, by residence 5.4 Age-specific abortion rates and other measures of induced abortion, by residence 5.5 Selected measures of induced abortion, by region and education 5.6 Total fertility, pregnancy, and induced abortion rates, by selected characteristics 5.7 Percentage distribution of types of abortions, by selected characteristics, all abortions since January 1994 5.8 Percentage of induced abortions since January 1994 resulting in complications requiring medical treatment, by type of abortion, by residence 5.9 Percentage distribution of primary reason for abortion since January 1994, by age at abortion, region, residence, and education 5.10 Percentage distribution of payment for most recent abortion since January 1997, by age at abortion, region, residence, and education 5.11 Percentage of women who received local anesthesia for their most recent abortion since January 1994, by year, type, age, region, residence, and education Chapter VI 6.1 Percentage of women who have ever had problem becoming pregnant in the previous 10 years, by duration of problem, by age, region, residence, and education 6.2 Percentage of women with infertility problems who sought treatment, by age, region, residence, education and length of problem 6.3 Percentage of women/couples who went to various types of place for treatment of infertility problems, by age, residence, and education 6.4 Percentage of treated women/couples who received various types of treatment for infertility problems, by age, residence, and education 6.5 Percentage of women treated for infertility problems who eventually become pregnant and percent who had a live birth, according to characteristics, length of problem, and where treated Chapter VII 7.1 Percentage of respondents who heard of specific contraceptive methods, by residence and marital status 7.2 Percentage of respondents who heard of specific contraceptive methods, by age and education 7.3 Percentage of respondents who know where to obtain specific contraceptive methods, by residence, marital status, and education 7.4 Percentage of respondents who have ever used specific contraceptive methods, by residence, marital status, and education 7.5 Percentage distribution of current contraceptive method by respondent’s age, women in union. -x- 7.6 Percentage distribution of current contraceptive method by number of living children, women in union 7.7 Percentage distribution of current contraceptive method by type of place of residence and for oversampled oblasts, women in union 7.8 Percentage distribution of current contraceptive method by region of residence, women in union 7.9 Percentage distribution of current contraceptive method by educational level, women in union 7.10 Percentage distribution of current contraceptive method, by marital status 7.11 Percent of All 15-39 Year-Old Respondents Reporting Current Use of Any Contraception or of Modern Contraception at Six Month Intervals from January 1994 to April 1999 7.12 Percentage distribution of source of selected contraceptive methods, by residence, among current users 7.13 Percentage distribution of payment for contraceptive method for current users of oral contraceptives, IUD, and condoms 7.14 Percentage distribution of primary reason for not using contraception, by union status 7.15 Percent of women with unmet need for family planning, according to two definitions by age, region, residence, and education 7.16 Percentage distributions of users of selected contraceptive methods according to whether they prefer to use a different method, by current and preferred method 7.17 Percentage distribution of reason not using preferred method of contraception, by residence 7.18 Percentage distribution of major problems or concerns with current contraceptive method, by current method 7.19 Contraceptive failure rates after one, two, and three years for selected methods of contraception, contraceptive episodes starting since January 1994 7.20 Contraceptive discontinuation rates (all reasons) after one, two, and three years for selected methods of contraception, contraceptive episodes starting since January 1994 7.21 One-year contraceptive discontinuation rates for selected reasons for selected contraceptive methods, contraceptive episodes starting since January 1994 7.22 Primary reason for discontinuing selected contraceptive methods, contraceptive episodes starting since January 1994 (Percentage Distributions) 7.23 Percent of women with poor opinion of selected aspects of various contraceptive methods, by residence, according to use of that method 7.24 Percentage of users of traditional methods who said that selected factors were important in their decision not to use a modern method, by residence. 7.25 Percentage distribution of perceived effectiveness of modern methods compared to method currently used, by residence, current users of traditional methods 7.26 Percentage distribution of time of most recent IUD insertion and length of time provider said IUD could be worn, by residence, women with IUD insertion since January 1994 7.27 Percentage distribution of the most serious problem women have had related to their IUD, by residence, women with insertion since January 1994 -xi- 7.28 Percentage distribution of length of time physician told women they could take oral contraceptives, by residence, women who started taking oral contraceptives since January 1994 7.29 Percentage distribution of the most serious problem women have had related to oral contraceptives, by residence, women who did take oral contraceptives since January 1994 7.30 Percent of fecund in union respondents wanting no more children, who are interested in being contraceptively sterilized, by selected characteristics 7.31 Percentage distribution of primary reason not interested in contraceptive sterilization, by residence Chapter VIII 8.1 Percent of women who received various family planning services after their most recent delivery or abortion, by residence among women who had a delivery or abortion since January 1994 8.2 Percent of women starting use of IUD, oral contraceptives, or injections since January 1994 with whom family planning provider discussed contraceptive options and percentage distributions of who selected method 8.3 Percent of women starting use of IUD, oral contraceptives, or injections since January 1994 to whom provider explained about possible side effects and percent of women receiving counseling who 1) understood most information of side effects; 2) were told when to return for follow-up, refill, etc.,; and 3) were given a pelvic examination, by region, residence, and method 8.4 Percent of women in union who have discussed use of family planning with their partner and percentage distribution of who women think should make decisions about whether to use contraception, by selected characteristics 8.5 Percent of women whose partner knew about her most recent abortion and percent who discussed with her partner whether to have an abortion, by selected characteristics Chapter IX 9.1 Percentage distribution of television viewing frequency, by age, region, residence, and education 9.2 Percentage of respondents who watch various types of television programs, by age, region, residence, and education 9.3 Percentage of respondents who watch television at various times, by age, region, residence, and education 9.4 Percentage distribution of frequency of radio listening, by age, region, residence, and education 9.5 Percentage of respondents who listen to various types of radio programs distribution of radio programs, by age, region, residence, and education 9.6 Percentage of respondents who listen to the radio at various times, by age region, residence, and education 9.7 Percentage distribution of frequency of reading daily newspapers by age, region, residence, and education -xii- 9.8 Percentage of women who read specific newspapers, by age, region, residence, and education 9.9 Percent of women who had seen any messages on TV or read anything in newspapers or magazines about family planning within the previous six months, and percent who think such important information should be broadcast, by selected characteristics 9.10 Percentage distribution of current contraceptive use, by whether women had been exposed to family planning (FP) messages in the media, among fecund sexually active women Chapter X 10.1 Percent of women who had sexual intercourse before ages 16, 18, 20, by current age, by residence 10.2 Percentage of respondents who reported having sexual intercourse within selected periods of time, by age, residence, region, and marital status, sexually experienced women 10.3 Percentage distribution of frequency of sexual intercourse in the previous 30 days, by age, by current marital status, among sexually experienced women 10.4 Percent of respondents between the ages of 15 and 24 who have ever had sexual intercourse, by current age, by residence 10.5 Percent of respondents between the ages of 15 and 24 who have ever had premarital sexual intercourse, by current age, by residence 10.6 Percentage distribution of relationship to first sexual partner, by age at first sex, by residence 15-24 year-old sexually experienced women 10.7 Percentage distributions of contraceptive method used at first sexual intercourse, by age at first sex, by residence, 15-24 year-old women with premarital sexual experience 10.8 Percentage distribution of numbers of sexual partners in the previous 12 months, by age, residence, and marital status, sexually experienced women Chapter XI 11.1 Percentage distribution of trimester of first prenatal care visit, by selected characteristics, all pregnancies ending in live birth since January 1994 11.2 Percentage distribution of number of prenatal care visits, by selected characteristics, all pregnancies with prenatal care ending in live births since January 1994 11.3 Percentage distribution of place of (most) prenatal care visits, by residence and region, all pregnancies ending in live birth since January 1994 11.4 Percent of respondents who had their blood pressure (BP) measured and percent who received an ultrasound during their most recent pregnancy ending in a live birth since January 1994, by selected characteristics 11.5 Percent of respondents who were told they had high blood pressure (BP), percent who were told they had anemia, and percent who took iron supplements during their most recent pregnancy ending in a live birth since January 1994, by selected characteristics 11.6 Percent of pregnancies ending in a live birth since January 1994 during which women were hospitalized, by residence, region, and year of delivery -xiii- 11.7 Percentage distribution of length of hospitalization by residence, region, and year of delivery, pregnancies ending in a live birth since January 1994 11.8 Percentage distribution of type of place of delivery for pregnancies ending in a live birth since January 1994, by selected characteristics 11.9 Percentage of respondents who received a post partum check-up within six weeks of birth, by selected characteristics, by year of birth, for most recent birth since January 1994 11.10 Percentage of women who smoked cigarettes at the time they became pregnant and percentage who continued smoking during pregnancy, by selected characteristics, most recent pregnancy ending in a live birth since January 1994 11.11 Percent of babies born to respondents since January 1994 who were breastfed, and mean duration of breastfeeding for those ever breastfed, by selected characteristics 11.12 Percentage distribution of current breastfeeding status, according to type of place of residence, by age for infants under one year of age at the time of interview 11.13 Percentage distribution of number of cigarettes typically smoked per day, by selected characteristics 11.14 Percentage distribution of years since most recent (non-pregnancy related) gynecologic exam, by age, by residence, and by marital status Chapter XII 12.1 Percentage of respondents who have never heard of selected STIs / conditions, by region, residence, age, education, and sexual experience 12.2 Percentage of respondents who have ever been diagnosed with selected STIs /conditions, by region, residence, age, and education 12.3 Percent of sexually active women who have experienced selected symptoms potentially related to sexually transmitted infections (STI ) during the past 12 months, by age, education, and place of residence 12.4 Percentage distribution of place of treatment for possible symptoms of STI, by selected characteristics 12.5 Percentage distribution of reasons for not seeking treatment for possible STI symptoms, by place of residence, and union status 12.6 Percent of respondents who are aware that individuals can be infected with HIV/AIDS or have other sexually transmitted infections (STIs) without showing any signs or symptoms of disease, by selected characteristics 12.7 Percentage distribution of opinions regarding the protection that condoms gives against HIV and other STI’s, by residence, region, age, education, and sexual experience 12.8 Percentage distribution of respondents’ perceived risk of sexually transmitted infection, by residence, region, age, education, and number of recent sexual partners Chapter XIII 13.1 Percent of respondents who recall parents/step-parents physically abusing each other and percent who were physically abused as children by someone in their household, by selected characteristics -xiv- 13.2 Percentage of ever married respondents subjected to particular types of violence ever and during the past 12 months 13.3 Percentage of respondents abused in past 12 months who sustained injuries, sought treatment, or were hospitalized, by selected characteristics 13.4 Percentage of respondents abused in past 12 months who discussed these incidents with various types of people, by selected characteristics 13.5 Percent of respondents abused in past 12 months whose partner had been drinking alcohol the last time he abused her, and percent whose partner had been drinking at any time in the past year when he abused her, by selected characteristics -xv- LIST OF FIGURES 3.1 Percentage distributions of current marital status, by age of respondent 4.1 Total fertility rates, most recent available, selected countries 4.2 Age-specific fertility rates, by place of residence 4.3 Percentage distributions of pregnancy outcomes since January 1994, by number of living children 4.4 Percentage distributions of planning status of pregnancies since January 1994, by number of living children 4.5 Percent of fecund women in union who want no more children, according to number of living children 5.1 Age-specific abortion rates, by place of residence 7.1 Percentage distribution of current contraceptive method among women in union 7.2 Percentage distribution of current contraceptive use among women in union, by number of living children 7.3 Percentage point change since January 1994 in percent of all 15-39 year-old women currently using contraception 7.4 One-year failure and discontinuation rates for selected contraceptive methods 7.5 Percent of respondents giving low ratings and for safety/health for selected contraceptive methods 10.1 Percent of respondents who have ever had sexual intercourse, by current age 10.2 Percent of respondents who ever had sexual intercourse before ages 16, 18, and 20, by current age 11.1 Percentage distribution of time of first prenatal visit for the last pregnancy since January 1994 11.2 Percentage distribution of length of hospitalization during last pregnancy since January 1994 11.3 Percent of respondents reporting selected behaviors/circumstances related to the health of infants/mothers for last pregnancy leading to a live birth since January 1994 -xvi- -1- 1999 Ukraine Reproductive Health Survey Summary of findings Introduction Since the break-up of the Soviet Union in 1991, after which it became an independent state, Ukraine, like the other countries in the region, experienced dramatic and far-reaching political, social, and economic changes. These changes have brought about major transitions in many aspects of life, some positive and some negative. One such area in which substantial change has been taking place is that of the financing and provision of health care and the structure of the Ukrainian health care system. The transitions that Ukraine has undergone, including those in the area of health care, have no doubt contributed to dramatic changes that have occurred in reproductive health and demographic indicators in recent years. There have been major changes observed in rates of childbearing, abortion, and contraceptive use. There are also unanswered questions about the degree to which there have been changes in such areas as the utilization of maternal-child health services, the prevalence of infertility problems, and maternal behaviors that affect maternal and infant health. Until recently, relatively little detailed and conclusive information was available about the situation in Ukraine with regard to many important reproductive health topics or the degree to which the reproductive health situation has changed over the past decade, however. The 1999 Ukraine Reproductive Health Survey (URHS) was a population-based, nationwide survey of women of reproductive age carried out from June to October of that year. It constituted the largest and most in-depth data collection effort in the area of reproductive health and related topics since Ukrainian independence. The URHS was performed in conjunction with the Ukraine Women=s Reproductive Health Initiative (UWRHI), a project sponsored by the United States Agency for International Development (USAID). This project consisted of a variety of components, designed to help to reduce maternal morbidity and mortality and improve reproductive health generally in Ukraine. The stated goals of this initiative were to improve the quality of reproductive health services, as well as access to those services, to increase the rate of modern contraceptive use, and to reduce abortion rates in service sites. It was anticipated that improved access to and quality of reproductive health services for women, expanded and improved use of effective contraception, and reduced reliance on abortion as a means of birth prevention would result in reductions in maternal morbidity and mortality. Seven collaborating agencies took part in the design and implementation of UWRHI activities that were intended to help achieve the following objectives: C the establishment of demonstration sites for training and delivery of family planning services C the institutionalization of reproductive health training -2- C increased public information, education, and communication about family planning C improved family planning policy environment C increased supply and distribution of family planning methods C improved methods of child delivery and maternal care There were two major reasons for carrying out the 1999 URHS. First, it was intended to fill a substantial need for data regarding the current status of reproductive health of Ukrainian women. Besides providing data on the current situation overall, it also adds to what is known about reproductive health trends and differentials within the population and allows more accurate determinations to be made about the needs of the population. Secondly, the URHS was designed to provide programmatically useful results. The data collected on reproductive health can be used to help direct, modify, or develop interventions, as well as to provide information to policy makers and health care program officials and providers. Methodology The 1999 Ukraine Reproductive Health Survey was designed to collect information from a representative sample of all women between the ages of 15 and 44 living in households throughout Ukraine. Although some pregnancy, childbearing, and abortion occurs outside of ages 15 to 44, the relative rarity of these events at those ages in Ukraine suggested that it would be most efficient to limit the sample to women in this age range. The 1999 URHS was implemented by the Kiev International Institute of Sociology (KIIS), which was responsible for selecting the sample of households and individuals, recruiting and training interviewers, conducting field work, processing the data, and performing some of the data analysis. The United States Agency for International Development (USAID) mission in Kiev was the source of all funding for the URHS and was consulted regarding the content of the survey. Technical assistance for all phases of the survey was provided by the Division of Reproductive Health of the United States Centers for Disease Control and Prevention (CDC/DRH). There were two survey questionnaires: a short household instrument and a much longer individual questionnaire (see Appendix A). The individual form was completed by selected women 15 to 44 years of age who agreed to be interviewed and covered a wide range of topics related to reproductive health status and needs in Ukraine. The sections of the questionnaire were: demographic characteristics; fertility, pregnancy, and abortion; contraception; information, education, and communication (IEC) concerning family planning; women’s health; socioeconomic characteristics of respondents; and intimate partner violence. The survey was designed to obtain interviews with a nationally representative sample of about 7,000 women. The sample was geographically self-weighting, with the exception of substantial over- sampling of two sites--the oblasts of Donetsk and Odessa. Three-stage cluster sampling was used to select survey respondents. Potential respondents consisted of all women between the ages of 15 and 44 years who lived in households anywhere in Ukraine. The first stage of sampling consisted of the selection of approximately 550 primary sampling units (census enumeration districts and postal zones) were selected across Ukraine. The second stage consisted of the selection of -3- households and women of childbearing age. Field work lasted from June through October of 1999. At least one 15-44 year-old woman was identified as living in 55% of sampled households. Of those women who were selected for interview, 85% were successfully interviewed, 8% were never found at home, and 6% refused to be interviewed. Characteristics of respondents Almost three-fourths of respondents were living in areas defined as urban. About half the urban population of women of childbearing age was living in cities of more than half a million people. The survey age distribution closely matched the distribution according to official national estimates. Just over six of every ten respondents were currently living in either a registered or unregistered marriage, 9% were either divorced or separated, 2% were widows, and 23% had never been married or lived with a man. As in most of eastern Europe and the former Soviet Union, Ukrainian women tend to marry at a young age compared to other developed countries. URHS data reveal that most first marriages take place when women are in their early twenties. Only about one-third of women between the ages of 20 and 24 years had never been in a registered or unregistered marriage. Survey data provide no evidence that the age at marriage has been rising in recent years. Ukrainian women tend to be well educated, as evidenced by the fact that only 11% of respondents had not completed secondary schooling, over two-thirds of women had finished secondary school, but had not received any post-secondary schooling, and one of every five respondents had received some post-secondary education. The largest ethnic-linguistic group consisted of Ukrainians who most often spoke Ukrainian (38%), but there were also large numbers of Ukrainians who usually spoke Russian (24%), mixed language and other language Ukrainians (13%), and ethnic Russians (regardless of language) (21%). One-half of interviewed women (50%) said they were currently employed outside the home and another 13% were on maternity leave from their jobs at the time they were interviewed. The proportion describing themselves as unemployed (i.e., not working, but wishing to do so) was 18%. Eighty-three percent of respondents’ homes had a color television, 43% had a telephone, 32% had a VCR, 25% had an automatic washing machine, and 33% of respondents lived in homes with automobiles. Pregnancy and fertility Pregnancy and childbearing represent topics of great interest in Ukraine and neighboring countries. The fact that the fertility rate is far below the replacement level and that the population of Ukraine began decreasing in recent years, due, in large part to extremely low fertility levels, has become a major concern. The 1999 URHS questionnaire collected an extensive amount of information on pregnancy and childbearing. Childbearing in Ukraine tends to start at a much earlier age than in other developed countries: about one-half of interviewed 20-24 year-olds had already had a child. Among respondents ages 25-29, 84% of women had already borne at least one child. Ukraine’s total fertility rate (TFR) according to survey data was about 1.4 births per woman for the two years preceding the survey, similar to the -4- official figure for Ukraine of 1.3 births. Age-specific fertility rates conform to the typical eastern European pattern, whereby childbearing tends to start and stop at a much earlier age than in other parts of Europe. Childbearing is heavily concentrated in the early years of marriage, with 81% of the TFR accounted for by births occurring before age 30. Forty-five percent of recent pregnancies to respondents reportedly resulted in a live birth and 7% reportedly ended in miscarriage or stillbirth. The remainder, just under half, were terminated by induced abortion. The proportion of pregnancies resulting in a live birth declined steadily with increasing age, from 59% for 15-24 year-olds to 21% among 35-44 year-olds. Only 15% of pregnancies to women with two previously born children resulted in a live birth. Fewer than half of recent pregnancies were said by respondents to have been planned at the time they occurred (i.e., the woman wanted to become pregnant at that time). Fifty-four percent were said to unplanned: 17% were mistimed and 38% were unwanted (the woman wanted no more children at the time she became pregnant). The likelihood of a pregnancy being planned fell sharply with increasing age, from 55% for 15-24 year-olds to only 20% for 35-44 year-olds. Pregnancies classified as unwanted resulted in a live birth only 5% of the time. Almost two-thirds of survey respondents said they wanted no more children. The proportions who wanted no more children increased sharply with the number of living children, from 11% of women with no children to 91% of women with two children and 87% of those with three or more children. Even among women with only one child, about one-half said they wanted no more. Induced abortion The incidence of induced abortion in Ukraine, as in most of the former Soviet republics has been very high in recent decades. However, official statistics have revealed that rates have been declining in recent years. Between 1990 and 1998, the official annual rate of abortion incidence fell by over 50%, from 77 abortions to about 36 abortions per 1,000 women of childbearing age. Overall, 43% of respondents had ever had an induced abortion and 20% had had more than one abortion. Among women in the oldest cohorts (ages 35-39 and 40-44), about two-thirds had had at least one abortion and about one-third had had at least two abortions during their lifetime. Three percent of all women and 8% of 40-44 year-olds listed five or more abortions. The total induced abortion rate (i.e., the mean number of lifetime abortions per woman based on current age-specific abortion rates) for Ukraine was 1.6 abortions per woman for the two years before interview. The abortion rate was .054, meaning that just over one of every 20 women reported having an abortion during a one-year period. The abortion ratio (i.e., the ratio of induced abortions to live births) was 1.10, indicating slightly more abortions than live births. All of these figures were substantially higher in urban areas than in rural areas. As with fertility, age-specific abortion rates were highest among women in their twenties (.091), followed by women 30-34 years of age (.069). Fourteen percent of recent abortions resulted in what women described as “complications requiring -5- medical treatment” immediately or soon after the procedure. Conventional abortions were about 50% more likely than miniabortions (i.e., early vacuum aspiration) to result in short-term complications. Among those women experiencing complications, 37% reported rehospitalization or extended hospitalization as a result. Thirteen percent of women with recent abortions reported that they received no anesthesia in association with the procedure. The likelihood of receiving anesthesia appears to have remained unchanged in recent years. Infertility There has been some concern expressed in recent years that infertility may be playing an increasing role in the unprecedentedly low levels of fertility now in effect in Ukraine. Fifteen percent of respondents reported having a problem becoming pregnant in the previous 10 years, with 10% having a problem lasting at least one year and 5% at least five years. Just over half of women who reported having difficulty becoming pregnant in the previous 10 years sought treatment of some kind for this problem. The most common treatment was the prescription of anti-inflammatory drugs, followed by: hormones, physiotherapy, treatments for blockage of the Fallopian tubes, and relaxation/spa therapy. Less commonly used were more costly and invasive treatments, such as laser therapy, laparoscopy, and in vitro fertilization. About half of the women receiving treatment eventually became pregnant. Forty percent had a live birth. Contraception Prior to this survey relatively, little national, systematic information existed on most aspects of contraceptive use in Ukraine. The URHS collected information on a broad array of topics related to contraception, including knowledge and use of contraceptive methods, source of methods, contraceptive failure and discontinuation, side effects, and reasons for nonuse of contraception. Virtually all women knew at least one modern contraceptive method, led by condoms (99% knowledge), the IUD (96%), and oral contraceptives (90%). Knowledge of where to obtain supplied contraceptive methods tended to be almost as high as knowledge of methods, indicating that most women who had heard of a method also knew where they could obtain that method. Overall, 74% of respondents and 87% of those currently in union reported ever using any contraceptive method. The figures for modern methods were 60% and 69%, respectively. Sixty-eight percent of women in registered or unregistered marriages were currently using contraceptive methods at the time of interview. More women/couples were employing modern methods of contraception than traditional methods (periodic abstinence and withdrawal), though the difference was not great (38% and 30%, respectively). IUDs (used by 19% of women in union) and condoms (14%) accounted for the vast majority of modern method use in Ukraine, with oral contraceptives (OCs) (3%) a distant third. Withdrawal, the most widely practiced method (20%) and periodic abstinence (10%), were also commonly employed. Contraceptive prevalence looks to have risen steadily in recent years, rising by about 7 percentage points in five years. -6- Women’s consultations and pharmacies were overwhelmingly the leading sources of oral contraceptives, supplying about three of every four users. Women’s consultations were the predominant source of IUDs, accounting for two-thirds of those currently used. Pharmacies supplied slightly over half of condom users. Among survey respondents who were not currently using contraception, three-fourths cited little or no sexual activity, an inability or difficulty in becoming pregnant (subfecundity), current pregnancy, or a desire to become pregnant, as their primary reason for non-use. There was a broad assortment of reasons for non-use given by the remaining 25% of non-users, many of which could be addressed by reproductive health interventions. By the conventional definition, unmet need for contraception was 15%, very high compared with the levels in most other developed countries. Using a definition that includes users of periodic abstinence and withdrawal (methods with typically low use- effectiveness) as having unmet need more than doubles the proportion in need, to 37%. Overall about 9% of contraceptive users became pregnant while using a method within one year of beginning use. After three years this rose to 19%. The failure rate for the IUD was 1.4% for the first year, which is in line with typical rates. The failure rate for oral contraceptives was 5.9% for the first year and 13.2% for three years. Condom failure was 7.1% for one year and 18.7% for three years. The highest failure rates for widely used methods were found for periodic abstinence and withdrawal. For periodic abstinence 15.6% of users became pregnant in the first year; for withdrawal the rate was 11.7%. Three-year rates for these methods was almost 30%. In general, discontinuation rates were very high across methods. For all methods combined, 29% of contraceptive use segments continued for no more than one year. Respondents were asked to rate a number of birth prevention methods with regard to safety and health effects, effectiveness, and cost, as well as to give each method an overall rating. The most noteworthy result is the nearly universally highly negative overall opinions held by respondents about both conventional induced abortion (96%) and miniabortion, i.e., vacuum aspiration in the early weeks of pregnancy (95%). Opinions about abortion were equally negative regardless of whether women had ever had an abortion. Abortion was by far the worst regarded method of birth prevention, but every method asked about was rated negatively overall by at least 40% of respondents. With regard to safety and health consequences, induced abortion was again viewed the most negatively of all methods (91% for conventional abortion and 88% for miniabortion). Despite the fact that most women want to have no more children and that most couples desire no more children long before reaching the end long before their potentially fertile years end, contraceptive sterilization is relatively rare in Ukraine; only 2% of married women of reproductive age with two or more children had been sterilized and virtually no men had undergone a vasectomy. Only 7% of fecund respondents who wanted no more children expressed an interest in sterilization. Contraceptive counseling An important component of the Ukraine Women’s Reproductive Health Initiative has been the development and implementation of interventions intended to improve health care workers’ counseling regarding contraceptive services. Only thirty-nine percent of women with a recent -7- induced abortion said that a health professional had spoken with them about ways of preventing an unintended pregnancy following their most recent abortion. Only 7% were referred for contraceptive services or counseling. About one out of every seven women undergoing an induced abortion left the facility where it was performed with a contraceptive method or a prescription for one. One- fourth of respondents with recent live births received counseling about contraception subsequent to their delivery. Just over half of women who recently started using a provider-supplied method said the provider had discussed family planning options with her. About two-thirds of recent IUD, pill, and injection users recalled their provider giving information on potential side effects and what to do about them. Information, education, and communication (IEC) Thirty-six percent of women reported seeing family planning information on television and 39% recalled seeing such information in newspapers or magazines in the previous six months. Despite a minority of women recalling seeing information on family planning in the mass media, 85% of women said that information on family planning should be broadcast. Sexual experience The URHS included a series of questions designed to study certain aspects of sexual behavior among respondents. The proportions of women who have had sex by the time they turn 16, 18 and 20 years old has increased in recent years, indicating that the age at first sex has been declining somewhat. Of respondents in the 20-24 year-old cohort, 11% first had sexual intercourse before age 16, 42% before age 18, and 74% before age 20. It has been hypothesized by some in the region that the dramatic declines in fertility and pregnancy rates in recent years in Newly Independent States (NIS) is attributable in large part to a decline in sexual activity rate, rather than other factors. About three-fourths of all sexually experienced respondents reported having sexual intercourse in the previous thirty days, 63% in the previous week, and 16% on the previous day. Among women currently in union, the proportion sexually active was 83% for the past month and 72% for the past week. Four of every ten women in union reported having intercourse at least 10 times in the previous 30 days. The overall median coital frequency was slightly over five times per month. It is difficult to detect in these data any indication that sexual activity rates have declined to a level that would contribute significantly to declines in fertility or pregnancy. The median age at first sexual intercourse, based on reports of whether young survey respondents had ever had sexual intercourse, was about 18.4 years. The proportion of 15 and 16 year-olds reporting that they had ever had intercourse was 6% and 11%, respectively. However, many girls became sexually active at ages 17 or 18. Just 14% of sexually experienced young women reported that their first sexual intercourse took place following marriage. About equal numbers of women said that their first sexual partner was a “fiancé” or boyfriend (each 36%). Just under half of young women who first had intercourse before marriage (47%) reported that they or their partner used -8- contraception during her first premarital experience. Condoms accounted for over half of this contraception (28%), with withdrawal the only other commonly used method (13%). Maternal and child health / Women’s health Ten percent of women received no prenatal care during their last pregnancy leading to a live birth. Another 3% waited until the third trimester of pregnancy to begin prenatal care. In only 65% of recent pregnancies did prenatal care begin during the first trimester, as recommended. Among women who received prenatal care, 81% made at least ten prenatal care visits. Seventy-eight percent of women with recent live births had a diagnostic ultrasound during pregnancy. Eighty-seven percent of women said that they had their blood pressure measured during pregnancy. Thirty-two percent of women with recent deliveries leading to a live birth reported being hospitalized for prenatal problems. In spite of economic changes and on-going health sector reform, the proportion of women hospitalized was virtually unchanged between 1994-96 and 1997-99. The median stay was between two and three weeks, with two-thirds lasting for two weeks or more. Fifty- five percent of women received a postpartum check-up within six weeks of delivery of their last baby. Overall, 9% of women were cigarette smokers at the time they became pregnant About half of those women reported that they stopped smoking during their pregnancy. Ninety-two percent of recently born babies were breastfed. The percentage breastfed has not changed significantly in recent years; the proportions were very similar for babies born in 1994- 1995, 1996-1997, and 1998-1999. The mean duration of breastfeeding for those babies who were breastfed was 7.5 months. Nineteen percent of respondents said that they currently smoked cigarettes. Few of the current smokers could be considered heavy smokers, though, with only 3% of women reporting that they typically smoked more than ten cigarettes per day. Sexually transmitted infections Knowledge of certain sexually transmitted infections and associated conditions was very widespread: syphilis (2% unaware of it), pelvic inflammatory disease (5%), gonorrhea (9%), and genital ulcers (9%). The conditions about which the most respondents were unaware were human papilloma virus (HPV) (74%), genital herpes (66%), and chlamydia (54%). A very high proportion of women reported having had pelvic inflammatory disease (PID) (38%) or genital ulcers (38%) at some time during their life. Other diseases that an appreciable number of women reported ever having been diagnosed with were: trichomoniasis (4%), syphilis (2%), gonorrhea (2%), and chlamydia (2%). Almost one-third of respondents who experienced symptoms consistent with STIs in the previous 12 months did not consult a health care provider for diagnosis or treatment About one-third of respondents were not aware that someone could be infected with HIV and exhibit no symptoms. About one-half of women lacked awareness that people with STIs could have no symptoms. Only 6% thought that condoms provided excellent protection against STIs. Five percent of Ukrainian women perceived themselves at high risk for acquiring an STI, with another 6% saying -9- they were at medium risk, 29% at low risk, and 60% at no risk. Domestic violence Almost one of every five respondents recalled that their parents or stepparents abused each other while the respondent was growing up and almost 30% reported that they were physically abused as a child by someone in their household. Nineteen percent of ever-married women had ever had a partner threaten to hit her, 18% had ever been pushed or slapped, 13% had been punched, kicked, or hit with an object, and 4% had been threatened with a weapon. Twenty-one percent had had any of these acts committed against her by her partner. Eight percent had experienced these types of violence within the previous 12 months. Fifty-four percent of women who reported abuse by their partner in the previous 12 months reported sustaining injuries from these incidents. 11 CHAPTER I INTRODUCTION Background Ukraine is an eastern European country bordered by the Russian Federation to the north and east, six smaller European countries to the west and northwest, and the Black Sea to the south. Its land area is about 604,000 square kilometers (233,000 square miles), making it the largest country entirely within Europe. The population in 1999 was estimated to be about 50 million people, the second most populous of the former Soviet republics. Owing primarily to a major decline in the rate of childbearing in Ukraine, the population of Ukraine has been declining in recent years. It is now estimated to be decreasing at an annual rate of approximately 0.6 percent. The country is divided into 26 oblasts and one autonomous region, the largest administrative divisions within the republics of the former Soviet Union. Since the break-up of the Soviet Union in 1991, after which it became an independent state, Ukraine, like the other countries in the region, experienced dramatic and far-reaching political, social, and economic changes. These changes have brought about major transitions in many aspects of life, some positive and some negative. One such area in which change has been taking place is that of the financing and provision of health care and the structure of the Ukrainian health care system. The on-going reform in the health care system has significantly affected such factors as the availability, cost, and quality of health care services of all kinds throughout the country (Barr and Field, 1996; Grischenko, 1997). In addition, the transitions that Ukraine has undergone, including those in the area of health care, have no doubt contributed to substantial changes that have occurred in reproductive health and demographic indicators in recent years (Steshenko and Irkina, 1999; Ukraine Cabinet of Ministers, 1997). There have been major changes noted in rates of childbearing, abortion, and contraceptive use. There are also unanswered questions about the degree to which there have been changes in such areas as the utilization of maternal-child health services, the prevalence of infertility problems, and maternal behaviors that affect maternal and infant health (such as breastfeeding, prenatal care practices, and immunization coverage). However, relatively little detailed and conclusive information was available about the situation in Ukraine with regard to a number of important reproductive health topics or the degree to which the reproductive health situation has changed over the past decade. This volume is the final report of the 1999 Ukraine Reproductive Health Survey (URHS). This nationwide survey of women of reproductive age was carried out from June to October of that year. It was a population-based survey, intended to generate results on a broad variety of reproductive health topics and to be representative of all women 15 to 44 years of age living in households in Ukraine. It constitutes the largest and most in-depth data collection effort in the area of reproductive health and related topics since Ukrainian independence. Another important national survey conducted in 1996, known as the “Health-1996 Sociological Survey”, was somewhat smaller and provided a considerable amount of valuable information on reproductive health,but, since it focused 12 on other topics as well, did not yield as much detail as the URHS with regard to certain topics, such as family planning and pregnancy outcomes (Cabinet of Ministers of Ukraine et al, 1997) . The Ukraine Women’s Reproductive Health Initiative The 1999 survey was performed in conjunction with the Ukraine Women=s Reproductive Health Initiative (UWRHI), a project sponsored by the United States Agency for International Development (USAID) (Bergthold et al., 1998). This project consisted of a variety of components, all designed to help to reduce maternal morbidity and mortality and improve reproductive health generally in Ukraine. The stated overall goals of this initiative were to improve the quality of reproductive health services and to improve access to those services. The interim goals of the initiative were to increase the rate of modern contraceptive use and to reduce abortion rates in service sites. Those developing the initiative anticipated that improved access to and quality of reproductive health services for women, expanded and improved use of effective contraception, and reduced reliance on abortion as a means of birth prevention would result in reductions in maternal morbidity and mortality. At the outset of the project, seven collaborating agencies were assigned specific roles in this initiative. The specific strategic objectives of the UWRHI, designed to help Ukraine meet the abovementioned goals were: • the establishment of demonstration sites for training and delivery of family planning services: each of the sites was to provide family planning services and training • the institutionalization of reproductive health training: at each demonstration site reproductive health was incorporated into the pre-existing program of refresher training • increased public information, education, and communication about family planning: the project produced videos, pamphlets, and other products to public awareness and knowledge about family planning • improved family planning policy environment: carrying out family planning/reproductive health advocacy work targeted at government agencies, legislators, and policy makers • increased supply and distribution of family planning methods: provision of oral contraceptives, IUDs, and injectable contraceptives to the demonstration sites • improved methods of child delivery and maternal care: this includes activities to promote breastfeeding, rooming in and other “family centered maternity care” nationwide. The UWRHI was to a great extent a response of the donor community to a perceived need to improve reproductive health and family planning services in Ukraine. In 1995, the Cabinet of Ministers adopted a National Family Planning program for 1995-2000 that called for widespread provision and promotion of modern contraception and a reduction in the number of abortions. The four primary components of the program were: 1) preventing unwanted pregnancies, 2) providing medical-genetic counseling, 3) treating infertility, and 4) educating the public. However, funds were never made available to implement the program due to an extreme shortfall in the Ministry of Health 13 (MOH) budget. The 1999 Ukraine Reproductive Health Survey As the largest and one of the first nationwide, population-based surveys of reproductive health and related issues to take place in post-independence Ukraine, the 1999 URHS provides a substantial amount of new information on a broad assortment of reproductive health topics. There were two major reasons for carrying out this survey. First, it was intended to fill a substantial need for data regarding the current status of reproductive health of Ukrainian women. Besides providing data on the current situation overall, it also adds to what is known about reproductive health trends and differentials within the population and allows more accurate determinations to be made about the needs of the population in this area. The survey allows tabulation of many basic indicators of, for example, contraceptive use, unintended pregnancy, unmet need for family planning services, use of reproductive health services, contraceptive failure, and abortion and related factors. The data help to determine where in the country particular reproductive health needs and problems are most prevalent or severe and in which segments of the population such problems are the most or least likely to exist. Secondly, the URHS was designed to provide programmatically useful results. The data collected on reproductive health can be used to help direct, modify, or develop interventions, as well as to provide information to policy makers and health care program officials and providers. The information coming from the survey should prove helpful for policy makers, health care providers, program officials, international organizations, NGOs, and others working in reproductive health and related fields. Since there are great similarities between Ukraine and other formerly communist republics, this information should also prove valuable for those working in other countries within the region. The 1999 URHS was also designed to provide important information for a broad cross-section of reproductive health and women’s health topics. One of the principle issues that the survey was designed to address was the use of abortion among Ukrainian women. Like most other former Soviet republics and countries under Soviet domination, abortion has been a dominant means of birth prevention for many years. The Ukraine Women’s Reproductive Health Initiative was designed to help determine effective means (and implement those means) to reduce reliance on induced abortion as a means of family planning and thereby improve reproductive health. The URHS examined the use of abortion in depth, including such factors as incidence, attitudes, cost, and complications. A second important issue examined was the use of contraception, in order to look at levels and trends in contraceptive prevalence and method selection and at the extent to which family planning methods are being practiced effectively. The questionnaire included detailed information on many aspects of contraception. Expanded and improved contraceptive use should improve maternal health by reducing the numbers of unintended pregnancies and induced abortions. It is also important to learn more about women=s opinions and attitudes regarding specific contraceptive methods and abortion, and about women=s knowledge of reproductive health issues, to determine how well informed the population is and to assist in the development of information, education, and communication (IEC) messages. 14 A broad assortment of other issues were addressed in the survey as well. The URHS was used to learn about such things as the reproductive health services women are using and their opinions about those services, women’s health behaviors, sexual activity, sexually transmitted infections, and domestic violence, among others. The 1999 URHS was also designed to help make determinations about possible impacts of the Women=s Reproductive Health Initiative. Examinations of those areas in which it was anticipated that the initiative may have an impact were performed. The survey questionnaire permits analysis of trends in some key topics, such as contraceptive use and abortion, in order to determine whether they have been changing in recent years and in particular areas of the country or segments of the population. This Final Report describes the key initial findings from the 1999 Ukraine Reproductive Health Survey in all of the areas examined. However, it was not possible to do an exhaustive analysis of data on any single topic, because of the scope and depth of the information collected in the URHS. Data analysis will continue after the publication of this report to utilize the data as fully as possible. 15 CHAPTER II SURVEY METHODOLOGY The 1999 Ukraine Reproductive Health Survey was designed to collect information from a representative household sample of all women between the ages of 15 and 44 living throughout Ukraine, excluding those living in institutional settings. Although some pregnancy, childbearing, and abortion occurs outside the ages 15 to 44, the relative rarity of these events at those ages in Ukraine suggested that it would be most efficient to limit the sample to women in this age range. Organizational Structure The 1999 URHS was implemented by the Kiev International Institute of Sociology (KIIS), a professional survey organization with extensive experience in all aspects of social science survey research. KIIS was responsible for selecting the sample of households and individuals, recruiting and training interviewers, conducting field work, processing the data, and performing part of the data analysis. The United States Agency for International Development (USAID) mission in Kiev was the source of all funding for the URHS. USAID also was consulted regarding the content of the survey, to ensure that the information collected would be of maximum value for its projects. Technical assistance for all phases of the survey was provided by the Division of Reproductive Health of the United States Centers for Disease Control and Prevention (CDC/DRH). CDC/DRH was the lead agency in development of the overall survey design, questionnaire construction, coordination of survey activities, and much of the data analysis. The participation of CDC/DRH was funded through a Participating Agency Service Agreement between the USAID Office of Population and CDC/DRH. Other cooperating agencies involved in the Ukraine Women’s Reproductive Health Initiative, particularly Johns Hopkins University/Population Communications Services (JHU/PCS) and The Futures Group International, contributed significantly to questionnaire development, as well as other aspects of the survey. Questionnaire Content The 1999 URHS consisted of two questionnaires: a short household instrument and a much longer individual questionnaire. Both questionnaires are included in Appendix A of this report. The household questionnaire was two pages long and was administered to any adult living in visited households. It consisted primarily of information regarding the individuals who lived in the household and the location of the residence. The individual form was completed by selected women 15 to 44 years of age who agreed to be interviewed. This questionnaire covered a wide range of topics related to reproductive health status and needs in Ukraine. The sections of the questionnaire were: I. Social and demographic characteristics of respondents II. Fertility, pregnancy, and abortion– includes a complete pregnancy history, detailed information on abortions and live births in the preceding five years, use of maternal- 16 child health services, and infertility problems and treatment. III. Contraception– includes knowledge and use of specific methods, a month-by-month calendar of contraceptive use in the preceding five years, contraceptive counseling, and detailed information on many aspects of family planning. IV. Information, education, and communication (IEC) and attitudes and beliefs concerning family planning V. Women’s health– includes information on sexual behavior and sexually transmitted infection knowledge and history VI. Socioeconomic characteristics of respondents VII. Intimate partner violence. Survey design The survey was designed to obtain interviews with a nationally representative sample of about 7,000 women between the ages of 15 and 44 years of age living throughout Ukraine. The survey was intended to be large enough to provide stable estimates regarding the main topics of interest at the regional level (there are five regions: the North, East, Central, South, and West) and for the urban and rural sectors of Ukraine. The sample was geographically self-weighting, with the exception of substantial over-sampling of two sites--the oblasts of Donetsk and Odessa. The two oversampled oblasts were the sites for USAID-funded reproductive health activities. Donetsk was a site of activities sponsored by the Women’s Reproductive Health Initiative that started in 1996. Odessa was the focus of USAID-sponsored activities implemented by The Policy Project (coordinated by The Futures Group International) that are designed to improve support for family planning activities. Oversampling of these areas was designed to allow local estimates to be made in regard to many of the topics addressed in the URHS. Three-stage cluster sampling was used to select survey respondents. Potential respondents consisted of all women between the ages of 15 and 44 years who lived in households anywhere in Ukraine. The first stage of sampling consisted of the selection of primary sampling units (PSU). Approximately 550 primary sampling units were selected across Ukraine. The sample was selected proportional to population size (PPS) of each of the country’s 26 oblasts and autonomous regions (with the exception of Odessa and Donetsk). Within each oblast the sample was split proportionally into five size-of-place categories, ranging from large cities to rural areas, using software that listed the estimated population of all locations. Population estimates were based on yearly updates made to census counts. Unfortunately, the most recent census in Ukraine took place when it was still part of the Soviet Union, in 1989. Within each size of place/oblast category, PSU (census enumeration districts) were selected with probability proportionate to size. Within rural areas, post offices were selected instead of places, under the assumption that all post offices cover roughly the same population. This process guarantees a selection of households approximately proportional to the 17 entire population according to oblast and size of place. The second stage of sampling consisted of the selection of dwelling units and respondents from the selected PSU. Within each selected PSU a random starting point was chosen, followed by selection of contiguous dwelling units, selected in a predetermined order. The number of dwellings visited per PSU varied from 23 to 30, depending on the size of place, since the average number of women of childbearing age per household varies according to size of place. Selection of women for interview was accomplished in the third stage by listing women in each visited household by descending age and selecting every second woman listed regardless of the household in which she was found. However, this procedure was slightly modified to ensure that no more than one woman per household was interviewed Data Collection The questionnaires were pretested in November 1998. Eight interviewers conducted pretest interviews with a total of about 50 women in Kiev and a nearby rural area. Based on these interviews, the survey questionnaires were modified. Data collection for the 1999 URHS was carried out by about 150 female interviewers living throughout Ukraine, most of whom were highly experienced in conducting interviews. Staff from KIIS, assisted by Dr. Petr Velebil, a Russian- speaking obstetrician-gynecologist and epidemiologist from the Czech Republic, conducted interviewer training sessions. Five such sessions were held, two in Kiev, one in Donetsk, one in Odessa, and one in L’viv. Each session had about 25-30 interviewers attending. Interviewer training sessions consisted of intensive training in field procedures and administration of the questionnaire. Field work lasted from June through October of 1999. Each interviewer was assigned to visit a small number of PSU in the part of the country in which she lived. Interviews took place at respondents’ homes and typically lasted from 60 to 75 minutes. Each interviewer forwarded her completed questionnaires to her regional supervisor, who reviewed each questionnaire and, if satisfactorily completed, sent it to the KIIS office in Kiev for data entry and final editing. Response rates At least one 15-44 year-old woman was identified as living in 55% of sampled households (Table 2.1, upper panel). In most of the remaining households, there were no resident females eligible for interview. Residents refused to provide interviewers with information concerning the household or its residents in fewer than 1% of the households visited. The difference between urban and rural areas was small, with urban households slightly less likely than rural ones to contain women eligible for interview. The lower panel of Table 2.1 presents information on response rates for women who were selected for interview. Of those 15-44 year-old women who were identified as living in visited households and selected as potential respondents, 85% were interviewed. The figure was somewhat higher in rural areas (89%) than in urban areas (84%). Eight percent of women selected for interview were never found at home and 6% refused to be interviewed. Individual refusal rates were about twice as high in urban areas as in rural areas. 18 Table 2.1 Percentage distribution of household and individual final interview status, by residence 1999 Ukraine Reproductive Health Survey Total Urban Rural Selected households Eligible woman identified 54.9 54.0 58.3 No eligible woman in household 43.5 44.3 40.2 Household refusal 0.6 0.7 0.2 Residents not at home 0.7 0.6 0.9 Unoccupied household 0.2 0.3 0.1 Other 0.3 0.3 0.3 Total 100.0 100.0 100.0 Number of households visited 16,886 13,383 3,503 ____________________________________________________________________ Selected eligible women Completed interviews 85.2 84.1 89.0 Selected women refused 5.6 6.3 3.0 Selected woman absent 7.7 7.9 6.9 Woman not competent 0.4 0.5 0.2 Other 1.2 1.2 0.9 Total 100.0 100.0 100.0 Number of selected women 8,367 6,587 1,780 Number of women interviewed 7,128 5,544 1,584 19 CHAPTER III CHARACTERISTICS OF RESPONDENTS This chapter presents selected social, economic, and demographic characteristics of the women who were interviewed in the 1999 URHS. The URHS included modules that covered such topics as demographic characteristics, marriage, education, language, ethnicity, religion, employment, and other economic topics. These data provide important background information about the population of women of childbearing age in Ukraine, giving some important insights into their social and economic conditions, as well as such things as the degree of heterogeneity and diversity in the population. It also lets us know the extent to which the survey sample is representative of Ukrainian population of women of childbearing age as a whole. Demographic and social characteristics Table 3.1 displays percentage distributions of URHS respondent characteristics according to selected demographic and social characteristics. Almost three-fourths of respondents (73%) were living in areas defined as urban. The remaining 27% lived in rural areas, i.e., villages or farms. This distribution has less to do with Ukraine being a heavily urbanized country than it does with the fact that the definition of urban includes settlements down to quite a small size. About half the urban population of women of childbearing age was living in cities of more than half a million people. With the exception of the Oblasts of Donetsk and Odessa, which were intentionally oversampled, the percentage distribution of the population by oblast was very similar in the sample and Ukraine’s official population statistics (data not shown). Donetsk constituted 21.7% of the sample, but only 10.1% of the total population, while the figures for Odessa were 17.9% and 5.2%, respectively. During analysis, sample weights have been applied to the results to compensate for this oversampling. With the appropriate sample weights the percentage distribution by oblast is similar to the official population estimates. All results presented in this report are based on weighted data, adjusting for oversampling in Donetsk and Odessa, but unweighted totals are shown in the report’s tables. The age distribution closely matched the distribution according to official national estimates. The distribution was very flat, with very similar proportions of respondents in each five-year age group, ranging from 16.4% for ages 20-24 to 17.3% for ages 35-39. The urban and rural age distributions were also very similar to each other. Just over six of every ten respondents were currently living in either a registered or unregistered marriage, with unregistered marriages being relatively rare (4% of women). Another 9% of respondents were either divorced or separated and 2% were widows. Twenty-three percent of women had never been in union (i.e., married or lived with a man). The percentage of women in registered marriages was considerably higher in rural areas than in urban areas (70% vs. 60%, respectively), principally a function of earlier age at marriage in rural Ukraine. The percentage divorced or separated was almost twice as high in urban areas as in rural areas. 20 Ukrainian women tend to be well educated, as evidenced by the fact that only 11% of respondents had not completed secondary schooling. About half of that 11% were 15-19 years old, so many of them, no doubt, were still in secondary school and will eventually complete it. Just over two-thirds of women had finished secondary school, but had not received any post-secondary schooling. Additionally one of every five respondents had received some post-secondary education. Within the “completed secondary” category there is considerable variation among women in educational attainment. A majority of women in this category obtained some additional professional technical training in addition to secondary school. The greatest difference between urban and rural women in educational attainment was that the former were about twice as likely as the latter to have received any post-secondary education (23% vs. 13%, respectively). Rural women were slightly more likely not to have completed secondary school. Women’s stated nationality was cross-classified with the language they most often spoke. This was done because neither nationality nor language alone completely describes the extent to which people may be considered to be ethnically Russian, Ukrainian, mixed, or something else, in a society with a long history of large populations of Ukrainians and Russians and not always a clear distinction between the two. The largest ethnic-linguistic group consisted of Ukrainians who most often spoke Ukrainian (38%), but there were also large numbers of Ukrainians who usually spoke Russian (24%), mixed language and other language Ukrainians (13%), and ethnic Russians (regardless of language) (21%). In rural areas, over two-thirds of women were Ukrainian-speaking Ukrainians and only 10% classified themselves as ethnic Russians. A clear majority of Russian-speakers are urban residents. With regard to religion, about three of every four respondents said they were Orthodox, while 11% described themselves as having no religion. Urban respondents were more likely that rural women to say they had no religion (13% vs. 7%, respectively). Although a high proportion of women reported belonging to a religion, relatively few attended religious services on a regular basis. Only 12% said they attended services at least monthly, with about half of them attending weekly. Even though the overall level of attendance was relatively low, the percent who never attended was lower in rural areas (26%) than in urban areas (35%). Table 3.2 displays most of the same characteristics as Table 3.1 according to respondents’ region of residence. It is clear that there are major social and demographic differences between different parts of Ukraine, with the most notable differences between the Western region and the rest of the country. In The West there were roughly equal percentages of respondents in urban and rural areas, making it much more rural than the other parts of Ukraine. The East, Ukraine’s most industrialized region, on the other hand is the most urban region (86%). Age distributions were very similar across regions. Western women were the most likely to be in a registered marriage and the least likely to be in an informal or unregistered union. There were major regional differences in language and ethnicity. The proportion of women reporting themselves to be predominantly Ukrainian-speaking and ethnically Ukrainian varied tremendously, ranging from 89% in the West and 72% in the Central region to only 5% in the South. On the other hand the percentage who were ethnically Russian ranged between 35% in the East to less than 3% in the West. In all regions except the West, an overwhelming majority of respondents said they were Orthodox (78%-85%). In the West, Orthodox was also in the majority, but much less so than elsewhere (58%). Attendance at religious services 21 was considerably more frequent in the East than elsewhere (18% at least weekly and 17% at least monthly), but even there most women attended services infrequently. Attendance was least common in the Central and Eastern regions. Economic characteristics Since the break-up of the Soviet Union and the downfall of communism in this part of the world, Ukraine has been undergoing dramatic economic changes. The dissolution of the former economic system and the concurrent growth of capitalism and privatization has led to economic freedoms that did not previously exist. The transition to a market economy, however, has also had some serious negative consequences for many individuals, at least in the short run. Certain economic protections, such as employment security and controlled prices, no longer exist. The URHS included several questions related to women’s employment and other economic issues. One-half of interviewed women (50%) said they were currently employed outside the home and another 13% were on maternity leave from their jobs at the time they were interviewed (Table 3.3). The proportion describing themselves as unemployed (i.e., not working, but wishing to do so) was quite high, at 18%. The employment situation was somewhat worse in rural areas than in urban areas. The percent unemployed was 22% in the former, compared with 17% in the latter. There were substantial differences in unemployment according to region, with the proportions ranging from 14% in the heavily industrialized East to 22% in the West, the most rural region of Ukraine (data not shown). The bottom panel of Table 3.3 displays the percentages of women who reported that they lived in households containing various possessions or amenities. Eighty-three percent of respondents’ homes had a color television, 43% had a telephone, 32% had a VCR, 25% had an automatic washing machine, and 33% of respondents lived in homes with automobiles. With the exception of automatic washing machines and automobiles, urban women were substantially more likely than rural women to have each of the possessions and amenities asked about. Marriage As is true throughout most of eastern Europe and the former Soviet Union, women tend to marry at a very young age compared to other developed countries. URHS data reveal that most first marriages take place when women are in their early twenties. Only about one-third of women between the ages of 20 and 24 years had never been in a registered or unregistered marriage (Table 3.4 and Figure 3.1). By ages 25-29 relatively few women (8%) had never been in union. Marriage has also been much more universal than in other developed countries. In the two oldest cohorts of women interviewed, the proportions of women who had never been in union were very low, below 3%. Divorce and separation, while not at the levels found in many western countries, is not a rare occurrence. Starting with the 25-29 year-old cohort, 10% or more of each cohort was currently divorced or separated. It also is evident that rural women tend to marry somewhat earlier than urban women. Among 20-24 22 year-olds, only 22% of rural respondents had never been in either a registered or unregistered marriage, compared with 41% in urban areas. In addition, the proportion of older respondents never in union was even lower in rural areas (under 2%) than it was overall. Divorce and separation was also less common in rural areas than in urban areas. Table 3.5, showing proportions of women ever in union and currently in union, confirms the tendency to marry young among Ukrainian women. Almost two-thirds of women between the ages of 20 and 24 years had already been in a registered or unregistered marriage (i.e., in union), and by ages 25-29, 93% had ever been in union (Table 3.5). In rural areas, age at marriage tends to be even younger than overall. 78% of 20-24 year-olds and 94% of 25-29 year-olds there had ever been in union. Table 3.6 allows one to look at recent trends in age at marriage, by showing the percentage of respondents in 5-year age various cohorts who had ever been in union before various ages. The main finding from this table is that there is no sign that age at marriage has been rising in recent years. The proportions of women who had married by 20 was relatively constant in the 20-24, 25-29 and 30-34 year-old cohorts, with slightly over four of every ten women married before age 20. This indicates little change in the age at marriage. There are also no signs of increasing age at marriage among younger cohorts. About 14-15% of 20-24 and 25-29 year-olds were already in union by age 18. By age 25, almost nine out of every ten women had been in union. These figures are typical for most of eastern Europe but are extremely high compared to other parts of the continent, where marriage most often takes place in the late twenties and thirties. 23 24 Table 3.1 Percentage distributions of socio-demographic characteristics of respondents, by residence 1999 Ukraine Reproductive Health Survey Characteristic Total Urban Rural Residence Urban, Total 72.7 City >500,000 34.0 City 200,000-500,000 12.5 City <200,000 17.8 Small town 8.4 Rural, Total 27.3 Region North 15.6 15.6 15.7 Central 11.1 9.0 16.7 East 35.0 41.6 17.4 South 17.6 19.3 13.0 West 20.8 14.6 37.2 Age 15-19 16.6 16.9 15.8 20-24 16.4 16.6 16.0 25-29 16.6 16.2 17.7 30-34 16.5 15.9 18.2 35-39 17.3 17.8 16.0 40-44 16.5 16.6 16.3 Marital status Registered marriage 62.5 59.9 69.5 Unregistered marriage 3.9 4.3 2.6 Divorced/separated 9.0 10.1 6.3 Widowed 1.8 1.7 2.1 Never married 22.8 23.9 19.6 Education < Complete secondary 11.3 10.4 13.5 < Grade 10 8.2 7.6 9.6 Technical after grades 7-8 3.1 2.8 3.9 Complete secondary 68.4 66.2 74.0 Complete secondary 27.6 25.3 33.8 Prof. Tech after grade 10-11 11.3 10.9 12.3 Complete secondary + tech. 29.5 30.0 27.9 > Complete secondary 20.4 23.3 12.5 Incomplete postsecondary 3.9 4.6 2.2 Complete postsecondary 16.4 18.7 10.3 25 Characteristic Total Urban Rural Language spoken at home/ Nationality Ukrainian-speaking / Ukrainian 37.8 25.8 69.7 Russian-speaking / Ukrainian 24.2 31.1 5.9 Other or mixed language / Ukrainian 12.5 13.3 10.3 Russian nationality 20.9 25.5 8.5 Other nationality 4.7 4.3 5.6 Religion * Orthodox 76.2 77.0 73.9 Roman Catholic 4.8 3.6 7.8 Other 7.9 6.6 11.2 None 11.2 12.8 7.2 Frequency of church attendance At least once/week 6.2 4.7 9.9 At least once/month 6.2 5.0 9.2 Less than once/month 55.4 55.5 55.4 Never 21.1 22.1 18.4 No religion 11.2 12.8 7.2 Total 100.0 100.0 100.0 Number of respondents 7128 5544 1584 *228 women did not state their religion. 26 Table 3.2 Percentage distributions of socio-demographic characteristics of respondents, by region of residence 1999 Ukraine Reproductive Health Survey Characteristic Total North Cent. East South West Residence Urban, Total 72.7 72.5 58.9 86.4 79.8 51.1 City >500,000 34.0 84.7 0.0 52.6 48.2 8.3 City 200,000-500,000 12.5 13.6 24.0 4.6 16.6 15.5 City <200,000 17.8 15.9 20.8 20.8 8.9 20.0 Small town 8.4 8.3 8.4 8.4 6.1 7.3 Rural, Total 27.3 27.5 41.1 13.6 20.6 48.9 Age 15-19 16.6 16.7 16.2 16.9 16.9 16.1 20-24 16.4 16.0 14.9 16.4 18.0 16.3 25-29 16.6 17.0 16.0 15.2 16.6 19.1 30-34 16.5 16.1 18.4 16.1 15.3 17.5 35-39 17.3 17.3 16.8 17.4 17.4 17.4 40-44 16.5 16.9 17.8 18.1 15.8 13.6 Marital status Registered marriage 62.5 61.8 64.3 59.9 58.4 70.1 Unregistered marriage 3.9 3.8 4.3 4.5 5.3 1.5 Divorced/separated 9.0 8.2 9.6 10.9 10.2 5.3 Widowed 1.8 2.0 2.7 1.8 1.8 1.2 Never married 22.8 24.3 19.0 23.0 24.2 21.9 Education < Complete secondary 11.3 8.7 12.6 12.3 11.4 10.6 Complete secondary 68.4 66.6 70.2 69.7 63.7 70.3 > Complete secondary 20.4 24.6 17.1 18.0 24.9 19.1 Language spoken at home/ Nationality Ukrainian-speaking Ukrainian 37.8 42.5 71.8 11.4 4.7 88.7 Russian-speaking Ukrainian 24.2 26.1 5.4 36.6 36.2 1.8 Other/Mixed Ukrainian 12.5 19.0 12.8 12.7 17.6 2.9 Russian nationality 20.9 10.0 6.9 35.4 32.1 2.5 Other nationality 4.7 2.5 3.0 4.0 9.4 4.2 Religion * Orthodox 76.2 85.4 84.7 77.8 80.7 58.1 Roman Catholic 4.8 2.2 2.0 0.3 0.4 19.1 Other 7.9 1.9 1.5 5.2 6.4 21.4 None 11.2 10.5 11.8 16.6 12.5 1.3 Frequency of church attendance At least once/week 6.2 3.2 1.8 2.8 3.6 18.4 At least once/month 6.2 4.5 2.0 2.1 5.0 17.3 Less than once/month 55.4 63.3 67.3 48.9 51.5 57.5 Never 21.1 18.6 17.1 29.6 27.4 5.4 No religion 11.2 10.5 11.8 16.6 12.5 1.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 7128 858 617 2669 1824 1160 *228 women did not state their religion. 27 Table 3.3 Percentage distributions of current employment status and percent of women who live in homes with selected possessions, by residence 1999 Ukraine Reproductive Health Survey Characteristic Total Urban Rural Current employment Employed 50.0 51.4 46.3 On maternity leave 12.8 11.7 15.6 Not employed* 37.3 36.9 38.1 Unemployed** 19.2 16.6 22.0 Total 100.0 100.0 100.0 Possessions in home Color television 82.9 88.6 67.9 Bathroom/Shower 79.8 86.6 61.6 Telephone 43.1 48.9 27.3 Automobile 32.8 33.0 32.2 VCR 30.2 33.5 21.3 Automatic washing machine 25.1 25.1 25.1 Personal computer 3.2 4.0 1.2 Number of respondents 7128 5544 1584 *Does not currently have a job, regardless of reason. Includes “unemployed”. **Does not have a job due to inability to find a job. 28 Table 3.4 Percentage distributions of current marital status by age of respondent, by residence 1999 Ukraine Reproductive Health Survey Age of respondent Marital status 15-19 20-24 25-29 30-34 35-39 40-44 Total All women Registered marriage 8.6 55.7 75.5 80.9 77.5 76.6 62.5 Unreg. marriage 2.2 5.5 5.3 4.1 3.3 2.9 3.9 Divorced/Separated 0.5 5.2 10.5 10.0 13.7 14.2 9.0 Widowed 0.1 0.2 1.2 1.8 2.9 4.5 1.8 Never married 88.6 33.4 7.5 3.2 2.6 1.8 22.8 Number of women 1,100 1,182 1,227 1,195 1,246 1,178 7,128 Urban Registered marriage 7.6 50.3 72.4 81.1 75.5 73.8 59.9 Unreg. marriage 2.8 6.1 5.5 4.7 3.8 3.3 4.3 Divorced/Separated 0.6 6.0 12.7 9.8 15.3 15.9 10.1 Widowed 0.1 0.2 0.1 1.5 2.6 4.9 1.7 Never married 88.8 41.4 8.3 2.7 2.7 2.3 25.1 Number of women 861 919 941 908 990 925 5,544 Rural Registered marriage 11.3 70.6 82.9 60.6 83.6 84.1 69.4 Unreg. marriage 0.5 4.0 4.8 2.7 1.9 1.6 2.6 Divorced/Separated 0.0 2.8 5.2 10.5 8.9 9.6 6.3 Widowed 0.0 0.4 1.5 2.5 4.1 3.6 2.0 Never married 88.2 22.2 5.7 3.7 1.6 1.2 19.6 Number of women 239 263 286 287 256 253 1,584 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 29 Table 3.5 Percent of respondents who have ever been in union and who are currently in union, by current age 1999 Ukraine Reproductive Health Survey Age % Ever in union % Currently in union All women 15-19 11.4 10.8 20-24 66.6 61.2 25-29 92.5 80.7 30-34 96.8 85.0 35-39 97.4 80.8 40-44 98.2 79.4 Total 77.3 66.4 Number of women 7,128 7,128 Urban women 15-19 11.2 10.4 20-24 62.5 56.4 25-29 91.7 77.9 30-34 97.0 85.7 35-39 97.1 79.3 40-44 97.9 77.1 Total 76.1 64.2 Number of women 5,544 5,544 Rural women 15-19 11.9 11.9 20-24 77.8 74.6 25-29 94.3 87.7 30-34 96.3 83.3 35-39 98.4 85.5 40-44 98.8 85.7 Total 80.4 72.1 Number of women 1,584 1,584 30 Table 3.6 Percent of women who were married or in a consensual union before selected ages by current age 1999 Ukraine Reproductive Health Survey Current age of respondent Married before: 15-19 20-24 25-29 30-34 35-39 40-44 Total Age 16 - 0.9 1.0 0.5 0.4 0.8 0.8 Age 18 - 14.2 14.9 9.7 9.7 7.4 11.2 Age 20 - 42.8 44.8 41.1 37.4 36.3 40.0 Age 25 - - 88.3 89.4 83.1 85.4 84.2 Age 30 - - - 95.7 94.0 94.1 93.5 Number of women 1,100 1,182 1,227 1,195 1,246 1,178 7,128 31 CHAPTER IV PREGNANCY AND CHILDBEARING The 1999 URHS questionnaire collected an extensive amount of information on pregnancy and childbearing. The survey instrument contained a complete pregnancy history, that included, for every pregnancy: its outcome, whether the pregnancy was intended, its duration (in months), and the gender of each live-born child. In addition, for pregnancies resulting in a live birth since the beginning of 1994, more detailed information was collected on prenatal care, hospitalization during pregnancy, and breastfeeding. Pregnancy and childbearing represent topics of considerable interest in Ukraine and nearby countries. In most countries of the region fertility has fallen to unprecedentedly low levels in recent years, with levels well below the replacement level of 2.1 births per woman. Figure 4.1 displays fertility rates for the year 2000 for selected European countries, including most of the countries formerly part of the Soviet bloc. There is considerable concern about these topics for a number of reasons. Fertility rates that have fallen to such a low level in Ukraine have led to worries about declining population size as well as related concerns, such as a rapidly aging population and an eventual shortage of working age people in the population. In fact, the population of Ukraine began decreasing in recent years, due, in large part to extremely low fertility levels. The decline is now estimated to be about 0.6%, about 300,000 people, per year. Despite the low level of fertility, there remain concerns, however, about very high rate of unintended pregnancy, which fuels the high incidence of induced abortion. The vital statistics system in Ukraine is considered to be quite complete in the area of fertility. Thus, official estimates of fertility rates are probably reliable. However, the URHS provides information on other aspects of pregnancy and childbearing that are not generally available from other sources. In this chapter we provide survey findings such topics as: pregnancy rates, pregnancy outcomes, fertility patterns, additional children desired, and the planning status of recent pregnancies. Fertility and pregnancy levels and patterns As in much of eastern Europe and the former Soviet Union, childbearing in Ukraine tends to start at a much earlier age than in other developed countries. About one-half of interviewed 20-24 year- olds had already had a child and the average number of live births for women in that cohort was about 0.6 (Table 4.1). Childbearing tends to begin earlier in rural areas, where 63% of 20-24 year- olds had had a live birth, than in urban areas, where 46% had begun childbearing. Among respondents ages 25-29, 84% of women had already borne at least one child. Mean family size for the oldest cohorts (which can reasonably be viewed as completed family size, since few women have children after about age 35) was 1.8 births per woman. Childlessness, at least in the older cohorts, was still fairly uncommon, with about 6% of the oldest respondents reporting that they had had no live births. Proportions of women with any live births and mean numbers of births were slightly, but consistently, lower among urban women than among rural women across cohorts. 32 Table 4.2 is identical to Table 4.1, except that it shows numbers of pregnancies rather than live births. Only about 9% of 15-19 year-olds reported ever having been pregnant, but among 20-24 year-olds, the figure was 61%. Because of the high levels of induced abortion, the mean numbers of pregnancies were far higher than the number of live births, starting at ages 25-29. In the three oldest cohorts, fewer than 5% of women reported that they had never been pregnant. The proportions ever pregnant were consistently higher among rural women than among urban women. The total fertility rate (TFR) (i.e., the mean number of children per woman based on current age- specific fertility) according to survey data was about 1.4 births per woman for the two years preceding the survey (Table 4.3). This was not substantially different from the official figure for Ukraine of 1.3 births. As in almost all of Europe, Ukraine’s total fertility rate is well below the replacement level of 2.1 births per woman. Age-specific fertility rates conform to the typical eastern European pattern, whereby childbearing tends to start and stop at a much earlier age than in other parts of Europe. Fertility is heavily concentrated in the early years of marriage, with 81% of the TFR accounted for by births occurring before age 30 (Figure 4.2). By far the highest fertility is at ages 20-24, where 11.5% of women bear children in a one-year period, almost twice as high as any other age group. The TFR in rural areas was almost 50% higher than in urban areas, 1.8 compared to 1.3 births per woman. The only age group in which there was not a substantial difference between urban and rural areas was at ages 25-29. There was considerable variation in fertility levels across Ukraine’s regions. The TFR ranged from 2.0 in the western region, which is the most rural and the most ethnically Ukrainian part of the country, to 1.1 in the East, which is the most industrialized and most ethnically Russian region. The centra l northern, and southern regions all have fertility rates of 1.4 to 1.5. In all regions the age pattern of childbearing is similar, heavily concentrated in the twenties and extremely low after ages 30-34. Fertility was much lower among women with any post- secondary education (TFR=1.1) than among women with less formal education. Table 4.4 shows that the total pregnancy rate (TPR) for the two years prior to the survey was 3.1 for Ukraine as a whole, meaning women average just over three pregnancies apiece during their lifetime, just over twice the total fertility rate. The age pattern of pregnancy is quite similar to that for fertility, but the age-specific pregnancy rates are highest relative to the fertility rates at the oldest ages. This is an indication that most abortions take place after women have completed childbearing, rather than to delay childbearing. Despite having the highest fertility rates, the West region has one of the lowest pregnancy rates, probably because of relatively low induced abortion incidence. Table 4.5 demonstrates that childbearing continues to typically begin shortly after marriage for Ukrainian couples. Among women in union for less than five years, 82% had ever been pregnant and 69% had had a live birth. Only about one percent of the oldest cohort of women who were ever in union never became pregnant and never had a live birth. Even among those married as recently as 5-9 years earlier, 96% had ever been pregnant and 92% had had a live birth. Almost all figures were slightly higher among rural women than among urban women. Table 4.6 presents percentage distributions of the number of live births to women according to age. The most interesting information in this table is the relatively small number of women with no live 33 births (at least at the older ages) and the similarly small numbers with large families. Women with more than three children have become quite rare and with the recent decline in fertility rates will, no doubt, become even rarer. Family sizes other than one or two children are becoming less common. Large families (more than two children) are considerably more common in rural areas than urban areas. Table 4.7 shows live birth distributions by years since first union and leads to conclusions similar to the previous table. Few women married 10 or more years report having no children. Table 4.8 allows an examination of changes over time in the onset of childbearing. The percentage of women with births before particular ages has not changed substantially with the exception of somewhat of an increase in births before age 20, from 19% for the oldest cohort to 26% for 20-24 year-olds. Even though childbearing starts relatively early for most women, few women begin childbearing at very young ages (i.e., before about age 18), with births before age 16 almost nonexistent. Once again it is possible to see the concentration of childbearing beginning in the early twenties: about one-quarter reported a birth by age 20, but about three-quarters by age 25. Table 4.9 displays the percentage distributions of numbers of pregnancies according to age at the time of interview. The general conclusions are similar to those seen with regard to live births. However, especially among the older cohorts, there are substantial numbers of women who have had a large number of pregnancies (about one-fourth of 40-44 year-olds had five or more pregnancies), a result of the very high abortion rates in effect, especially in previous decades. Pregnancy Outcomes Forty-five percent of pregnancies to respondents that ended since January 1994 resulted in a live birth and 7% reportedly ended in miscarriage or stillbirth (Table 4.10 and Figure 4.3). The remainder, just under half of pregnancies, were terminated by induced abortion. The ratio of conventional surgical abortions to miniabortions was slightly higher than 3:2 for Ukraine as a whole (with under 1% of pregnancies ending in abortions that were self-induced or otherwise performed without professional medical or surgical intervention). The proportion of pregnancies resulting in a live birth declined steadily with increasing age, from 59% for 15-25 year-olds to 21% among 35-44 year-olds. This again supports the contention that most couples still have their children shortly after marriage, while they are still young. The West has a much higher proportion of live births (65%) than elsewhere (37%-45%). Pregnancies to women with no previous live births were the most likely to result in a live birth (76%). Only 15% of pregnancies to women with two previously born children resulted in a live birth however, demonstrating the strong desire among most women to have no more than two children. The small group of women with three or more children were much more likely to have pregnancies end in a live birth. Rural pregnancies were more likely than urban pregnancies to result in a live birth. Differences in birth outcomes by educational attainment were small. Planning status of pregnancies Table 4.11 shows that fewer than half of pregnancies ending in 1996 or later (44%) were said by 34 respondents to have been planned at the time they occurred (i.e., the woman wanted to become pregnant at that time). Fifty-four percent were said to unplanned: 17% were mistimed (i.e., she wanted to wait longer to become pregnant) and 38% were unwanted (she wanted no more children at the time she became pregnant). Given such high levels of unintended pregnancy and widespread acceptance and availability of induced abortion, it is not surprising that there are high rates of abortion in Ukraine. Since women/couples in Ukraine still tend to have a child or children shortly after marriage, it is not surprising that the likelihood of a pregnancy being planned fell sharply with increasing age, from 55% for 15-24 year-olds to only 20% for 35-44 year-olds (Figure 4.4). Likewise, pregnancies were more likely to be unintended as the number of living children rose to two. Among the relatively small number of women with three or more children the likelihood of the pregnancy being planned rose again. The proportion of pregnancies categorized as unwanted rose from 19% to 73%. Pregnancies were the most likely to be planned in the West (56%) and least likely in the East (36%). They were also more likely to be planned in rural areas than urban areas. There was little difference according to respondent’s education. Of course, pregnancies ending in live birth were the most likely to be planned (80%) and those ending in abortion were the least likely (18%). The most important point revealed in Table 4.12 (outcome according to planning status of the pregnancy) is that pregnancies classified as unwanted rarely (5% of the time) resulted in a live birth. In 92% of unwanted pregnancies, the pregnancy was terminated by abortion. In urban areas, only 3% of unwanted pregnancies resulted in a live birth. Mistimed pregnancies were much more likely to end in a live birth, 35% of the time. Planned pregnancies ended with a live birth 84% of the time, with 11% ending in miscarriage or stillbirth and 5% terminated by induced abortion. Pregnancy Intentions Respondents who reported that they were able to become pregnant were asked how many more children they would like to have. Overall, almost two-thirds (66%) of survey respondents said they wanted no more children (Table 4.13). As might have been expected, the proportions who wanted no more children increased sharply with the number of living children, from 11% of women with no children to 91% of women with two children and 87% of those with three or more children (Figure 4.5). Even among women with only one child, about one-half said they wanted no more, showing that one-child families have become a very acceptable option in Ukrainian society. Very few women who already had children reported that they wanted to have more than two children altogether. Among women with one living child, only 4% said they wanted at least two more. Among those with two living children, fewer than 1 % said they wanted any more. Only those without children yet were somewhat likely to report wanting at least three children (17%). In spite of the substantial differences noted in fertility levels between urban and rural areas of Ukraine, urban-rural differences in fertility preferences were very small. Table 4.14 displays numbers of children planned at the time of interview compared with the number planned at the time respondents desired at the time of their first marriage. It is worth noting that the category of women wanting no children when they married is not included because there were only 10 such women, a dramatic demonstration of the persistence of a pronatalist attitude in Ukraine, 35 despite the extremely low level of childbearing in effect in recent years. 36 37 38 39 40 41 Table 4.1 Percentage of respondents who have had one or more live births and mean number of live births, by age at interview, by residence 1999 Ukraine Reproductive Health Survey Age of respondent Percent with any live births Mean number of live births Number of women All women 15-19 5.6 0.1 1,100 20-24 50.3 0.6 1,182 25-29 84.0 1.2 1,227 30-34 91.4 1.5 1,195 35-39 93.1 1.7 1,246 40-44 94.3 1.8 1,178 Total 69.1 1.2 7,128 Urban women 15-19 5.1 0.1 861 20-24 45.7 0.5 919 25-29 81.8 1.1 941 30-34 91.2 1.4 908 35-39 92.4 1.6 990 40-44 93.4 1.7 925 Total 68.1 1.1 5,544 Rural women 15-19 7.2 0.1 239 20-24 62.9 0.7 263 25-29 89.2 1.4 286 30-34 91.8 1.7 287 35-39 95.2 1.9 256 40-44 96.8 2.0 253 Total 74.7 1.2 1,584 42 Table 4.2 Percentage of respondents who have had one or more pregnancies and mean number of pregnancies, by age at interview, by residence 1999 Ukraine Reproductive Health Survey Age of respondent Percent with any pregnancies Mean number of pregnancies Number of women All women 15-19 9.0 0.1 1,100 20-24 61.1 1.0 1,182 25-29 90.1 2.1 1,227 30-34 95.1 2.8 1,195 35-39 96.4 3.2 1,246 40-44 96.5 3.6 1,178 Total 74.8 2.1 7,128 Urban women 15-19 8.5 0.1 861 20-24 57.5 0.9 919 25-29 89.1 2.0 941 30-34 85.5 2.8 908 35-39 96.0 3.1 990 40-44 96.1 3.6 925 Total 73.6 2.1 5,544 Rural women 15-19 9.8 0.1 239 20-24 70.8 1.2 263 25-29 92.5 2.3 286 30-34 95.4 2.9 287 35-39 97.6 3.3 256 40-44 97.6 3.6 253 Total 78.1 2.2 1,584 43 Table 4.3 Age-specific and total fertility rates*, by residence, region, and education 1999 Ukraine Reproductive Health Survey Residence Region Education Age of respondent Total Urban Rural North Central East South West Low Med. High 15-19 .049 .044 .064 .036 .061 .043 .045 .067 .034 .057 .032 20-24 .115 .098 .158 .131 .147 .091 .102 .138 .132 .125 .077 25-29 .066 .067 .065 .073 .056 .046 .068 .091 .069 .062 .078 30-34 .036 .030 .052 .038 .023 .021 .050 .054 .042 .038 .030 35-39 .014 .012 .021 .022 .005 .009 .009 .028 .045 .014 .011 40-44 .004 .002 .008 .000 .000 .003 .002 .013 .000 .005 .001 Total Fertility Rate 1.42 1.27 1.83 1.50 1.46 1.06 1.38 1.96 1.61 1.51 1.14 *All rates are annual rates, based on reports for the two-year period preceding the date of interview. 44 Table 4.4 Age-specific and total pregnancy rates*, by residence, region, and education 1999 Ukraine Reproductive Health Survey Residence Region Education Age of respondent Total Urban Rural North Central East South West Low Med. High 15-19 .059 .052 .078 .046 .076 .052 .056 .075 .053 .064 .042 20-24 .203 .181 .260 .225 .279 .174 .213 .187 .209 .228 .128 25-29 .165 .170 .153 .183 .153 .151 .182 .166 .205 .161 .165 30-34 .111 .113 .104 .116 .103 .104 .139 .099 .070 .122 .084 35-39 .050 .052 .045 .065 .023 .051 .061 .043 .149 .053 .031 40-44 .025 .024 .027 .018 .006 .023 .051 .026 .009 .023 .037 Total Pregnancy Rate 3.06 2.97 3.33 3.26 3.20 2.77 3.51 2.97 3.47 3.25 2.43 *All rates are annual rates, based on reports for the two-year period preceding the date of interview. 45 Table 4.5 Percent of women ever in union with any live births and percent ever pregnant, by years since first union and residence 1999 Ukraine Reproductive Health Survey Years since first union Percent ever pregnant Percent with any live births Number of women All women 0-4 82.4 68.7 1,051 5-9 95.7 91.6 1,268 10-14 98.2 95.7 1,220 15-19 97.6 96.2 1,117 20+ 99.2 98.7 921 Total 94.7 90.2 5,577 Urban 0-4 81.2 66.3 815 5-9 95.7 91.1 961 10-14 98.1 95.5 935 15-19 97.3 95.9 861 20+ 99.2 98.2 724 Total 94.3 89.4 4,296 Rural 0-4 85.8 74.8 236 5-9 95.7 92.6 307 10-14 98.6 96.4 285 15-19 98.4 96.8 256 20+ 99.7 99.7 197 Total 95.7 92.2 1,281 46 Table 4.6 Percentage distribution of number of live births, by current age and residence 1999 Ukraine Reproductive Health Survey Current age of respondent Number of live births 15-19 20-24 25-29 30-34 35-39 40-44 Total Total 0 94.5 50.2 16.5 8.9 7.1 5.5 29.4 1 5.5 43.2 57.1 44.9 31.2 26.2 35.1 2 0.0 6.0 22.9 39.2 53.1 56.7 30.2 3 0.0 0.5 3.0 5.6 6.6 9.6 4.3 4+ 0.0 0.1 0.6 1.4 2.1 1.9 1.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,100 1,182 1,227 1,195 1,246 1,178 7,128 Urban 0 94.9 54.4 17.7 8.4 7.4 6.1 31.6 1 5.1 40.8 59.8 47.4 32.5 26.0 34.9 2 0.0 4.4 20.4 38.9 53.5 58.7 29.5 3 0.0 0.2 1.8 4.0 5.3 8.7 3.4 4+ 0.0 0.2 0.3 1.3 1.4 0.5 0.6 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 861 919 941 908 990 925 5,544 Rural 0 93.3 37.1 10.4 8.9 4.8 2.8 25.4 1 6.7 50.8 43.5 29.7 20.1 18.3 28.5 2 0.0 10.8 37.5 47.7 60.3 55.9 35.8 3 0.0 1.3 7.3 10.7 9.9 15.8 7.6 4+ 0.0 0.0 1.2 2.9 4.9 7.2 2.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 239 263 286 287 256 253 1,584 47 Table 4.7 Percentage distribution of number of live births, by number of years since first union, by residence 1999 Ukraine Reproductive Health Survey Number of years since first union Number of live births 0-4 5-9 10-14 15-19 20+ Total All women 0 31.3 8.4 4.3 3.9 1.9 9.8 1 62.6 57.2 42.6 24.3 20.1 42.1 2 5.7 30.3 44.7 60.8 60.2 40.0 3+ 0.4 4.1 8.5 11.1 17.8 8.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,051 1,268 1,220 1,117 921 5,577 Urban 0 33.7 8.9 4.5 4.1 2.5 10.6 1 61.9 62.3 48.9 27.2 21.8 45.2 2 4.3 26.6 40.2 60.4 61.9 38.3 3+ 0.2 2.2 6.4 8.4 13.8 5.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 815 961 935 861 724 4,296 Rural 0 25.2 7.4 3.6 3.2 0.5 7.9 1 64.6 45.1 27.5 16.9 15.6 34.4 2 9.3 38.9 55.5 61.7 55.3 44.4 3+ 0.9 8.6 13.4 18.2 28.6 13.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 236 307 285 256 197 1,281 48 Table 4.8 Percentage of women who had a live birth before selected ages, by current age 1999 Ukraine Reproductive Health Survey Current age of respondent Live birth before: 15-19 20-24 25-29 30-34 35-39 40-44 15-44* Age 16 0.1 0.0 0.1 0.0 0.2 0.1 0.1 Age 18 4.2 5.5 5.3 2.8 3.7 2.9 4.0 Age 20 -- 25.7 26.0 22.8 20.9 19.0 22.9 Age 25 -- -- 76.4 77.9 74.0 73.8 75.5 Age 30 -- -- -- 89.7 89.2 88.1 89.0 Median age at first birth NA NA 21.8 21.8 22.0 22.1 -- Number of women 1100 1182 1227 1194 1246 1176 7,125** *Table only includes women who have reached the age in question. **Data missing for 3 women. 49 Table 4.9 Percentage distribution of number of pregnancies, by current age, by residence 1999 Ukraine Reproductive Health Survey Current age of respondent Number of pregnancies 15-19 20-24 25-29 30-34 35-39 40-44 Total All women 0 90.9 38.6 9.7 4.9 3.6 3.3 25.1 1 7.5 34.8 28.6 15.5 10.6 8.0 17.4 2 1.4 18.2 29.5 28.9 23.8 20.2 20.4 3 0.1 5.8 18.7 22.6 26.1 24.5 16.4 4 0.0 1.5 7.8 14.6 15.9 18.9 9.8 5 0.0 0.6 2.9 6.8 10.8 8.2 4.9 6 0.0 0.2 1.9 3.0 3.7 6.0 2.5 7 0.0 0.3 0.2 1.7 1.9 4.7 1.5 8+ 0.0 0.0 0.7 1.9 3.5 6.2 2.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,100 1,182 1,227 1,195 1,246 1,178 7,128 Urban 0 91.2 42.1 10.6 5.0 4.0 3.6 26.3 1 7.3 33.4 31.1 17.0 11.4 8.9 18.0 2 1.3 16.6 28.5 28.4 23.9 18.3 19.4 3 0.2 5.4 17.0 22.9 25.9 24.2 15.9 4 0.0 1.3 7.3 13.1 15.1 19.6 9.4 5 0.0 0.8 2.7 6.7 10.3 7.9 4.8 6 0.0 0.3 1.8 2.9 3.8 6.2 2.5 7 0.0 0.2 0.2 1.5 2.3 4.6 1.5 8+ 0.0 0.0 0.7 2.3 3.1 6.7 2.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 861 919 941 908 990 925 5,544 Rural 0 90.3 28.8 7.5 4.7 2.4 2.4 21.9 1 8.1 38.7 22.3 12.2 8.3 5.5 15.9 2 1.6 22.8 31.8 30.4 23.4 25.1 22.9 3 0.0 7.0 22.8 21.7 26.7 25.4 17.5 4 0.0 2.1 8.9 17.9 18.4 16.9 10.9 5 0.0 0.2 3.7 6.7 12.3 8.9 5.3 6 0.0 0.0 2.3 3.3 3.4 5.7 2.5 7 0.0 0.4 0.0 2.2 0.5 5.2 1.4 8+ 0.0 0.0 0.7 1.1 4.6 4.8 1.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 239 263 286 287 256 253 1,584 50 Table 4.10 Percentage distributions of outcomes of pregnancies ending since January 1994, by selected characteristics 1999 Ukraine Reproductive Health Survey Pregnancy outcome Live birth Stillbirth Miscarriage Induced abortion Total Characteristic Total Conventional Miniabortion Self-induced Pregs. Total 45.3 0.4 7.1 47.2 28.7 17.8 0.7 100.0 2,802 Age 15-24 59.3 0.5 7.5 32.7 20.5 11.0 1.2 100.0 913 25-34 43.9 0.3 6.9 48.8 29.1 19.2 0.5 100.0 1,443 35-44 20.7 0.3 6.8 72.2 44.4 27.5 0.3 100.0 446 Region North 44.9 0.3 5.3 49.5 22.5 24.9 2.1 100.0 336 Central 44.4 1.2 7.0 47.3 25.1 21.8 0.4 100.0 243 East 36.7 0.5 6.8 56.0 38.5 17.1 0.4 100.0 1,029 South 39.8 0.1 8.2 52.0 33.5 17.8 0.7 100.0 754 West 65.3 0.0 8.1 26.6 14.8 11.6 0.2 100.0 440 Residence Urban 41.5 0.5 6.4 51.7 30.5 20.4 0.8 100.0 2,162 Rural 54.8 0.2 8.9 36.1 24.2 11.4 0.5 100.0 640 Living children* 0 75.9 0.7 8.3 15.1 8.9 5.1 1.1 100.0 985 1 35.0 0.2 7.8 57.0 34.7 21.7 0.6 100.0 1,126 2 14.8 0.2 3.5 81.5 47.4 33.8 0.3 100.0 561 3+ 42.9 0.0 8.2 48.9 40.3 8.6 0.0 100.0 130 Education < Comp. secondary 47.8 1.0 10.5 40.7 26.9 13.3 0.5 100.0 247 Comp. secondary 45.7 0.3 6.9 47.2 29.6 16.8 0.8 100.0 2,019 > Comp. secondary 42.8 0.4 6.3 50.6 26.3 23.8 0.5 100.0 536 *Living children at the time of the pregnancy 51 Table 4.11 Percentage distribution of planning status of pregnancies ending since January 1994, by selected characteristics 1999 Ukraine Reproductive Health Survey Planning status of pregnancy Characteristic Planned Mistimed Unwanted Unsure Total Number of pregs. Total 43.6 16.6 37.5 2.3 100.0 2,802 Age 15-24 55.4 23.6 18.8 2.2 100.0 913 25-34 43.3 15.8 38.5 2.5 100.0 1,443 35-44 19.9 5.0 72.9 2.2 100.0 446 Region North 42.3 16.9 39.4 1.5 100.0 336 Central 46.5 13.6 38.7 1.2 100.0 243 East 36.9 17.5 43.2 2.4 100.0 1,029 South 41.2 19.8 36.6 2.4 100.0 754 West 56.2 13.7 26.9 3.4 100.0 440 Residence Urban 39.7 17.8 39.9 2.5 100.0 2,162 Rural 53.2 13.6 31.4 1.8 100.0 640 Living children* 0 74.3 19.3 3.6 2.8 100.0 985 1 34.6 22.6 40.6 2.1 100.0 1,126 2 12.2 3.8 82.5 1.6 100.0 561 3+ 32.8 2.8 60.6 3.8 100.0 130 Education < Comp. secondary 45.7 18.9 32.3 3.1 100.0 247 Comp. secondary 43.3 16.1 38.3 2.3 100.0 2,019 > Comp. secondary 43.5 17.5 36.9 2.2 100.0 536 Pregnancy outcomes Live birth 80.2 12.7 4.4 2.7 100.0 1,251 Stillbirth/miscarriage 75.8 12.3 10.3 1.6 100.0 204 Abortions 18.0 21.1 59.7 1.2 100.0 1,347 * Living children at the time that pregnancy occurred 52 Table 4.12 Percentage distribution of outcomes of pregnancies ending since January 1994, by planning status and by residence 1999 Ukraine Reproductive Health Survey Outcome of pregnancy Planning status / Residence Live birth Stillbirth / Miscarriage Induced abortion Total Number of pregnancies Total Planned 83.5 11.5 5.0 100.0 1,236 Mistimed 34.6 6.0 59.5 100.0 459 Unwanted 5.3 3.2 91.5 100.0 1,045 Unsure 52.7 9.9 37.4 100.0 62 Urban Planned 83.6 11.1 5.2 100.0 893 Mistimed 32.8 5.7 61.4 100.0 373 Unwanted 3.1 3.0 93.9 100.0 846 Unsure 50.0 7.7 42.3 100.0 50 Rural Planned 83.2 12.2 4.5 100.0 343 Mistimed 40.4 6.5 53.1 100.0 86 Unwanted 12.5 4.1 83.3 100.0 199 Unsure * * * 100.0 12 *Fewer than 25 pregnancies in category 53 Table 4.13 Number of additional children desired, by number of living children, by residence among fecund women currently in union 1996 Ukraine Reproductive Health Survey Additional children desired Living children 0 1 2 3+ Unsure Total Number of women Total 0 11.1 32.4 30.6 16.6 9.4 100.0 459 1 49.3 28.9 1.6 2.2 18.1 100.0 1,952 2 92.1 1.8 0.1 0.7 5.3 100.0 1,799 3+ 86.8 1.9 0.0 5.5 5.8 100.0 300 Total 66.3 15.9 3.6 3.2 11.0 100.0 4,510 Urban 0 11.9 33.3 29.5 15.9 9.4 100.0 373 1 50.7 27.9 1.4 1.9 18.1 100.0 1,567 2 92.1 2.1 0.1 0.7 4.9 100.0 1,305 3+ 90.6 0.2 0.0 3.9 5.2 100.0 172 Total 65.5 16.7 3.7 2.9 11.2 100.0 3,417 Rural 0 8.6 29.6 33.8 18.7 9.3 100.0 86 1 44.9 31.6 2.2 3.3 18.0 100.0 385 2 92.2 1.0 0.2 0.6 5.9 100.0 494 3+ 83.0 3.6 0.0 7.1 6.3 100.0 128 Total 68.4 14.1 3.4 3.7 10.4 100.0 1,093 NOTE: Currently pregnant women are considered to have one more living child than they actually do. 54 Table 4.14 Percentage distribution of total number of children desired, by number desired at time of first marriage, by residence, fecund women currently in union 1996 Ukraine Reproductive Health Survey Total number of children currently desired, including currently living children Number of children desired at time of first union* 0 1 2 3+ Unsure Total Number of women Total 1 3.1 62.9 29.8 2.3 1.9 100.0 853 2 1.1 21.9 69.7 5.9 1.4 100.0 2,189 3+ 0.3 16.1 51.1 29.3 3.2 100.0 268 Unsure 2.9 29.3 47.9 13.4 6.5 100.0 1,122 Urban 1 3.4 65.5 27.2 1.7 2.2 100.0 672 2 1.5 23.6 68.7 5.0 1.2 100.0 1,632 3+ 0.4 17.3 51.6 28.7 2.0 100.0 195 Unsure 2.8 34.1 48.7 9.0 5.4 100.0 857 Rural 1 2.2 55.9 36.8 3.9 1.1 100.0 181 2 0.0 18.1 72.0 8.2 1.7 100.0 557 3+ 0.0 13.7 49.9 30.7 5.8 100.0 73 Unsure 3.5 18.2 46.0 23.5 8.8 100.0 265 *Only ten respondents desired to have no children when married. These respondents are not included in the table. 55 CHAPTER V INDUCED ABORTION The incidence of induced abortion in Ukraine, as in most of the former Soviet republics, has been very high in recent decades (Popov, 1991; Blayo, 1993). However, official statistics have revealed that rates have been declining in recent years. Figure 5.1 shows the trend in induced abortion rates in recent years in Ukraine, according to official Ministry of Health statistics. (These figures have been adjusted to eliminate miscarriages and stillbirths, which are usually combined with induced abortions when official statistics are compiled.) It is readily seen that the trend in abortion rates has been steadily downward since at least the middle of the 1980s. Between 1990 and 1998, the official rate of abortion incidence fell by over 50%, from 77 abortions to about 36 abortions per 1,000 women of childbearing age. Figure 5.2 shows abortion rates based on recent survey data for several countries in eastern Europe and the former Soviet Union. Abortion rates in these countries have been among the highest in the world for several decades. Although the rate for Ukraine is considerably lower than in some other countries in the region, it is still quite high by international standards. As we will see below, abortion remains perhaps the most important means of birth prevention in Ukraine, despite the recent decline in incidence. Proportions of women with any abortions By any measure, induced abortion is a common procedure in Ukraine. The simplest way to look at the incidence of abortion is to examine the proportion of women who undergo the procedure. Overall, 43% of respondents had ever had an induced abortion of any type (Table 5.1). Twenty percent of respondents had had more than one abortion. These figures tend to understate the incidence of abortion, however, since many younger women have not yet been at risk or have been at risk for a relatively short time for unintended pregnancy or, therefore, abortion. Among women in the oldest cohorts (ages 35-39 and 40-44), about two-thirds had had at least one abortion and about one-third had had at least two abortions during their lifetime (Table 5.1). Women between 40 and 44 years of age averaged 1.6 abortions. However, since most of the abortions to women in the oldest cohorts did not take place recently, these figures may not be good indicators of recent abortion activity. Few females under the age of 20 reported having had any induced abortions. Percentages of women with abortions, as well as mean numbers of abortions, were consistently higher in urban areas than in rural areas. Table 5.2 shows that the percentages of women with any abortions differ relatively little between the North, Central, South, and East regions of the country, but the percentage is far lower in the West, the part of the country that is the most ethnically Ukrainian and the most rural; only 28% of women reported any abortions (compared to 43% nationally) and 9% reported having more than one abortion (compared to 20% nationally). Women with the least education were less likely than other women to have had abortions. Abortions were the least common among ethnically Ukrainian women who spoke primarily Ukrainian and were highest among women describing themselves as ethnically Russian. Although the largest numbers of women reported having had only zero or one abortions, many respondents reported having multiple abortions (Table 5.3). Three percent of all women and 8% of 40-44 year-olds listed 5 or more lifetime abortions. 56 Current incidence of abortion The total induced abortion rate (i.e., the mean number of lifetime abortions per woman based on current age-specific abortion rates) for Ukraine as a whole was about 1.6 abortions per woman for the two years before interview (Table 5.4). The abortion rate (i.e., the probability that a woman reported having an abortion during the previous 12 months) was .054, meaning that just over one of every 20 women have an abortion during a one-year period. The abortion ratio (i.e., the ratio of induced abortions to live births) was 1.10, indicating about equal numbers of abortions and live births. All of these figures were substantially higher in urban areas than in rural areas. As with fertility, age-specific abortion rates were highest among women in their twenties (.091), followed by women 30-34 years of age (.069) (Figure 5.2). It should be noted that the induced abortion rate according to the survey (.054) was about 30 percent higher than the official rate published by the Ministry of Health (about .039 for the same period). This is an indication that the official statistics miss a significant proportion of abortions that are occurring, possibly because many abortions are being performed by providers who are not reporting them for any number of reasons. It also is an indication that reporting of abortion experience among URHS respondents tended to be relatively complete. If, in fact, the official rates of abortion are somewhat underreported, it makes it difficult to draw conclusions on the actual trends in abortion rates in recent years. Table 5.5 shows abortion indicators according to region and respondents’ educational attainment. Abortion levels were slightly higher in the South then elsewhere (TAR=2.05, compared to 1.57 nationally) and much lower in the West, where the rate was only 0.77 abortions per woman. Abortion rates tended to be slightly lower among the best educated women than among other Ukrainian women. Table 5.6 displays total pregnancy, fertility, and abortion rates according to selected characteristics of respondents. During the two years prior to interview, the total pregnancy rate was barely above three pregnancies per woman, with slightly higher rates of abortions than live births. The total abortion rate in Donetsk Oblast, one of the UWRHI project sites, was slightly above the national rate. The rate in Odessa was about the same as the national rate. Types of abortions, complications, and cost Until fairly recently, almost all induced abortions in Ukraine consisted of procedures that would be considered “conventional abortions” in the West. However, many abortions now performed are what are commonly referred to as “miniabortions”. This procedure, also sometimes referred to as “menstrual regulation”, is performed using vacuum aspiration early in pregnancy. It tends to be a simpler, more easily performed procedure than those employed for conventional abortions. Of all abortions undergone by survey respondents since the beginning of 1994, 61% were reported to be conventional abortions and 38% were miniabortions (Table 5.7). An additional 1% were reported as self-induced or otherwise performed outside of a medical setting. The distribution of types of abortion seems to be stable, with similar distributions in 1994-1996 and 1997-1999. Miniabortions were most common among 25-34 year-old women (39%), in the North region (54%), in urban areas (39%), and among the best educated women (49%). They were least common relative to conventional procedures in the East region (30%). 57 Women were asked about complications and health problems associated with each of their recent induced abortions (including miniabortions) since the beginning of 1994, both “soon after” and at least six months after the procedure. Fourteen percent of abortions performed since January 1994 resulted in what women described as “complications requiring medical treatment” immediately or soon after the procedure (Table 5.8, left-hand panel). As might have been expected, conventional abortions were about 50% more likely than miniabortions to result in short-term complications (16% vs. 11%). Although the differences were not statistically significant, complication rates were slightly higher among urban women than rural women for each type of abortion. When interpreting these data, it should be kept in mind that what constitutes a “complication” is subjectively defined by the respondent and not by medical personnel. Among those women experiencing complications, 37% (5% of all women undergoing abortions) reported rehospitalization or extended hospitalization as a result, with a higher likelihood of hospitalization following conventional abortions (39% vs. 32%) (Table 5.8, center panel). Six percent of abortions were reported to have resulted in long-term problems, with the likelihood of problems twice as high from conventional abortions as from miniabortions (Table 5.8, right-hand panel). There were no notable differences in long-term complication rates between urban and rural areas. When asked why they decided to have an abortion, the overwhelming majority of women gave as their primary reason that they wanted no more children (60%) or gave what were considered to be “social/economic reasons”, i.e., such reasons as inadequate resources or inadequate housing (25%) (Table 5.9). Smaller numbers of abortions were attributed to such factors as: continuing the pregnancy presented a health risk for the woman (4%), not being married (4%), the woman’s partner did not want a child (2%), and a risk of birth defects (2%). The percentage wanting no more children, not surprisingly, rose with age. It was also the lowest in the South region. Social/economic reasons were most often given by the least well educated women, whom it is assumed could least afford larger families. Thirteen percent of abortions occurring in 1997 or later were free of charge to women (Table 5.10). An additional 14% were paid for with goods or services, rather than with money. Thus, about 7 of every 10 abortions were paid for with money. The vast majority of these (63% of all abortions) were reported to have cost the equivalent of less than US $30. Only 4% cost more than US $50. There were noteworthy differences in payment according to women’s residence. Rural women were more likely than urban women not to pay for their abortions and tended to pay less when they were not free. Abortions in the Central and East regions were more likely than in other regions to be free. As education rose, so did the amount women paid for abortions. Thirteen percent of women with abortions since January 1994 reported that they received no anesthesia in association with their most recent abortion (Table 5.11). The likelihood of receiving anesthesia appears to have remained unchanged in recent years. Women having miniabortions were about twice as likely as those having conventional abortions not to have had anesthesia. Older women and urban women were less likely than others not to receive anesthesia. Women in the East region were the most likely to be anesthetized (91%), while women in the Central region were the least likely (77%). 58 59 60 Table 5.1 Percentage of respondents who have had any induced abortions or two or more induced abortions and mean number of induced abortions, by age at interview, by residence 1999 Ukraine Reproductive Health Survey Age of woman Percent with 1 or more abortions Percent with 2 or more abortions Mean number of abortions Number of women All women 15-19 1.8 0.2 0.0 1,100 20-24 22.8 5.5 0.3 1,182 25-29 44.3 16.7 0.7 1,227 30-34 57.6 27.8 1.1 1,195 35-39 65.5 32.0 1.3 1,246 40-44 67.2 37.2 1.6 1,178 Total 43.3 20.0 0.8 7,128 Urban women 15-19 2.2 0.3 0.0 861 20-24 23.7 6.0 0.3 919 25-29 46.9 18.3 0.8 941 30-34 59.6 29.5 1.2 908 35-39 67.3 33.7 1.4 990 40-44 70.7 41.0 1.7 925 Total 45.1 21.5 0.8 5,544 Rural women 15-19 0.8 0.0 0.0 239 20-24 20.4 4.2 0.3 263 25-29 37.9 12.7 0.6 286 30-34 52.8 24.0 0.9 287 35-39 60.1 27.0 1.2 256 40-44 57.6 26.7 1.2 253 Total 38.7 15.9 0.6 1,584 61 Table 5.2 Percentage of respondents who have had any induced abortions or two or more induced abortions and mean number of induced abortions, by selected characteristics 1999 Ukraine Reproductive Health Survey Age of woman Percent with 1 or more abortions Percent with 2 or more abortions Mean number of abortions Number of women All women 43.3 20.0 0.8 7,128 Residence Urban 45.1 21.5 0.8 5,544 Rural 38.7 15.9 0.6 1,584 Region North 44.0 16.8 0.8 858 Central 48.8 22.9 0.9 617 East 47.6 23.3 1.0 2,669 South 49.2 27.0 1.1 1,824 West 27.7 9.2 0.4 1,160 Education <Complete secondary 20.8 10.8 0.4 778 Complete Secondary 46.7 22.1 0.9 4,828 >Complete secondary 44.6 18.0 0.8 1,522 Language at home/Ethnicity Ukrainian.-speaking/Ukrainian 38.4 15.2 0.7 2,157 Russian-speaking/Ukrainian 41.9 19.5 0.8 2,071 Other, Mixed/Ukrainian 46.5 23.2 1.0 839 Russian nationality 51.9 27.3 1.2 1,688 Other nationality 43.9 20.2 0.9 373 62 Table 5.3 Percentage distribution of number of abortions, by current age, by residence 1999 Ukraine Reproductive Health Survey Current age of respondent Number of abortions 15-19 20-24 25-29 30-34 35-39 40-44 Total All Women 0 98.2 77.2 55.8 42.5 34.3 32.5 56.6 1 1.7 17.3 27.6 29.8 33.7 30.1 23.4 2 0.2 4.1 10.5 15.1 16.8 17.2 10.7 3 0.0 0.9 4.1 6.9 7.4 7.8 4.5 4 0.0 0.4 1.1 3.4 3.5 4.9 2.2 5-9 0.0 0.1 0.8 2.3 4.0 6.9 2.4 10+ 0.0 0.0 0.3 0.2 0.4 0.8 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 1,100 1,182 1,227 1,195 1,246 1,178 7,128 Urban 0 97.8 76.3 53.2 40.2 32.5 28.8 54.8 1 1.9 17.7 28.5 30.1 33.8 29.7 23.6 2 0.3 4.2 11.9 15.1 17.6 18.4 11.3 3 0.0 1.0 3.9 7.9 7.7 8.7 4.9 4 0.0 0.6 1.4 3.4 3.8 6.1 2.5 5-9 0.0 0.2 0.9 2.8 4.4 7.5 2.6 10+ 0.0 0.0 0.2 0.2 0.3 0.8 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 861 919 941 908 990 925 5,544 Rural 0 99.2 79.7 62.1 47.2 39.5 42.4 61.3 1 0.8 16.2 25.2 28.9 33.5 30.9 22.8 2 0.0 3.6 7.0 14.8 14.5 13.8 9.1 3 0.0 0.6 4.5 4.9 6.5 5.2 3.7 4 0.0 0.0 0.5 3.2 2.7 1.7 1.4 5-9 0.0 0.0 0.4 1.1 2.9 5.2 1.6 10+ 0.0 0.0 0.4 0.0 0.4 0.8 0.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of women 239 263 286 287 256 253 1,584 63 Table 5.4 Age-specific abortion rates and other measures of induced abortion*, by residence 1999 Ukraine Reproductive Health Survey Age of respondent Total Urban Rural 15-19 .013 .014 .012 20-24 .091 .090 .092 25-29 .091 .105 .070 30-34 .069 .080 .049 35-39 .033 .039 .019 40-44 .018 .020 .016 Total Abortion Rate 1.57 1.74 1.29 Abortion Rate** .054 .058 .045 Abortion Ratio*** 1.10 1.42 0.72 *All rates are annual rates, based on reports for the two-year period preceding the date of interview. **Proportion of women 15-44 years of age having induced abortions in one year. ***Ratio of induced abortions to live births 64 Table 5.5 Selected measures of induced abortion*, by region and education 1999 Ukraine Reproductive Health Survey Region/ Education Total Abortion Rate Abortion Rate** Abortion Ratio*** All women 1.57 .054 1.10 Region North 1.76 .060 1.16 Central 1.60 .054 1.12 East 1.74 .058 1.63 South 2.05 .070 1.45 West 0.77 .027 0.39 Education <Comp secondary 1.82 .052 0.91 Comp. Secondary 1.62 .055 1.09 >Comp secondary 1.40 .048 1.22 *All rates are annual rates, based on reports for the two-year period preceding the date of interview. **Proportion of women 15-44 years of age having induced abortions in one year. ***Ratio of induced abortions to live births 65 Table 5.6 Total fertility, pregnancy, and induced abortion rates*, by selected characteristics 1999 Ukraine Reproductive Health Survey Total Rate of: Characteristic Pregnancy Fertility Induced Abortion All women 3.06 1.42 1.57 Residence Urban 2.97 1.27 1.74 Rural 3.33 1.83 1.29 Region North 3.26 1.50 1.76 Central 3.20 1.46 1.60 East 2.77 1.06 1.74 South 3.51 1.38 2.05 West 2.97 1.96 0.77 Education <Comp secondary 3.47 1.61 1.82 Comp. secondary 3.25 1.51 1.62 >Comp secondary 2.43 1.14 1.40 Oversampled oblasts Donetsk (East) 2.66 1.06 1.71 Odessa (South) 2.88 1.30 1.59 *For the period 2 years prior to interview. 66 Table 5.7 Percentage distribution of types of abortions, by selected characteristics, all abortions since January 1994 1999 Ukraine Reproductive Health Survey Type of abortion Number of Characteristic Conventional Miniabortion Self-induced* Total abortions Total 61.1 37.8 1.1 100.0 2,032 Year 1994- 1996 62.9 36.2 0.8 100.0 1,054 1997 -1999 59.1 39.4 1.5 100.0 978 Age 15-24 66.9 31.4 1.7 100.0 710 25-34 60.1 39.1 0.9 100.0 1,005 35-44 63.9 35.8 0.3 100.0 317 Region North 43.2 53.9 2.9 100.0 235 Central 56.9 42.5 0.6 100.0 181 East 69.6 29.8 0.6 100.0 855 South 61.5 37.4 1.1 100.0 583 West 58.2 40.8 1.1 100.0 178 Residence Urban 59.6 39.1 1.3 100.0 1,684 Rural 66.4 33.0 0.6 100.0 348 Education < Comp. secondary 69.2 29.0 1.8 100.0 149 Comp. secondary 63.3 35.6 1.1 100.0 1,474 > Comp. secondary 50.6 48.5 0.9 100.0 409 * Includes all abortions for which medical intervention was not used. 67 Table 5.8 Percentage of induced abortions since January 1994 resulting in complications requiring medical treatment, and percentage of complications resulting in hospitalization, by type of abortion, by residence 1999 Ukraine Reproductive Health Survey Type of abortion Complications requiring medical treatment “Soon after abortion” Received additional hospitalization after abortion Long-term health problems after abortion *** % N % N % N Total All abortions* 14.1 2,032 37.4 272 5.7 2,004 Regular abortions 15.9 1,285 38.6 194 7.1 1,281 Miniabortions 10.9 723 31.9 73 3.3 717 Urban All abortions* 14.8 1,684 39.1 230 5.9 1,679 Regular abortions 16.9 973 40.3 164 7.4 1,050 Miniabortions 11.4 554 34.4 62 3.4 607 Rural All abortions* 12.1 348 30.0 42 5.2 343 Regular abortions 13.0 312 31.3 30 6.3 231 Miniabortions 9.5 169 ** 11 3.0 110 NOTE: Abortions for which women did not remember whether they had complications have been excluded. *Total does not equal sum of regular abortions and miniabortions because it includes self-induced abortions as well. ** Fewer than 25 abortions with problems requiring medical treatment ***At least six months after abortion 68 Table 5.9 Percentage distribution of primary reason for abortion since January 1994, by age at abortion, region, residence, and education 1999 Ukraine Reproductive Health Survey Reason for abortion Characteristic Want no more children Social/ economic reason Pregnancy dangerous to woman Not married/ no partner Partner did not want child Risk of fetal defects Other Total Number of abortions Total 59.8 25.1 4.3 3.7 2.2 1.7 3.2 100.0 2,032 Age 15-24 50.6 28.9 3.4 7.9 2.9 1.7 4.6 100.0 710 25-34 62.0 24.4 4.8 1.8 2.2 1.9 2.9 100.0 1,005 35-44 73.2 18.5 4.6 0.4 0.8 1.1 1.4 100.0 317 Region North 62.9 16.6 5.9 5.1 3.4 1.3 4.7 100.0 235 Central 63.5 24.9 3.9 2.8 1.7 0.6 2.8 100.0 181 East 61.9 26.2 3.1 3.2 1.4 1.3 2.8 100.0 855 South 50.4 29.7 5.8 3.7 4.3 2.9 3.1 100.0 583 West 61.2 24.0 3.8 4.4 0.6 2.7 3.3 100.0 178 Residence Urban 59.9 25.2 4.1 4.0 2.3 1.5 2.9 100.0 1,684 Rural 59.3 24.5 5.0 2.4 1.9 2.4 4.5 100.0 348 Education < Comp. secondary 48.7 32.4 7.3 5.6 3.9 0.0 2.2 100.0 149 Comp. secondary 62.9 24.5 3.8 3.1 1.6 1.0 3.0 100.0 1,474 > Comp. secondary 52.8 24.4 4.8 4.9 3.9 4.9 4.4 100.0 409 69 Table 5.10 Percentage distribution of payment for most recent abortion since January 1997, by age at abortion, region, residence, and education 1999 Ukraine Reproductive Health Survey Payment Monetary Characteristic None < $30 $ 31-50 > $ 50 Non monetary, goods/other Total Number of abortions Total 13.1 62.5 7.0 3.6 13.8 100.0 789 Age 15-24 12.7 66.3 8.4 3.6 9.0 100.0 257 25-34 14.9 58.5 6.3 3.8 16.6 100.0 406 35-44 8.2 67.9 6.4 2.9 14.7 100.0 126 Region North 9.6 70.2 1.9 7.7 11.6 100.0 104 Central 23.2 62.3 1.5 0.0 13.0 100.0 69 East 16.9 58.3 6.4 1.7 16.7 100.0 329 South 6.5 63.2 14.6 6.1 9.6 100.0 221 West 7.1 64.3 8.6 2.9 17.1 100.0 66 Residence Urban 11.8 61.7 8.6 4.0 14.0 100.0 646 Rural 17.7 65.2 1.7 1.9 13.5 100.0 143 Education < Comp. secondary 28.3 60.6 3.8 1.8 5.6 100.0 63 Comp. secondary 12.9 61.7 6.4 3.3 15.7 100.0 556 > Comp. secondary 7.9 65.8 10.2 5.2 10.9 100.0 170 70 Table 5.11 Percentage of women who received local anesthesia for their most recent abortion since January 1994, by selected characteristics 1999 Ukraine Reproductive Health Survey Characteristic Anesthesia No anesthesia Don’t remember Total Abortions Total 86.1 13.2 0.7 100.0 1,430 Year 1994 86.2 12.8 0.9 100.0 200 1995 86.0 13.7 0.3 100.0 204 1996 87.7 11.8 0.5 100.0 238 1997 85.1 14.5 0.5 100.0 266 1998 84.8 14.0 1.2 100.0 323 1999 87.7 12.0 0.3 100.0 199 Type of abortion Regular abortions 90.4 8.7 0.9 100.0 805 Miniabortions 80.9 18.6 0.5 100.0 491 Age 15-24 85.2 14.6 0.3 100.0 492 25-34 85.7 13.4 0.9 100.0 710 35-44 89.3 9.9 0.8 100.0 228 Region North 85.9 13.5 0.6 100.0 178 Central 76.8 23.2 0.0 100.0 125 East 91.4 7.7 0.9 100.0 594 South 84.7 15.3 0.0 100.0 395 West 80.4 18.2 1.4 100.0 138 Residence Urban 88.3 11.2 0.5 100.0 1,164 Rural 78.9 19.9 1.2 100.0 266 Education < Comp. secondary 88.2 10.5 1.3 100.0 100 Comp. secondary 84.2 14.5 0.7 100.0 1,016 > Comp. secondary 89.6 10.0 0.4 100.0 314 71 CHAPTER VI INFERTILITY There can be little doubt that the typical desired family size has declined to very low levels and that abortion rates remain high. However, there has been some concern expressed in recent years that infertility may be playing an increasing role in the unprecedentedly low levels of fertility now in effect in Ukraine and other countries in the region. There are several factors that have suggested to researchers that there has been a growing inability among the population to have as many children as they would like. Among these factors are the increasing spread of sexually transmitted infections, high levels of chronic alcohol abuse (especially in males), and the high incidence of repeat abortions. All of these factors can potentially lead to a reduction in the ability to become pregnant or bear a child. There have also been anecdotal reports of increases in the numbers of women/couples seeking infertility treatment. However, to our knowledge, no definitive research has been conducted to determine the extent to which infertility has been suppressing rates of childbearing or to estimate the numbers of couples who are being affected by infertility. The 1999 URHS included a module designed to collect information from respondents about their difficulties they have experienced in having children and any treatment they might have undergone in response to difficulties becoming pregnant or bearing a child. Although the survey data does not allow a thorough analysis of the extent and impact of infertility in Ukraine, it does provide the ability to examine certain aspects of the infertility situation, such as the proportion of couples who report problems becoming pregnant and the probability that couples receive treatments of various types. Prevalence of infertility Table 6.1 presents the proportion, among women who had ever tried to become pregnant, who said they had experienced problems becoming pregnant in the last 10 years, according to how long the problem lasted. Overall, almost one of every six respondents (16%) reported ever having such a problem. When the definition of an infertility problem is narrowed to longer durations, we still find that 14% had a problem lasting at least one year, 12% lasting at least two years and 7% had a problem lasting at least five years, seemingly relatively large percentages. The percentages reporting difficulty becoming pregnant were slightly higher than overall in urban areas and among the least well educated. Problems were less common in the West region. Treatment Overall, just over half of women who reported having difficulty becoming pregnant in the previous 10 years (52%) sought treatment for the problem (Table 6.2). In about two-thirds of those cases where treatment was sought, only the woman sought treatment. The proportion seeking treatment tended to increase with age, education of the respondent, and the length of the problem. The likelihood that both partners would seek treatment increased sharply with respondent=s education. The initial source of treatment for infertility problems overwhelmingly tended to be women=s consultation clinics (72%) (Tale 6.3). The remaining 28% sought treatment at an assortment of types of facilities, including 6% who went to private clinics or offices. Of those women who were treated, 72 29% went to more than one place. The secondary sources also consisted of a wide array of types of places, including 7% private clinics or offices. The best educated, the oldest, and urban women were the most likely to go to more than one type of facility and to utilize a private second source. A broad assortment of infertility treatments were used by survey respondents or their partners, with the most common being the prescription of anti-inflammatory drugs, reported by 48% of such women (Table 6.4). Other treatments commonly mentioned were: hormones (24%), physiotherapy (19%), treatments for blockage of the Fallopian tubes (16%), and relaxation/spa therapy (15%). Less commonly used were more technologically advanced and more costly treatments requiring greater intervention, such as: laser therapy (5%), laparoscopy (5%), and in vitro fertilization (IVF) (2%). Every treatment listed, except for relaxation therapy was more commonly used by urban women than rural women and by the best educated than less well educated women. The differences are especially large for such treatments as IVF and laser therapy. Use of physiotherapy and relaxation therapy increased sharply with the age of the respondent. About half of the women receiving treatment eventually became pregnant (Table 6.5). Forty percent had a live birth. In spite of the different types and places of treatment, there were only small, and statistically insignificant, differences in the likelihood of becoming pregnant or having a live birth by age, residence, education, and the duration of the problem. It is difficult to interpret this result. It could mean that many of the infertility problems tend to disappear themselves or are alleviated by relatively little intervention. It also may indicate that modern, more expensive, technologically advanced treatments are not yet in widespread enough use to have affected rates of treatment success. 73 Table 6.1 Percentage of women who have ever had problem becoming pregnant in the previous 10 years, by duration of problem, by age, region, residence, and education 1999 Ukraine Reproductive Health Survey Duration of problem becoming pregnant Characteristic Ever 1+ year 2 + years 5+ years Number of women Total 15.9 13.9 12.3 6.7 2,528 Age 15-19 32.2 14.2 6.3 0.0 45 20-24 30.6 24.3 19.9 3.7 322 25-29 26.6 23.5 20.9 11.8 507 30-34 15.9 15.4 14.5 9.4 533 35-39 8.0 7.7 7.1 5.5 577 40-44 3.3 3.3 3.3 2.9 544 Region North 17.3 15.6 13.5 6.6 289 Central 15.7 15.2 14.1 9.4 192 East 17.9 15.3 13.3 7.1 803 South 15.4 12.9 11.9 5.7 739 West 13.1 11.5 9.9 5.9 505 Residence Urban 16.4 14.3 12.9 6.9 1,886 Rural 14.7 12.9 10.9 6.0 642 Education < Comp. secondary 23.8 18.0 16.2 8.7 142 Comp. secondary 15.2 13.6 12.0 6.2 1,844 > Comp. secondary 16.1 13.7 12.1 8.0 542 74 Table 6.2 Percentage of women with infertility problems who sought treatment, by age, region, residence, education and length of problem 1999 Ukraine Reproductive Health Survey Person who sought treatment Characteristic Did not seek treatment Woman Partner Both Number of women Total 47.7 34.0 0.3 18.0 415 Age 15-19 * * * * 14 20-24 55.1 31.4 0.0 13.5 100 25-29 47.4 33.2 0.0 19.3 135 30-34 39.6 38.0 0.0 22.4 93 35-39 41.5 39.1 0.0 19.4 52 40-44 * * * * 21 Region North 58.0 30.0 0.0 12.0 50 Central 40.0 26.7 0.0 33.3 30 East 52.6 30.7 0.9 15.8 151 South 44.8 35.9 0.0 19.3 118 West 37.9 43.9 0.0 18.2 66 Residence Urban 47.1 34.8 0.4 17.6 319 Rural 49.1 31.9 0.0 18.9 96 Education < Comp. secondary 54.2 36.5 0.0 9.3 33 Comp. secondary 48.1 34.9 0.4 16.5 286 > Comp. secondary 43.8 29.7 0.0 26.5 96 Length of problem** 1 + years 42.6 36.2 0.0 21.2 361 2 + years 41.4 36.3 0.0 22.4 326 5 + years 37.6 35.5 0.0 26.9 179 *Fewer than 25 respondents in category. **Does not include those who did not remember. Categories are not mutually exclusive, so total does not equal 415. 75 Table 6.3 Percentage distribution of women/couples who sought for treatment of infertility problems, by initial and second place of treatment, by age, residence, and education 1999 Ukraine Reproductive Health Survey First place of treatment Second place of treatment Characteristic Women consult. MCH center FP center Private clinic Other Women consult. MCH center FP center Private clinic Other None Total No. of women Total 72.4 4.7 6.6 5.9 10.4 1.5 2.6 4.2 7.3 13.6 70.9 100.0 266 Age 15-24 76.8 3.5 9.5 7.8 2.4 1.1 4.5 2.4 2.4 15.0 74.7 100.0 56 25-34 72.2 3.4 6.0 4.6 13.8 1.0 1.9 4.8 8.6 11.9 71.7 100.0 130 35-44 66.5 10.9 4.4 7.4 10.8 3.6 2.1 4.7 9.9 17.2 62.6 100.0 40 Residence Urban 77.4 3.6 5.5 7.4 6.1 0.8 2.8 3.3 9.7 14.5 68.9 100.0 176 Rural 59.6 7.4 9.5 2.1 21.4 3.1 2.1 6.4 0.9 11.3 76.0 100.0 50 Education < Comp. sec. * * * * * * * * * * * 100.0 16 Comp. sec. 68.9 4.9 6.0 6.4 13.8 2.1 2.3 4.7 5.3 12.3 73.3 100.0 159 > Comp. sec. 83.6 5 .3 5.3 2.3 3 .5 0.0 4.2 3.9 14.7 21.2 56.1 100.0 51 76 Table 6.4 Percentage of treated women/couples who received various types of treatment for infertility problems, by age, residence, and education 1999 Ukraine Reproductive Health Survey Type of infertility treatment Characteristic Hormones Anti- inflammatory drugs Fallopian blockage treatment Physio- therapy Laser therapy Laparoscopy/ Microsurgery Relaxation/ Spa therapy IVF Other Number of women Total 24.2 48.0 15.5 18.9 4.7 4.7 14.9 2.2 18.8 226 Age 15-24 21.4 62.3 12.5 14.1 5.2 1.8 7.2 0.0 17.7 56 25-34 26.8 46.8 16.2 19.1 6.1 5.3 15.3 3.1 16.3 130 35-44 20.0 32.6 17.5 25.0 0.0 7.4 24.9 2.4 29.9 40 Residence Urban 26.7 50.0 17.5 21.5 5.5 5.1 15.9 2.3 18.1 176 Rural 16.0 42.0 8.0 10.0 2.0 4.0 12.0 2.0 21.9 50 Education < Comp. sec * * * * * * * * * 16 Comp. sec 22.0 44.0 14.4 16.5 3.8 3.9 12.6 0.6 21.0 159 > Comp. sec 31.4 58.7 21.5 25.4 7.6 9.6 7.8 7.7 15.6 51 NOTE: Row percentages add to more than 100 percent, since some women received more than one type of treatment. *Fewer than 25 women in category. 77 Table 6.5 Percentage of women treated for infertility problems who eventually become pregnant and percent who had a live birth, according to selected characteristics and length of problem 1999 Ukraine Reproductive Health Survey Characteristic Percent who become pregnant Percent who had a live birth Number of women Total 52.8 40.4 226 Age 15-24 53.7 37.3 56 25-34 51.3 41.7 130 35-44 56.7 40.6 40 Residence Urban 52.1 40.9 176 Rural 54.5 39.1 50 Education < Comp. secondary * * 16 Comp. secondary 50.5 40.5 159 > Comp. secondary 56.7 42.5 51 Length of problem 1 + year 53.5 43.3 207 2 + years 54.5 45.6 188 5 + years 54.0 46.1 108 *Fewer than 25 respondents in category 79 CHAPTER VII CONTRACEPTION One of the principal reasons for carrying out the 1999 Ukraine Reproductive Health Survey was to perform an in-depth examination of contraceptive knowledge, attitudes, and practices among Ukrainian women. Prior to this survey, relatively little national systematic information existed on most aspects of contraceptive use in Ukraine (Vovk, 1997). Until recently, the conventional wisdom had been that the prevalence of use of modern contraception in eastern Europe and the former Soviet Union was quite low, leading to high levels of unintended pregnancy and induced abortion there. Recent surveys in other countries in the region, however, have shown that overall contraceptive use, as well as the use of effective modern contraceptive methods, is often very widespread, despite high rates of induced abortion. Thus, it was not surprising to find in the URHS that the use of family planning methods in Ukraine has reached a very high level. This survey collected information on a broad array of topics related to contraception, including knowledge and use of contraceptive methods, source of methods, contraceptive failure and discontinuation, side effects, and reasons for nonuse of contraception, among others. Virtually no respondents refused to provide information on any of the topics related to contraception about which they were asked. Knowledge and ever use of contraceptive methods In general, knowledge of the most readily available methods was widespread. Table 7.1 shows that virtually all women knew at least one modern contraceptive method (99.6%). Nearly all respondents said that they had heard of condoms (99% knowledge) and the IUD (96%), followed by oral contraceptives (90%). A majority of respondents also were familiar with female sterilization (67%), spermicides (60%), and the diaphragm (58%). The only modern method asked about for which knowledge remained very low was contraceptive implants, which remain unavailable to most Ukrainians, known by only 18% of respondents. Among non-supplied methods, both periodic abstinence and withdrawal were known by between 80% and 90% of women. Knowledge of every method was higher in urban than in rural areas, but, for most methods these differences were relatively small, the differences being greatest for sterilization (female and male), spermicides, diaphragms, and implants. Not surprisingly, most contraceptive methods tended to be much more widely known by women currently or previously in union than those never in union. For most methods, knowledge rose with age up to ages 25-29 and remained relatively constant from 25- 29 to 40-44 (Table 7.2). However, all age groups and education level groups had at least 97% knowledge of condoms. With the exception of condoms, knowledge increased sharply with educational attainment for every method asked about. Knowledge of where to obtain supplied contraceptive methods tended to be almost as high as knowledge of methods, indicating that most women who had heard of a method also reported that they knew where they could obtain that method. Knowledge of method source ranged from 97% for condoms to 13% for implants. Differentials paralleled those for knowledge of methods: higher in urban women, better educated women, and women ever in union. Overall, 74% of all respondents and 87% of those currently in union reported ever using any contraceptive method (Table 7.4). The figures for modern methods were 60% and 69%, 80 respectively. The methods most likely to have ever been used were withdrawal (47%), condoms (44%), periodic abstinence (38%), and the IUD (30%). With the exception of oral contraceptives (14%), all other methods had been practiced by very few women. Except for withdrawal, all other widely used methods were more likely to have been used by urban than by rural women. In general, there was very little difference between currently in union and previously in union women in regard to ever use. Ever use increased substantially with educational attainment, except for some rarely used methods. Current Contraceptive Prevalence About two-thirds (68%) of women in registered or unregistered marriages were currently using contraceptive methods at the time of interview (Figure 7.1 and Table 7.5). In addition, more women/couples were employing modern methods of contraception than traditional methods (periodic abstinence and withdrawal), though the difference was not great (38% and 30%, respectively). It should be noted that users of methods considered to be of very poor or no effectiveness, particularly douching and folk methods, were not considered to be users of contraception in these tabulations. Including such women would have raised the contraceptive prevalence rate by approximately 3 percentage points. IUDs (used by 19% of women in union) and condoms (14%) accounted for the vast majority of modern method use in Ukraine, with oral contraceptives (OCs) (3%) a distant third. Withdrawal (at 20%, the most widely practiced method overall) and periodic abstinence, i.e., rhythm, calendar, and related methods (10%), were also widely used. Only about 1% of women had been contraceptively sterilized, despite the fact that most respondents wanted to have no more children. Contraceptive prevalence was highest between ages 25-29 and 35-39, at just over 70%. Prevalence was by far the lowest at ages 15-19 (47%). In the youngest cohort, most modern contraceptors were using condoms. At the older ages, IUDs, withdrawal, and periodic abstinence were the most commonly used methods. Overall contraceptive prevalence was only 34% among women with no living children, another indication that most couples still want to have a child soon after marriage (Figure 7.2 and Table 7.6). Prevalence peaked at 75% among those with two living children, before falling back to 63% for those with three or more living children. Unlike most other contraceptive methods, use of condoms and oral contraceptives fell steadily as the number of children increased. Use of the IUD was rare among women with no children. As expected, contraceptive sterilization was very rare except among women with at least two children. Even among that group only 3% had been sterilized. The greatest differences in contraceptive use between urban and rural areas were not so much in prevalence (69% vs. 63%, respectively), but in the types of methods selected (Table 7.7). In urban areas, 42% of couples were using a modern method, while 27% were using a traditional method. In rural areas, however, this was almost reversed; use of traditional methods exceeded modern methods, 36% to 27%. Condom and OC use was much less prevalent in rural areas than in urban areas, while the reverse was true for withdrawal. Table 7.7 also shows prevalence figures for the Donetsk and Odessa Oblasts, the two oversampled oblasts in the URHS. Contraceptive prevalence there was 65% and 72%, respectively. Most noteworthy, however, is that women in both oblasts relied more heavily on modern methods (45% and 47%) than other Ukrainian women, even those in urban areas. Table 7.8 reveals that, despite other reproductive differences that have been noted between Ukraine’s regions, there is almost no variation in contraceptive prevalence by region. There 81 is however, a correlation with the types of method employed. The western region relies much more heavily than others on traditional contraception (42% traditional and 25% modern). In all other regions the figures were more or less reversed. Most of the traditional use in the West is withdrawal. The Central and East regions are areas of particularly high IUD use. Contraceptive use among women in union was also strongly correlated with educational attainment (Table 7.9). Among the relatively small number of women who had not completed secondary school, only about 57% were using contraception, less than the prevalence among better educated women (66% for those who completed secondary school and 76% for those who received any post- secondary education. The prevalence of condom, oral contraceptive, and periodic abstinence use, showed great proportional increase with educational attainment. Reliance on withdrawal decreased somewhat with increasing education. Table 7.10 shows current contraceptive use according to union status. Thirty-five percent of women previously in union and 22% of those never in union were using contraception. The majority of users never in union, were relying on condoms. Recent trends in contraceptive prevalence Table 7.11 and Figure 7.3 show the trend in contraceptive prevalence in Ukraine from the beginning of 1994 to the date of the survey, based on data from the URHS contraceptive calendar. In the calendar, women reported, to the best of their recollection, their month-by-month contraceptive history for the previous five years. Because the survey questionnaire included no marriage or sexual activity history, these calculations include all interviewed women, rather than just women in union or sexually active women. Overall prevalence looks to have risen steadily among 15 to 39 year-old women in Ukraine during that time period. In just over five years prevalence rose by about 7 percentage points, more than 1 percentage point per year. Recent trends in contraceptive prevalence have been similar in urban and rural areas. Very notably, during this time there were greater increases in the use of modern contraception (5 percentage points) than in the use of traditional methods (2 percentage points). Source of contraceptive methods Percentage distributions of sources of oral contraceptives (OCs), IUDs and condoms (the most widely used supplied methods) are displayed in Table 7.12. Women’s consultation centers and pharmacies were overwhelmingly the leading sources of OCs for respondents, supplying about three of every four users. Women’s consultation centers were the predominant source of IUDs, accounting for two-thirds of those currently used. Most of the remainder were supplied by hospitals. Pharmacies supplied slightly over half of condom users. Substantial numbers were also provided by women consultation centers and drug kiosks. Major sources of supply for these methods were quite similar for urban and rural women. Information collected in the survey about the cost of contraceptive methods proved to be problematic because of women’s difficulty in remembering the amount they paid as well as substantial changes in the costs of goods and services and in the value of Ukrainian currency. However, it is informative to examine the types of payments women or couples made for their current contraceptive method. Table 7.13 shows that among OC users, 82% paid for their pills. A slightly higher percentage of 82 IUD users received their supplies without paying–about one-fourth said they did not pay. About three-fourths of condom users said they paid for their supplies, but an additional 11% did not know (probably because their partner obtained their condoms). There were very small differences between urban and rural areas with regard to whether respondents paid for their contraceptive method. Reasons for not using contraception Among survey respondents who were not currently using contraception, two-thirds cited lack of sexual activity, an inability or difficulty in becoming pregnant (subfecundity), current pregnancy, or a desire to become pregnant, as their primary reason for non-use (Table 7.14). These women are not likely to be targeted as potential users of contraception in a family planning program. There was a broad assortment of reasons for non-use given by the remaining 34% of non-users, many of which could be addressed by reproductive health interventions. The most commonly given reasons were “occasional sex only” (9%) and “don’t know” (8%). Fear of health consequences or side effects (3%), partner objections (3%), and cost/access issues (3%), were the next most commonly cited reasons. It is important to note that certain reasons, particularly a preference for abortion and religion, were almost never mentioned. Not surprisingly, there were large differences in reasons for non-use according to marital/union status. Among those not currently in union, lack of sexual activity and infrequent sexual activity were, of course, the most important factors. Among those currently in union, factors such as subfecundity, pregnancy, wanting to become pregnant, and fear of side effects were more often cited than among other respondents. Unmet need for contraception Table 7.15 presents estimates of the percentage of women in need of family planning services according to two definitions. By the first definition (the conventional definition), women who are sexually active, not pregnant, able to become pregnant, do not want to become pregnant, and are not using any contraceptive method are considered to have unmet need for contraception. By this definition, unmet need was 15%, very high compared with the levels in most other developed countries. The second definition additionally includes users of periodic abstinence and withdrawal (methods with typically low use-effectiveness) as having unmet need. This definition more than doubles the proportion with unmet need to 37%. This is an extremely high level of unmet need, fitting well with Ukraine’s high abortion rate. Women with no living children were substantially less likely to be in need than those with children by both definitions I and II. Respondents who had completed secondary school but had no post-secondary education were more likely to have unmet need than others were. There were virtually no differences across regions of the country. Rural women were more likely to have unmet need than urban women. It should be kept in mind, however, that these indicators only take into account whether people are using a method, but do not include such factors as consistency of use and method effectiveness. Preference for other methods/Problems with current method Current users of contraception were asked if they would prefer to use a method of pregnancy prevention other than the one they were currently using. A relatively low 25% of women said they preferred a different method, but the percentages varied considerably according to the method currently used (Table 7.16). The two methods that women were the most likely to want to switch from were withdrawal (37%) and condoms (30%), both male controlled methods with relatively low 83 use-effectiveness. Users of the IUD and tubal ligation were the most likely to be satisfied with their present method, with only 10% and 11%, respectively, preferring a different method. The IUD was also by far the method most commonly mentioned as being the one women preferred to use, among women using a different method (mentioned by about 40%). Oral contraceptives were the only other method frequently mentioned by respondents as one they would like to adopt. Table 7.17 shows that about one-half of women who reported that they preferred to be using a different method, said that the major reason for their failure to use that method was either cost (27%) or fear of health consequences or side affects associated with the method (20%). The only other reasons frequently cited were that the physician would not prescribe their preferred method (15%) and that she did not know enough about the method or how to obtain it (14%). The most notable difference between urban and rural areas was that cost was much more likely to be a major factor in rural areas than in urban areas. It is noteworthy that all four of the most common reasons given for not using preferred methods all could be addressed by interventions designed to improve contraceptive use. Overall, about 80% of contraceptive users said they were having no major problems or concerns with their current method (Table 7.18). The proportion with no concerns ranged from 73% among those using a traditional method to 84% for condom users, 85% for IUD users, and 87% for sterilized women. The problem/concern most often mentioned, especially for traditional methods and condoms, was low effectiveness of the method. Among women using an IUD or who had been sterilized, health concerns were the leading concern. Among users of OCs, side effects were the predominant concern. Contraceptive failure and discontinuation Data from the questionnaire’s contraceptive/pregnancy calendar were used to calculate rates of contraceptive failure (the probability of becoming pregnant while using a particular method) and discontinuation (the probability of stopping use of a particular method for any reason) for the most widely used methods. Table 7.19 presents rates of failure after one, two, and three years for all methods combined and for five specific methods. Overall about 9% of contraceptive users became pregnant while using a method within one year of beginning use. After three years this rose to 19%. Of course, there were substantial differences between methods. There were quite small differences in failure rates between urban and rural areas. The failure rate for the IUD, based on calendar data, was 1.4% for the first year, which is in line with typical rates (Figure 7.4). Failure rates after three years rose to 3.5%. Urban-rural differences were small. The failure rate for oral contraceptives was 5.9% for the first year and 13.2% for three years, somewhat higher than the rates typically seen (Hatcher et al., 1998). Condom failure was 7.1% for one year and 18.7% for three years. The highest failure rates for widely used methods were found for periodic abstinence and withdrawal. For periodic abstinence 15.6% of users became pregnant in the first year; for withdrawal the rate was 11.7%. Three-year rates for these two methods was almost 30%. There were no consistent differences between urban and rural areas in contraceptive failure or use-effectiveness, as the inverse is known. Anecdotal reports have suggested that there is a considerable amount of method switching, as well as frequent starting and stopping of contraception in the much of the former Soviet Union. The 84 URHS data support this belief. In general, contraceptive discontinuation rates were very high across methods. For all methods combined, 29% of contraceptive use segments continued for no more than one year (Table 7.20). After three years, about half of women had discontinued use. Of the five methods most widely used, all except the IUD exhibited extremely high rates of discontinuation, from 29% (withdrawal) to 54% (OCs) in the first year and from 53% (withdrawal) to 74% (OCs) after three years (Figure 7.4). Only 6% of IUD segments ended within one year. Table 7.21 displays some reason-specific one year discontinuation rates for the five leading methods of contraception in Ukraine. For oral contraceptive users there were a wide variety of reasons for discontinuation, including: to give the body a rest (15% of segments terminating in less than one year), side effects (9%), health concerns (8%), cost/supply problems (7%), and physician’s decision (7%). Especially of concern is the high rate of discontinuation to “give the body a rest”, which has no medical justification. Side effects were somewhat of a problem for IUD users, causing 10% discontinuation in the first year. Concerns about health were responsible for 2% discontinuation. Condoms tended to be discontinued for a more effective method (7%), because of cost (4%), or inconvenience of the method (3%). The major reason for discontinuing periodic abstinence and withdrawal was to use a more reliable method. Table 7.22 shows percentage distributions of reasons for discontinuing the five most widely used methods. It should be kept in mind that these distributions are not the same as discontinuation rates and that percentages should only be compared within methods, not between methods. Oral contraceptive users cited a wide assortment of reasons for stopping. The most commonly given reasons were “giving her body a rest”, side effects, health concerns, pregnancy (i.e., failure), and desire to get pregnant. Physician’s decision and cost/supply issues were also mentioned relatively often. Among IUD users the principal reasons for discontinuation were to give the body a rest, physician’s decision/recommendation, health concerns, and pregnancy while using. Condom use was discontinued for a broad assortment of reasons, led by pregnancy and want of a more reliable method. Periodic abstinence and withdrawal use tended to be terminated because of pregnancy (over 40%), desire for a more reliable method, or inconvenience of the method. In the case of withdrawal, partner’s objections were commonly cited. Opinions about fertility control methods Respondents were asked to rate a number of birth prevention methods with regard to safety and health effects, effectiveness, and cost, as well as to give each method an overall rating. For each characteristic, women rated each method between 1 (extremely negative) and 10 (extremely positive). Table 7.23 and Figure 7.5 show the percentages of women who gave very low ratings (3 or less) for each of seven methods. (Not included in these tabulations are women who did not have an opinion about particular characteristics for a given method. For some methods, particularly injectables and tubal ligation, the proportions of women with no opinion were very high.) Survey findings regarding feelings about abortion run counter to the opinion sometimes expressed that women in this region of the world tend to prefer abortion to contraception. Probably the most noteworthy result is the nearly universally negative overall opinions held by respondents about both conventional induced abortion (96%) and miniabortion (95%). Opinions about abortion were equally negative regardless of whether women had ever had an abortion (top panel, Table 7.23). Despite the fact that abortion was by far the most poorly regarded method of birth prevention, every 85 method asked about was rated negatively overall by at least 40% of respondents who had an opinion about the method. Condoms and the IUD were the only methods not viewed very negatively by a majority of respondents, 41% and 49% negative, respectively. After conventional abortion and miniabortion, female sterilization (81%) and injectables (73%), methods that were not widely used in Ukraine, were the methods most often viewed negatively. Except for abortion, users of a particular method were far less likely than non-users to view that method negatively. IUD users (3%) and oral contraceptive users (8%) were particularly unlikely to view their method negatively. With regard to safety and health consequences, induced abortion was again viewed the most negatively (91% for conventional abortion and 88% for miniabortion). Slightly over one-half of respondents considered female sterilization (57%) and injectables (53%) to be unsafe. Condoms (9% negative) were considered the safest method by a wide margin, followed by the IUD (27%). As with overall opinions, users of a particular method were less likely than others to consider that method unsafe. None of the methods about which women were asked in the survey were widely considered to be of low effectiveness. However, even the methods known to be of extremely high reliability, such as sterilization and the IUD were considered by at least 7% of respondents to be of low effectiveness. Interestingly, sterilized women were no less likely than others to believe that sterilization was of low effectiveness. Only condoms were viewed by more than a small proportion of women (58%) as very costly. Because condoms play such an important role in preventing the spread of HIV/AIDS and other STIs, the fact that so much of the population views them as very costly is essential information for policy makers and the reproductive health community. The IUD was viewed as expensive by 15% of women. Cost was the only aspect of contraception which was generally viewed more negatively by users than by non-users. This probably reflects greater awareness of the actual costs of obtaining methods among those women who have actually used particular methods. Use of non-supplied methods Because non-supplied methods of contraception tend to have higher probabilities of failure than modern, supplied methods, the URHS examined the reasons that women and couples chose methods such as periodic abstinence and withdrawal. The survey asked every respondent who was currently using any non-supplied method (mainly periodic abstinence or withdrawal) whether a number of factors were at least “somewhat important” in their method selection. These factors included: health/side effects of supplied methods; the naturalness of the method; partner preference; lack of knowledge/ information about other methods; cost of other methods; difficulty in obtaining other methods; and religious beliefs. All but religion were cited by a substantial proportion (i.e., at least 47% or more) of users of non-supplied methods as being at least “somewhat important” in influencing their method choice (Table 7.24). The possible health and side effects of supplied methods (81%) and the naturalness of non-supplied methods (82%) were by far the most important factors cited in choosing withdrawal and periodic abstinence. About two of every three women said that the cost of other methods played an important role in method selection, about the same as the proportion mentioning their partner’s preferences. Several factors that family planning/reproductive health programs could affect seem to play a significant role in the decision-making process. In addition to the cost of other methods, difficulty in obtaining other methods and a lack of knowledge 86 about other methods influenced the choices of 52% and 47%, respectively, of users of less effective, non-supplied methods. Rural women were slightly more likely to cite the cost and availability of other methods as a reason. Table 7.25 reveals non-supplied method users’ opinions about the effectiveness of their current method relative to “methods received from a doctor or pharmacy, like the IUD or pills”. Only about one of every five such women were aware that methods such as the IUD prevented pregnancy more effectively than the method they were using. Another one-third felt that their current method was actually more effective than modern methods. Twelve percent admitted that they did not know the relative effectiveness of the methods. By publicizing the relative effectiveness of various types of contraception, disseminating accurate information on health effects, and improving knowledge of and access to other methods, reproductive health programs in Ukraine can contribute to increased use of highly effective methods and, hence, reduced reliance on induced abortion to prevent unwanted births. IUD use The IUD has been the most popular form of modern contraception in much of eastern Europe and the former Soviet Union for many years. However, little information has been collected on a national basis in Ukraine on side effects or other aspects of IUD provision and use. The URHS included a series of questions for respondents who had an IUD inserted since the beginning of 1994, relating to the timing of insertions, information given by the IUD provider, and problems encountered related to the IUD. Tables 7.26 and 7.27 provide some findings from these questions. Most IUD insertions (71%) took place neither following a delivery nor an abortion (top panel, Table 7.26). There were, however, substantial numbers of insertions after induced abortions (23%). Eighty-five percent of recent Ukrainian IUD users reported that their provider told them how long their IUD could be left in place (Table 7.26, bottom panel). About one in ten IUD users were told that the device could be left in place for six or more years, about half reported being told that it could be left in place for 4-5 years, and 23% said they were told that the IUD could only be left in place for less than four years. Unfortunately, because we do not have information on the type of IUD that women used (this question was not asked because women were unlikely to know the type) we cannot assess the adequacy of these recommendations, since there are considerable differences between different types of IUDs as to how long they remain effective. Six percent of IUD users reported that their provider did not give them any information regarding how long the device could be left in place and another 9% could not remember whether their physician told them anything about how long her IUD should remain. About three of every ten women with an IUD inserted since January 1994 reported that they experienced physical problems associated with the device (Table 7.27). The proportion was very similar in urban and rural areas of Ukraine. About half of those reporting problems mentioned either heavy bleeding during menstrual periods or bleeding or spotting between periods. Inflammation/discharge/infection was the only other specific problem frequently mentioned. 87 Oral contraceptive use The questionnaire included a module on oral contraceptive use for respondents who reported any segments of OC use beginning since January 1994. This module was similar to the one used for IUDs, including questions on information given by providers, problems related to pill use, and related topics. Although oral contraceptives are not widely used in Ukraine currently, they seem to be growing in popularity and are being promoted as a safe and effective form of pregnancy prevention that is appropriate for many women in the population. Despite the relatively small number of current OC users interviewed (210), there were a considerable number of brands of OCs being used, with 23 different brands mentioned (data not shown). The most widely used brands among current users were Tri-Regol (26%), Regividon (22%), Marvelon (19%), and Triqvilar (17%). Twelve percent of OC users reported that they were using Postinor, a very high dose pill also used as a morning-after pill. Slightly fewer than one-half (43%) of recent OC users in the URHS reported that their physician did not tell them how long they could continue to take OCs (Table 7.28). Unlike the IUD, however, this is not of great concern, since most women can take OCs for many years with no ill effects. Fourteen percent reported that their physician told them they should only take pills for less than two years. As was shown previously, many physicians continue to tell patients that they should discontinue OCs after various lengths of time to “give the body a rest”, a recommendation that is not supported by medical evidence. About one in four women were told they could take OCs as long as they wanted. Rural women were less likely to be told this and more likely to be told they should take OCs only for a short period of time. Forty-one percent of recent and current OC users reported having had physical problems related to their use of this contraceptive method (Table 7.29). Nausea and weight gain/bloating were the most commonly reported problems, each reported by 8% of users. Additionally, 6% reported headaches and 5% cited bleeding between menstrual periods. Contraceptive sterilization Despite the fact that most women want to have no more children and that most couples desire no more children long before reaching their potentially fertile years end, contraceptive sterilization is rarely employed as a method of pregnancy prevention in Ukraine. The URHS found that only 2% of married women of reproductive age with two or more children had been sterilized and that virtually no men had undergone a vasectomy. This low reliance on sterilization seems to be a phenomenon observable throughout the region. Recent surveys in Russia, the Czech Republic, and Romania, for instance, also revealed similarly low prevalence of sterilization (Czech Statistical Office et al. 1995, Romanian Ministry of Health 1995, VCIOM 1998), as does anecdotal information from much of eastern Europe and the former Soviet Union. A number of factors probably contribute to the low prevalence of sterilization, one of which is legislative. Except for medical reasons, it is only legally permissible for women with three or more children or, if a woman is over 30 years of age, with two children. This law, however, actually represents a liberalization of sterilization practices. Until after the break-up of the Soviet Union, only women with a medical condition contraindicating pregnancy or childbirth could legally be sterilized. 88 Regardless of the regulations on when sterilizations are permitted, the survey results show that few women claim to be interested in tubal ligation. Overall, among fecund respondents who wanted to have no more children, only 7% expressed interest in sterilization (Table 7.30). An additional 5% said they were not sure if they would be interested, leaving an overwhelming 88% who were not interested. There were a few noteworthy differentials in sterilization interest according to women’s characteristics. Respondents in the West were the least likely to be interested. Women with the largest families and those with the highest levels of education, were more likely to express interest than others. Non-users of contraception were less likely than users to be interested, but there was little difference between users of various methods of contraception. When asked the reason for not being interested in sterilization, the factor most commonly given (respondents could only give one reason) was that women simply “had not thought about it”, cited by 34% of respondents (Table 7.31). This indicates that sterilization is not even a contraceptive option that many women ever consider. The next most common reason was a fear of health risks associated with sterilization (25%). Other reasons that were given with some frequency were lack of information about sterilization (10%), fear of operation (9%), and might eventually want another child (8%). Women rarely mentioned religion, cost of the procedure, or partner’s objections as major factors. Although, at first appearance, increasing the incidence of contraceptive sterilization seems an obvious way to decrease levels of unintended pregnancy and induced abortion and, hence, reduce maternal morbidity and mortality, there are a number of major obstacles to overcome before such a change can actually occur. Legal barriers would need to be removed. There is currently not adequate equipment available to provide sterilization to large numbers of women (or men). Maybe, most importantly, the procedures are not currently ones that are even considered to be acceptable contraceptive options for all but a small minority of Ukrainians. Any movement directed at trying to increase the use of sterilization as a family planning method will have to address all of these problems. 89 90 91 92 93 94 Table 7.1 Percentage of respondents who heard of specific contraceptive methods, by residence and marital status 1999 Ukraine Reproductive Health Survey Residence Marital status Contraceptive method Total Urban Rural Currently in union Previously in union Never in union Condoms 98.7 98.9 97.9 98.7 98.9 98.3 IUD 95.9 96.2 95.0 98.5 98.3 87.1 Oral contraceptives 90.1 91.9 85.4 91.1 92.8 86.1 Female sterilization 67.2 70.5 58.2 71.4 76.9 50.1 Spermicide 60.2 64.4 49.1 62.2 65.4 52.1 Diaphragm 57.8 62.5 45.3 61.1 66.3 44.2 Injectables 48.0 50.6 41.2 50.5 52.1 38.9 Vasectomy 45.4 49.2 35.4 48.0 52.8 34.6 Implants 18.0 20.5 11.5 18.5 21.0 15.3 Withdrawal 88.2 88.7 86.9 93.6 92.2 70.5 Periodic abstinence 81.9 84.1 76.0 86.3 86.7 66.8 Any method 99.6 99.7 99.6 99.9 99.8 99.8 Any modern method 99.6 99.6 99.5 99.8 99.8 98.8 Any traditional method 92.3 92.9 90.7 96.3 95.3 79.3 Number of women 7128 5544 1584 4796 800 1532 95 Table 7.2 Percentage of respondents who heard of specific contraceptive methods, by age and education 1999 Ukraine Reproductive Health Survey Age Education Contraceptive method Total 15-19 20-24 25-29 30-34 35-39 40-44 <Comp. Sec. Comp. Sec. >Comp. Sec Condoms 98.7 98.2 99.0 98.7 99.5 98.4 98.1 97.3 98.6 99.7 IUD 95.9 83.5 97.7 98.5 98.6 98.7 98.1 83.5 97.0 98.7 Oral contraceptives 90.1 82.2 89.8 92.4 92.4 93.5 90.5 80.2 90.1 95.8 Female sterilization 67.2 39.6 62.9 73.6 76.4 78.8 71.4 42.1 66.2 84.3 Spermicide 60.2 46.1 58.3 62.8 66.3 66.2 61.4 38.9 58.8 76.8 Diaphragm 57.8 35.0 52.7 60.5 65.2 68.6 64.4 29.3 56.8 77.0 Injectables 48.0 33.0 45.4 50.4 56.8 53.2 49.0 28.8 47.2 61.4 Vasectomy 45.4 23.9 44.0 50.7 52.1 53.4 48.3 21.8 42.4 68.8 Implants 18.0 10.3 17.6 17.4 22.5 20.5 19.9 8.6 16.5 28.3 Withdrawal 88.2 65.5 88.8 94.2 95.0 94.0 91.6 68.9 89.5 94.6 Periodic abstinence 81.9 61.3 80.4 85.7 88.1 88.3 87.3 60.6 82.2 92.4 Any method 99.6 98.7 99.8 99.9 99.8 99.9 99.7 98.6 99.7 100.0 Any modern method 99.6 98.7 99.8 99.8 99.8 99.9 99.5 98.3 99.7 100.0 Any traditional method 92.3 76.2 93.2 96.2 97.5 96.0 95.0 77.9 93.4 96.7 Number of women 7128 1100 1182 1227 1195 1246 1178 778 4828 1522 96 Table 7.3 Percentage of respondents who know where to obtain specific contraceptive methods, by residence, marital status, and education 1999 Ukraine Reproductive Health Survey Residence Marital status Education Contraceptive method Total Urban Rural Currently in union Previously in union Never in union <Comp. Sec. Comp. Sec. >Comp. Sec. Condoms 96.9 97.3 95.7 97.3 97.6 95.3 94.4 96.8 98.3 IUD 90.7 91.3 89.1 95.1 95.6 75.6 72.4 92.3 95.5 Oral contraceptives 85.1 87.2 79.7 86.8 89.4 78.4 71.8 85.2 92.3 Spermicide 55.5 59.5 44.8 57.4 61.4 47.1 33.9 54.2 71.9 Diaphragm 51.4 55.3 41.2 54.8 59.5 37.6 24.0 50.5 69.8 Female sterilization 49.8 51.8 44.3 53.3 58.8 35.2 28.7 49.4 62.9 Injectables 40.2 42.0 35.6 42.5 45.0 31.5 24.0 39.6 51.3 Vasectomy 31.9 34.1 26.3 33.8 38.6 23.2 14.1 30.5 49.7 Implants 13.0 14.6 8.9 13.5 15.9 10.5 5.1 12.2 20.2 Periodic abstinence* 74.3 76.7 67.9 79.3 80.0 56.9 49.5 74.5 87.2 Number of women 7128 5544 1584 4796 800 1532 778 4828 1532 *Knows where to get information about using periodic abstinence 97 Table 7.4 Percentage of respondents who have ever used specific contraceptive methods, by residence, marital status, and education 1999 Ukraine Reproductive Health Survey Residence Marital status Education Contraceptive method Total Urban Rural Curr. in union Prev. in union Never in union <Comp. Sec. Comp. Sec. >Comp. Sec. Condoms 44.1 49.1 30.7 49.2 51.8 25.6 24.2 43.0 58.9 IUD 29.7 30.7 27.0 38.0 39.1 1.1 11.7 31.8 32.7 Oral contraceptives 13.8 15.8 8.5 16.0 16.5 6.0 5.2 13.4 20.0 Spermicide 4.2 5.1 2.1 5.1 4.6 1.5 0.8 3.7 7.8 Injectables 1.2 1.4 0.8 1.5 1.2 0.4 0.8 1.2 1.6 Female sterilization 1.0 1.0 1.0 1.4 0.7 0.0 1.0 1.1 0.8 Diaphragm 0.6 0.8 0.3 0.7 1.4 0.1 0.2 0.6 1.1 Vasectomy 0.1 0.1 0.1 0.1 0.3 0.0 0.0 0.1 0.0 Implants 0.1 0.2 0.1 0.2 0.0 0.1 0.0 0.1 0.2 Withdrawal 47.1 46.6 48.4 55.9 55.8 17.2 24.7 48.3 55.4 Periodic abstinence 37.6 39.7 31.8 45.1 45.0 12.0 14.3 37.1 52.2 Any method 74.2 76.0 69.5 87.2 83.9 31.6 40.8 76.4 85.5 Any modern method 59.8 64.3 48.0 69.4 70.4 27.0 32.0 60.5 73.0 Any traditional method 57.3 57.9 55.8 68.6 67.3 19.9 28.4 59.0 68.0 Number of women 7,128 5,544 1,584 4,796 800 1,532 778 4,828 1,532 98 Table 7.5 Percentage distribution of current contraceptive use, by method, by respondent’s age, women in union 1999 Ukraine Reproductive Health Survey Age Current contraceptive method Total 15-19 20-24 25-29 30-34 35-39 40-44 Using any method 67.5 47.4 63.0 71.6 71.7 70.9 61.1 Using a modern method 37.6 27.2 33.9 42.0 41.9 40.1 30.2 IUD 18.6 3.4 12.9 19.3 21.5 23.1 16.6 Condoms 13.5 20.8 15.8 16.0 15.0 10.7 9.6 Oral contraceptives 3.0 1.2 4.3 3.3 3.0 2.9 1.9 Female sterilization 1.4 0.0 0.1 1.1 1.6 2.3 1.7 Spermicide 0.8 1.9 0.8 1.6 0.4 0.7 0.4 Other methods 0.3 0.0 0.1 0.7 0.3 0.4 0.1 Using a traditional method 29.9 20.2 29.2 29.7 29.9 30.8 30.9 Withdrawal 19.5 13.8 24.2 20.6 19.9 17.0 17.8 Periodic abstinence 10.4 6.4 4.9 9.1 10.0 13.9 13.1 Using no method* 32.5 52.6 37.0 28.4 28.3 29.1 38.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 4,794** 121 737 993 1,009 1,000 934 *Includes users of douche and folk methods **Data missing for 2 women. 99 Table 7.6 Percentage distribution of current contraceptive use, by method, by number of living children, women in union 1999 Ukraine Reproductive Health Survey Living children Current contraceptive method Total 0 1 2 3+ Using any method 67.5 33.7 68.9 74.8 62.8 Using a modern method 37.6 21.2 41.4 39.5 27.6 IUD 18.6 2.6 18.4 22.8 17.5 Condoms 13.5 14.6 17.2 10.8 7.1 Oral contraceptives 3.0 2.5 3.7 2.8 0.6 Female sterilization 1.4 0.5 0.4 2.5 1.8 Spermicide 0.8 1.0 1.2 0.5 0.4 Other methods 0.3 0.0 0.5 0.2 0.2 Using a traditional method 29.9 12.5 27.5 35.3 35.3 Withdrawal 19.5 9.3 18.0 22.5 24.6 Periodic abstinence 10.4 3.2 9.5 12.8 10.7 Using no method* 32.5 66.3 31.1 25.2 37.2 Total 100.0 100.0 100.0 100.0 100.0 Number of respondents 4794 448 2009 1906 322 *Includes users of douche and folk methods 100 Table 7.7 Percentage distribution of current contraceptive use, by method, by type of place of residence and for oversampled oblasts, women in union 1999 Ukraine Reproductive Health Survey Place of residence Oversampled oblasts Current contraceptive method Total Urban Rural Donetsk Odessa Using any method 67.5 69.2 63.3 65.4 71.7 Using a modern method 37.6 41.9 27.2 44.8 46.5 IUD 18.6 19.0 17.8 20.5 15.4 Condoms 13.5 16.5 6.4 17.8 22.5 Oral contraceptives 3.0 3.6 1.4 4.4 4.6 Female sterilization 1.4 1.4 1.4 1.1 1.4 Spermicide 0.8 1.0 0.3 0.7 1.9 Other methods 0.3 0.4 0.0 0.3 0.7 Using a traditional method 29.9 27.3 36.1 20.6 25.2 Withdrawal 19.5 16.2 27.4 10.1 15.5 Periodic abstinence 10.4 11.1 8.7 10.5 9.7 Using no method* 32.5 30.8 36.7 34.6 28.3 Total 100.0 100.0 100.0 100.0 100.0 Number of respondents 4,794 3,641 1,153 1,038 842 *Includes users of douche and folk methods 101 Table 7.8 Percentage distribution of current contraceptive use, by method, by region of residence, women in union 1999 Ukraine Reproductive Health Survey Region Current contraceptive method Total North Central East South West Using any method 67.5 68.3 68.1 66.3 68.9 67.1 Using a modern method 37.6 37.8 37.7 43.1 42.9 24.8 IUD 18.6 15.9 25.2 21.9 17.1 12.7 Condoms 13.5 16.1 8.9 15.9 16.4 8.2 Oral contraceptives 3.0 3.1 2.3 3.0 4.8 1.8 Female sterilization 1.4 1.4 1.4 1.3 1.2 1.6 Spermicide 0.8 0.9 0.0 0.6 2.1 0.5 Other methods 0.3 0.4 0.0 0.4 0.5 0.1 Using a traditional method 29.9 30.5 30.4 23.2 26.0 42.3 Withdrawal 19.5 21.5 20.1 12.7 14.9 31.7 Periodic abstinence 10.4 9.0 10.3 10.5 11.1 10.6 Using no method* 32.5 31.7 31.9 33.7 31.1 32.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 4,794 566 426 1,777 1,194 831 *Includes users of douche and folk methods 102 Table 7.9 Percentage distribution of current contraceptive use, by method, by educational level, women in union 1999 Ukraine Reproductive Health Survey Educational level Current contraceptive method Total <Complete secondary Complete secondary >Complete secondary Using any method 67.5 56.5 65.9 75.9 Using a modern method 37.6 28.6 35.7 46.6 IUD 18.6 15.2 19.1 17.9 Condoms 13.5 8.0 11.6 21.6 Oral contraceptives 3.0 2.1 2.7 4.3 Female sterilization 1.4 2.3 1.4 1.1 Spermicide 0.8 0.7 0.6 1.6 Other methods 0.3 0.5 0.3 0.2 Using a traditional method 29.9 27.9 30.2 29.3 Withdrawal 19.5 23.6 20.1 16.1 Periodic abstinence 10.4 4.3 10.1 13.2 Using no method* 32.5 43.5 34.1 24.1 Total 100.0 100.0 100.0 100.0 Number of respondents 4,794 290 3,456 1,048 *Includes users of douche and folk methods 103 Table 7.10 Percentage distribution of current contraceptive use, by method, by marital status 1999 Ukraine Reproductive Health Survey Marital status Current contraceptive method Total Currently in union Previously in union Never in union Using any method 53.5 67.5 34.9 21.7 Using a modern method 31.2 37.6 22.9 16.6 IUD 13.8 18.6 12.4 0.5 Condoms 12.9 13.5 7.5 13.8 Oral contraceptives 2.5 3.0 1.6 1.6 Female sterilization 1.0 1.4 0.7 0.0 Spermicide 0.7 0.8 0.3 0.4 Other methods 0.3 0.3 0.4 0.2 Using a traditional method 22.3 29.9 12.0 5.1 Withdrawal 14.5 19.5 6.6 3.7 Periodic abstinence 7.8 10.4 5.4 1.4 Using no method* 46.5 32.5 65.1 78.3 Total 100.0 100.0 100.0 100.0 Number of respondents 7,128 4,794 800 1,532 *Includes users of douche and folk methods 104 Table 7.11 Percent of All 15-39 Year-Old Respondents Reporting Current Use of Any Contraception or of Modern Contraception at Six Month Intervals from January 1994 to April 1999 1999 Ukraine Reproductive Health Survey Total Urban Rural Date % Using Any Method % Using Modern Method % Using Traditional Method % Using Any Method % Using Modern Method % Using Traditional Method % Using Any Method % Using Modern Method % Using Traditional Method 1/1994 48.8 27.7 21.1 49.5 30.4 19.1 46.9 20.9 26.0 7/1994 50.1 29.1 21.0 51.2 32.1 19.1 47.0 21.3 25.7 1/1995 50.7 29.4 21.3 51.6 32.0 19.6 48.3 22.7 25.6 7/1995 51.1 30.0 21.1 52.5 32.9 19.6 47.7 22.3 25.4 1/1996 51.6 30.1 21.5 52.6 33.0 19.6 49.0 22.5 26.5 7/1996 51.7 30.5 21.2 52.9 33.4 19.5 48.8 22.9 25.9 1/1997 52.4 30.6 21.8 53.1 33.4 19.7 50.5 23.5 27.0 7/1997 53.1 31.3 21.8 53.8 34.1 19.7 51.0 23.9 27.1 1/1998 53.6 31.6 22.0 54.7 34.9 19.8 50.6 22.9 27.7 7/1998 53.9 32.0 21.9 55.4 35.4 20.0 50.1 23.1 27.0 1/1999 54.2 32.1 22.1 55.4 35.6 19.8 51.1 23.1 28.0 4/1999 55.9 32.9 23.0 56.9 36.3 20.6 52.4 23.9 28.5 105 Table 7.12 Percentage distribution of source of selected contraceptive methods, by residence, among current users 1999 Ukraine Reproductive Health Survey Contraceptive method Total Urban Rural Source of method OCs IUD Condoms OCs IUD Condoms OCs IUD Condoms Women’s consultation centers 39.3 66.0 10.0 41.1 69.9 9.6 * 55.8 12.2 Pharmacy 34.6 3.7 56.6 34.8 2.8 56.2 * 6.0 59.1 Hospital 6.6 20.4 2.1 5.9 17.8 2.3 * 27.1 0.5 Drug kiosk 1.7 0.1 7.3 1.2 0.0 7.1 * 0.5 9.1 Maternity house 2.1 5.3 0.5 2.5 5.0 0.6 * 6.0 0.0 Private clinic/physician 1.0 0.4 0.3 1.2 0.3 0.3 * 0.9 0.0 MCH center 0.4 0.1 0.4 0.5 0.2 0.4 * 0.0 0.0 Other source 15.7 4.4 22.8 12.8 4.0 23.5 * 3.7 30.1 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 198 1,005 973 179 780 867 19 225 106 *Fewer than 25 respondents Table 7.13 106 Percentage distribution of method of payment for contraceptive method for current users of oral contraceptives, IUD, and condoms 1999 Ukraine Reproductive Health Survey Contraceptive method Total Urban Rural Type of payment OCs IUD Condoms OCs IUD Condoms OCs IUD Condoms Cash 82.3 72.4 76.0 80.8 72.3 75.9 * 72.6 76.8 Payment in goods or services 0.2 1.4 0.3 0.2 1.4 0.4 * 1.4 0.0 No payment 16.8 26.1 10.8 18.2 26.1 10.5 * 26.0 12.6 Don’t remember/Don’t know 0.7 0.1 12.7 0.8 0.2 13.2 * 0.0 10.7 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number of respondents 198 1,005 1,016 179 780 906 19 225 110 *Fewer than 25 respondents in category 107 Table 7.14 Percentage distribution of primary reason for not using contraception, by union status 1999 Ukraine Reproductive Health Survey Union status Reason for not using contraception Total Currently in union Previously in union Never in union Reasons related to pregnancy, fecundity, or sexual activity 66.7 62.7 80.8 59.3 Not sexually active 25.4 3.9 64.8 48.6 Subfecund 13.5 18.4 8.7 0.8 Pregnant 12.6 18.9 1.4 5.5 Want pregnancy 8.2 11.7 2.1 3.6 Difficult to get pregnant 7.0 9.8 3.8 0.8 Other reasons 33.3 37.3 19.2 40.7 Occasional sex only 8.8 4.7 10.1 24.7 Partner objections 2.7 3.2 0.6 4.3 Fear of side / health effects 2.7 3.9 1.2 0.0 Cost / availability / difficult to use 2.6 3.2 0.6 3.2 Breastfeeding / postpartum 1.9 3.0 0.0 0.0 Doctor will not prescribe 1.6 2.2 1.3 0.0 Haven’t bothered 1.0 1.5 0.4 0.0 Previous side effects 0.6 0.9 0.0 0.0 Religion 0.6 1.0 0.1 0.0 Prefer abortion 0.1 0.2 0.0 0.0 Other 2.6 3.4 0.8 2.2 Don’t know 8.2 10.3 4.2 6.3 Total 100.0 100.0 100.0 100.0 Number of women 1,391 877 372 142 108 Table 7.15 Percent of women with unmet need for family planning, according to two definitions by age, region, residence, and education 1999 Ukraine Reproductive Health Survey Characteristic Definition I* Definition II** Total 14.9 37.0 Age 15-24 10.6 23.7 25-34 16.8 43.8 35-44 17.3 43.5 Region North 14.6 36.9 Central 15.5 38.9 East 15.8 33.5 South 13.2 31.8 West 14.8 46.5 Residence Urban 13.9 33.8 Rural 17.5 45.6 Living children 0 7.4 14.1 1 19.0 43.2 2+ 17.4 50.1 Education < Complete secondary 11.7 22.9 Complete secondary 16.7 40.2 > Complete secondary 10.7 34.3 *Definition I: Women are considered to be in need if they are fecund, sexually active or in union, not pregnant, did not want to get pregnant at the time of interview, and are not using any type of contraception. **Definition II is the same as definition I, except that it also includes women using typically less effective methods of contraception (withdrawal and periodic abstinence). 109 Table 7.16 Percentage distribution of users of selected contraceptive methods according to whether they prefer to use a different method, by current and preferred method 1999 Ukraine Reproductive Health Survey Contraceptive method preferred by women Respondent’s current method Prefers current method Prefers other method IUD Pills Steriliz. (f. or m.) AM- after pills Sperm- icide Condom Natural methods Other Not Sure No. of users IUD 89.9 10.1 0.0 2.5 1.4 0.9 0.8 0.3 0.6 2.1 1.5 997 Tubal ligation 88.6 11.4 8.0 0.0 0.0 0.9 0.0 0.6 0.0 0.0 1.9 68 Periodic abst. 77.9 22.1 9.5 3.9 2.0 0.6 0.8 2.1 0.2 1.7 1.4 556 Pills 76.9 23.1 10.8 0.0 1.0 0.2 2.4 0.0 3.5 2.3 2.8 198 Spermicide 75.6 24.4 10.1 1.6 1.2 0.8 0.0 0.0 3.5 3.9 3.5 53 Condoms 69.9 30.1 12.2 6.5 1.9 2.0 1.9 0.4 1.3 3.2 0.7 1,014 Withdrawal 62.7 37.3 16.0 5.7 1.6 2.9 2.3 2.5 1.5 1.7 3.1 970 All methods 74.8 25.2 9.7 4.4 1.7 1.7 1.5 1.2 1.1 2.1 1.8 4,037 * *Includes methods with fewer than 50 users, which are not listed separately. 110 Table 7.17 Percentage distribution of reason not using preferred method of contraception, by residence 1999 Ukraine Reproductive Health Survey Residence Reason not using preferred method Total Urban Rural Cost 27.2 23.1 38.0 Fear of side / health effects 20.2 19.8 20.3 Doctor will not prescribe 15.3 16.6 11.9 Do not know enough about / how to obtain it 13.6 14.9 10.0 Husband objects to it 4.2 4.4 3.6 Poor effectiveness 2.9 3.1 2.7 Current method is permanent / long term 1.9 2.5 0.5 Difficult to get 1.3 1.5 0.7 Method is not natural 0.9 1.2 0.2 Religious reasons 0.4 0.4 0.5 Other 8.0 8.8 6.6 Don’t know 4.1 3.7 5.0 Total 100.0 100.0 100.0 Number of respondents 881 674 207 111 Table 7.18 Percentage distribution of major problems or concerns with current contracep

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