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Albania: Reproductive Health Survey, 2002 Final Report

Publication date: 2005

Albania Reproductive Uealth Survey 2002 • REPRODUCTIVE HEALTH SURVEY ALBANIA, 2002 FINAL REPORT Edited by: Leo Morris, Ph.D. MPH Joan Herold, Ph.D. Silva Bino, M.D. Alban Yili, M.D. Danielle Jackson, MPH Institute of Public Health (IPH) Albania Ministry of Health Institute of Statistics (INSTAT) TIRANA, ALBANIA Division of Reproductive Health Centers for Disease Control and Prevention (DRH/CDC) ATLANTA, GEORGIA USA United States Agency for International Development (USAID) United Nations Population Fund, Albania (UNFPA) United Nations Children’s Fund (UNICEF) May, 2005 Albania Reproductive Health Survey, 2002 Final Report I P R E FA C E PREFACE In Albania, some models of services related to reproductive health have traditionally existed; this is especially the case for mother and child care services. Meanwhile, reproductive health programs are relatively new and began to function after the fall of the old system. During this period of time, Albania has faced a range of health problems which have followed economic and especially social changes in the country. For 50 years Albania followed a pro-natalist policy, with modern family planning methods banned; and it was almost taboo to discuss sexuality and contraception in public. Abortion was also banned before the year 1991 and half of the maternal deaths in the 80’s were caused by abortion complications. The Ministry of Health of Albania has started to adapt specific policies to cope with increasing risks, which are mostly related to changing life styles, and to meet as well the increasing demands from the population for specific services. Products of such policies are new programs of family planning and programs of sex education. Through these approaches we aim to support the Albanian women and men of reproductive age taking rational decisions for the number of children they want to have, the time they want them, child spacing, and safe sex. Only a few years ago the Albanian parliament passed a law on reproductive health, which regulates management and functioning of all services concerning reproductive health in public and private institutions. The law guarantees the rights of every individual and every couple related to reproduction in coherence with national policies and well known international principles. The reproductive health survey of Albania has provided baseline data for new developments in recent years in this field, developments which have affected lifestyle, legislation, policies and social services. Until this survey was in place there was no comprehensive comparative analysis of the main indicators of family planning and reproductive health, utilizing data from a nation-wide representative sample. A main objective of this survey is to assess reproductive health status and needs, which will help us design new programs and adjust existing ones according to the needs of the population. I strongly believe that the results presented in this report will serve most managers and professionals who operate in the field of reproductive health, as a important reference in their everyday activities. Vice Minister of Health Saemira Pino PREFACE II Albania Reproductive Health Survey, 2002 Final Report III E X E C U T IV E SU M M A R Y EXECUTIVE SUMMARY ALBANIA REPRODUCTIVE HEALTH SURVEY: 2002 BACKGROUND The Albania Reproductive Health Survey (RHS) 2002 was conducted by the Institute of Public Health, with the support of the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA) and United Nations Children’s Fund (UNICEF), and with the technical assistance of the Division of Reproductive Health (DRH) of the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, USA. It is the ﬁ rst national survey on reproductive health, for both female and male respondents, in Albania, and the 18th survey of this type in 13 countries of Eastern Europe and the Former Soviet Union since 1993. The results obtained from this population-based survey provide the Ministry of Health, NGO’s and donor agencies the current status of the reproductive health situation in the country and make possible the comparison of results with other national and international surveys. The Institute of Statistics (INSTAT) provided information from the 2001 census to serve as the sampling frame for the national sample and also was responsible for data processing. A principal objective of the study was to examine the reproductive health status of the population and needs that can be used to help direct or modify program interventions. Until this survey, relatively little detailed and reliable population-based information was available about important reproductive health topics in the country. The RHS examines patterns and levels of fertility, contraceptive use and method selection, health behaviors, knowledge of HIV/AIDS, attitudes toward speciﬁ c contraceptive methods, domestic violence and sexual abuse, as well as sex education and sexual behavior of young adults. These data are particularly useful in assisting policy makers and program ofﬁ cials in evaluating health service needs and identifying reproductive health behaviors associated with poor health outcomes. METHODOLOGY Results of the Albania RHS are based on in- person face-to-face interviews with 5,697 women and 1,740 men in their homes. The household-based survey was designed to collect information from a representative sample of reproductive age men (15-49 years of age) and women (15-44 years of age), regardless of marital status, who were living in Albania when the survey was conducted in late 2002. Male and female samples were selected independently. For analysis purposes, three strata were constructed for the sample design: Metropolitan Tirana, other urban areas and other rural areas. As in other countries in Eastern Europe, the survey had a three-stage sampling design: (1) selection of census sectors with probability proportional to the number of households in the 2001 census (2) clusters of households randomly selected in each census sector chosen in the ﬁ rst stage of the sample and (3) random selection of one eligible respondent in each household. Executive Summary IV CHARACTERISTICS OF THE SAMPLE The average size of a household in Albania with at least one eligible female respondent is 5.1, ranging from 4.6 in urban areas to 5.4 in rural areas. Almost two-thirds (65%) of the female sample were currently married compared with 60% of the male sample and 36% of females reported secondary complete or post-secondary education compared with 43% of the male sample; there was a marked differential in educational attainment of urban and rural Albanians. About 80% of both samples reported their religion to be Muslim, but only 5% reported that they attend religious services at least once a month. FERTILITY TRENDS AND LEVELS Albania has had a 21% decline in the Total Fertility Rate (TFR) between 1993 and 2002. The survey data show that the TFR has declined from 3.3 children per woman during the three-year period from August 1993 to July 1996 to 2.8 from 1996-1999 to 2.6 from 1999-2002. Women 20-29 years of age at birth contribute 65% of the fertility rate. The TFR for women with post-secondary education is estimated to be 2.0 compared with 2.7 for women with primary school education. Over 90% of married women (93%) have had a live birth and 11% have had four or more children. The median age of ﬁ rst intercourse for all women is 21.1, ﬁ rst marriage is 21.9 and ﬁ rst live birth is 23.4. Unfortunately, the survey rate of 73 abortions per 1,000 live births for the three years prior to the survey is 64% lower than the ofﬁ cially reported rate of 200 per 1000 live births. Since the apparent underreporting by survey respondents is at least 50% and may be as high as 77% (upper limit of 95% conﬁ dence interval), and since the underreporting is most likely not random but associated with the characteristics of the respondent, further analysis of the abortion data is probably unreliable and beyond the scope of this report. MATERNAL and CHILD HEALTH Nineteen percent of women with births in the past ﬁ ve years reported that they did not have prenatal care during their pregnancy. No prenatal care was highest among rural women (26%), older women (28%), women primary education (25%) and women classiﬁ ed as low socioeconomic status (SES) (26%). Of women with prenatal care, one-fourth (24%) reported a pregnancy complication, including risk of preterm delivery and anemia related to pregnancy as the most frequent complications reported. Almost all women (94%) gave birth in a medical facility. Ten percent of births to rural women, women older than 34, low SES women and women with birth order 3 or greater were reported to be at home. Fifteen percent of women with no prenatal care reported a home birth. Only 19% of women reported a post-partum care visit following delivery. Postnatal baby clinic visits were more common with 86% of women reporting a postnatal clinic visit for their baby. The overwhelming majority of babies were breastfed (93%) with a mean duration of 14.3 months. However, exclusive breastfeeding was only 2.8 months on the average and full breastfeeding 4.9 months on the average. The infant mortality rate (IMR) calculated for the period from August 1992 to July Albania Reproductive Health Survey, 2002 Final Report V 2002 is 26.2 per 1000 and the under ﬁ ve mortality rate for the same period is 31.9 per 1000. These results are similar to the results of the MICS survey carried out in 2000: infant mortality was 28 per 1000 and the child mortality rate was 33 per 1000. The survey IMR of 26.2/1000 for the period, 1992-2002, is 29% higher than the ofﬁ cial rate reported between 1995 and 2000. AWARENESS AND USE OF CONTRACEPTION Nine out of 10 Albanian women have heard of at least one modern method and 87% have heard of at least one traditional method, predominantly withdrawal. However, while 81% of women have heard of the condom, only two-thirds of women have heard of oral contraception or tubal ligation. Less than 35% have heard of other modern methods. There are 13 percentage point differences for most modern methods between women living in urban areas vs. rural areas. Males have principally heard of the condom (89%) and withdrawal (89%). Knowledge of other modern methods is very low, reaching only 33% for oral contraceptives. Women who have heard of contraception believe that withdrawal is much more effective at preventing pregnancy than are modern methods. Males said that tubal ligation was best at preventing pregnancy followed by the condom and withdrawal. Contraceptive prevalence is 75% for married women (8% modern methods) and 77% for married men (3% modern methods). For both genders, the predominant method is withdrawal, 67% reported by the females sample and 74% reported by the male sample. Only three groups of married women reported at least a 15% contraceptive prevalence for modern methods: High SES (18%), post-secondary education (17%) and living in metro Tirana (15%). Married men with post-secondary education (13%) and high SES (12%) were the only groups to surpass a level of 9% using modern methods. Almost three out of four women (73%) using traditional methods thought that withdrawal was more effective at preventing pregnancy than modern methods. Among men using traditional methods, 48% thought withdrawal was more effective than modern methods and 42% thought that they were equally effective. NEED FOR CONTRACEPTIVE SERVICES Unmet need for contraception is a very speciﬁ c estimate that measures the gap between desired fertility levels and the contraceptive practices adopted to ensure that fertility preferences are met. In addition to unmet need for any contraceptive method, the Albania survey also estimated the need for modern contraception – an indicator used in other Eastern European surveys. It is estimated that 46% of all women and 68% of married women have unmet need for modern contraception if unintended pregnancies were to be prevented. Among married women, since only 8% report using modern contraception, only 12% of the potential “demand” for modern contraception has been met. The highest percentage of “met demand” was for women living in Metro Tirana (22%), women with a post-secondary education (26%) and women classiﬁ ed as high SES (27%). Two-thirds of women (68%) expressed a desire for more information about Executive Summary VI contraception. The desire for more information was highest among non-users (75%), young adults 15-24 years of age (84%), and never married women (85%). Ninety percent of women and 77% of men said that information about contraception should be broadcast on radio or television. REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES Women said that the ideal number of children for a young family in Albania was 2.6, coincidentally equal to the total fertility rate found in the three years prior to the survey. For men, the ideal number of children was 2.4. Almost all women (96%) and 89% of men agree that both the husband and wife should decide together on how many children a couple should have. Only 26% of women and 11% of men knew the most likely time during the menstrual cycle that a woman would get pregnant. Only 9% of unmarried women and 10% of 15-19 year olds responded correctly to this question. Also, only about one-ﬁ fth of women and men knew that the likelihood of pregnancy was lower if the mother was breastfeeding. Almost three-fourths of women (72%) and 53% of men agreed that seeking an abortion is a woman’s personal decision. Of those not agreeing, 26% of women and 45% of men said that abortion was alright under certain circumstances. Only one percent of females and males said that abortion is never acceptable. More than 75% of women and more than 84% of men agree that the husband should help with chores if the wife works, the main job of women is housework and every individual should get married. Three- quarters of women (75%) and 64% of men agree that a married woman needs her husband’s permission to work. HEALTH BEHAVIORS Only 24% of women and 14% of men visited a health facility in the past 12 months. Only 16% of those women visiting a health facility received counseling for family planning. The main reasons expressed by women as a barrier in getting medical advice or treatment for themselves were “lack of money” (46%) and “not wanting to go alone” (41%). The two main reasons expressed by men ware “lack of money” (54%) and “did not know where to go” (40%). Of sexually experienced women, two- thirds (69%) have never had a routine gynecological exam. About one-half of women (52%) were aware of breast self- exam, but only 8% have ever practiced breast self-exam. Only 3% of sexually experienced women had ever had a pap smear for cervical cancer screening. Fully 70% of these women had never heard of screening for cervical cancer. Almost one-half of men (46%) smoke compared with only 3% of women. YOUNG ADULTS More than 90 percent of women 15-44 years of age (92%) agree that age appropriate sex education topics concerning human reproduction, contraception and sexually transmitted infections should be taught in school. For men 15-49 years of age, 84% agree. For young adult women 15-24 years of age, two-thirds (64%) have discussed sex education topics with a parent before they reached age 18, but only 15% discussed HIV/AIDS and 8% discussed contraception. Albania Reproductive Health Survey, 2002 Final Report VII For young adult men, only 11% discussed any sex education topic with a parent before age 18, and only 9% discussed HIV/AIDS and 2% methods of contraception. Three fourths (77%) of young adult women and 64% of young adult men said that they were taught some sex education topic in school by age 18. However, only about one-half of females and males received information about HIV/AIDS and only 30% of males and 24% of females received information about contraceptive methods. One-third of young adult women (32%) reported sexual experience and 14%, or 42% of those with sexual experience, had premarital sex; almost all (99%) reported to be their ﬁ ancée or boy friend. Among young adult males, 29% reported having had sexual experience and 27%, or 91% of those with sexual experience, had premarital sex. Most men with premarital sexual experience reported their ﬁ rst partner to be a girl friend (43%), a lover (19%) or a friend (14%). Only 1% reported that their ﬁ rst sexual encounter was with a prostitute. Four out of ﬁ ve (81%) females said that they or their partner used a contraceptive method at ﬁ rst intercourse, mostly withdrawal, with the following distribution: withdrawal (96%), condoms (3%) and other modern methods (1%). Eight-ﬁ ve percent of men reported contraceptive use at ﬁ rst intercourse, including withdrawal (56%), condoms (43%) and other modern methods (1%). Eighteen percent of unmarried males and 5% of unmarried females15-24 years of age were sexually active at least once in the past three months. Only 15% of sexually active unmarried males reported using a modern method at last intercourse similar to the 11% of sexually active unmarried females. Of all sexually experienced men, 72% report two or more lifetime partners versus only 3% of females. KNOWLEDGE OF HIV/ AIDS TRANSMISSION AND PREVENTION Almost all women and men of reproductive age (96%) have heard of or are aware of HIV/AIDS; However, only 56% of women and 45% of men believe that HIV can be asymptomatic, and only 17% of women and 33% of men know where HIV tests are provided. Seventy-three percent of all women and 69% of all men identiﬁ ed monogamy, partner limitation and condom use as prevention measures against HIV/AIDS (UNAIDS indicator no. 1). However only 1% of both women and men had correct knowledge that HIV could be asymptomatic, and is not spread by mosquito bites or through medical treatment (UNAIDS indicator no. 2). Seventy-nine percent of both women and men say they have no risk of contracting HIV/AIDS; 95% of the women who say that they are not at risk say they are monogamous (41%), not sexually active (32%) or they trust their partner (23%), and 87% of the males give the same three reasons plus 8% saying they use condoms. Of those that think they have some risk, the overwhelming proportion of women (91%) stated that their risk was from medical or dental treatment. Slightly over half of the men (54%) also gave this reason followed by unprotected sex with casual partners (16%). VIOLENCE AGAINST WOMEN The data in this report on violence against women, also known as “gender-based violence”, represent the ﬁ rst national Executive Summary VIII population-based information on the issue of violence against women in Albania. Women who have ever been married reported both lifetime intimate partner violence (IPV) and IPV during the past 12 months. During their lifetime, among these women, 30% report verbal abuse, 8% physical abuse and 3% sexual abuse; during the past 12 months, the corresponding reports are 23%, 5% and 2%, respectively. Except for sexual abuse, men report inﬂ icting more abuse on their partners than reported by women indicating a possible reluctance of women to report IPV even in a private interview. Lifetime, 33% of men reported inﬂ icting verbal abuse, 14% physical abuse and 1% sexual abuse. In the past 12 months the corresponding reports are 19%, 5% and <1%, respectively. Of women reporting physical violence in the past year, less than half (46%) talked to anyone about this violence, mostly with family, a relative or a friend. Only 20% talked to the police, a health provider or a legal adviser. All women were asked if they have been forced to have sexual intercourse against their will during their lifetime. Only 2% of women reported that they have ever experienced forced sexual intercourse, lower than the prevalence reported in other countries of this region. About 90% of these women reported that the perpetrator of forced sex was their husband or partner or ex-husband or ex-partner. It is notable that no woman reported forced sexual intercourse by a casual partner or stranger. Albania Reproductive Health Survey, 2002 Final Report IX TA B LE O F C O N T E N TS PREFACE . I EXECUTIVE SUMMARY . III TABLE OF CONTENTS . IX LIST OF TABLES . XIII LIST OF FIGURES . XXVII CHAPTER 1: BACKGROUND . 1 (Silva Bino, Ranee Seither) CHAPTER 2: METHODOLOGY . 9 (Leo Morris) Sampling Design Questionnaire Data Collection Response Rates CHAPTER 3: CHARACTERISTICS OF THE SAMPLE . 15 (Joan Herold, Leo Morris) Household Characteristics Characteristics of the Respondents CHAPTER 4: FERTILITY AND PREGNANCY . 27 (Joan Herold, Leo Morris) Fertility Experience Age at First Intercourse, Union and Birth Current Sexual Activity Induced Abortion Planning Status of the Last Pregnancy Future Fertility Preferences CHAPTER 5: MATERNAL AND CHILD HEALTH .49 (Alban Yili, Nedime Ceka, Leo Morris) Prenatal Care Intrapartum Care Postnatal Care Pregnancy and Postpartum Complications Poor Birth Outcomes Breastfeeding Infant and Child Mortality Table of Contents X CHAPTER 6: CONTRACEPTION AWARENESS AND KNOWLEDGE OF USE . 83 (Ndola Prata) Contraceptive Awareness and Knowledge of Use Knowledge about Contraceptive Source Most Important Source of Information about Contraception Knowledge about Contraceptive Effectiveness CHAPTER 7: CONTRACEPTIVE USE AND PREFERENCE . 99 (Joan Herold, Silva Bino) Current Contraceptive Use Source of Contraception Satisfaction with and Preference for Current Method Reasons for Not Using Contraception Intention to Use Contraception among Nonusers CHAPTER 8: NEED FOR CONTRACEPTIVE SERVICES AND CONTRACEPTIVE COUNSELING . 121 (Leo Morris, Alban Yili) Potential Demand and Unmet Need for Family Planning Services Contraceptive Counseling CHAPTER 9: OPINIONS ABOUT CONTRACEPTION AND ABORTION . 131 (Ranee Seither, Joan Herold, Alban Yili) Introduction Desire for More Information about Contraception Opinion on the Best Source of Contraceptive Information Opinion on Appropriateness of Broadcasting Contraceptive Information on Radio and Television Opinions Regarding the Advantages and Disadvantages of Pill and IUD Use Opinions on Risks to Women’s Health Due to Use of Selected Birth Prevention Methods Opinions on Risks to Women’s Health Due to Abortion Conclusion CHAPTER 10: REPRODUCTIVE HEALTH KNOWLEDGE AND ATTITUDES . 149 (Ranee Seither, Alban Yili) Ideal Family Size Knowledge of the Menstrual Cycle Knowledge of the Fertility Effect of Breastfeeding Attitudes Toward Abortion Attitudes and Perceptions about Gender Norms Albania Reproductive Health Survey, 2002 Final Report XI CHAPTER 11: HEALTH BEHAVIORS . 173 (Alban Yili, Florina Serbanescu) Use of Health Care and Preventive Services Prevalence of routine gynecologic visits among sexually experienced women Breast Self Exam Cervical Cancer Screening Prevalence of Selected Health Problems Impaired Fecundity Smoking and Alcohol Consumption CHAPTER 12: SEX EDUCATION . 205 (Joan Herold, Silva Bino) Introduction Opinions About Sex Education in Schools Discussions With Parents Sex Education in School Sources of Information on Sexual Matters Impact of Sexuality Education on Knowledge About Pregnancy Issues CHAPTER 13: YOUNG ADULT SEXUAL AND CONTRACEPTIVE EXPERIENCE . 231 (Joan Herold, Leo Morris) Sexual Experience First Sexual Intercourse Current Sexual Activity Attitudes Toward Condom Use CHAPTER 14: KNOWLEDGE AND EXPERIENCE OF SEXUALLY TRANSMITTED INFECTIONS AND KNOWLEDGE OF HIV/AIDS TRANSMISSION AND PREVENTION . 265 (Ndola Prata, Silva Bino, Leo Morris) Awareness of STIs and Knowledge of Symptoms Related to STIs Most Important Source of Information and Messages About STIs Self-Reported Diagnosis, Testing and Treatment of STIs Perceived Risk of STIs Knowledge of HIV/AIDS Knowledge of HIV/AIDS Transmission Knowledge of HIV/AIDS Prevention Beliefs About the Risk of HIV/AIDS and Self-Perceived Risk of HIV/AIDS Table of Contents XII CHAPTER 15: VIOLENCE AGAINST WOMEN . 313 (Mary Goodwin, Silva Bino, Florina Serbanescu) Introduction Comparison of Violence Across Countries of Eastern Europe History of Witnessing or Experience Abuse During Childhood Women’s Experience of Intimate Partner Violence Male Inﬂ iction of Intimate Partner Violence Characteristics of Physical or Sexual Violence Experienced by Women in the Past Year Women’s Attitudes and Beliefs About the Effects of Violence Prevalence of Forced Sexual Intercourse GLOSSARY . i REFERENCES . v APPENDIX A: SAMPLING ERROR ESTIMATES . xiii APPENDIX B: PARTICIPANT INSTITUTIONS . xvii APPENDIX C: FEMALE QUESTIONNAIRE . xxi APPENDIX D: MALE QUESTIONNAIRE . lxxiii Albania Reproductive Health Survey, 2002 Final Report XIII LIST O F TA B LE S List of Tables Table 2.1 A Results of Household Visits and Interview Status of Eligible Women by Stratum (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 2.1 B Results of Household Visits and Interview Status of Eligible Men by Stratum (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 3.1 A Size of Households with at Least One Eligible Respondent by Stratum (Percent Distribution) Female Sample, Reproductive Health Survey: Albania 2002 Table 3.1 B Size of Households with at Least One Eligible Respondent by Stratum (Percent Distribution). Male Sample, Reproductive Health Survey: Albania 2002 Table 3.2 A Percentage of Households with Basic Household Amenities and Goods, by Stratum, for Women Aged 15–44 Years Reproductive Health Survey: Albania 2002 Table 3.2 B Percentage of Households with Basic Household Amenities and Goods, by Stratum, for Men Aged 15–49 Years Reproductive Health Survey: Albania 2002 Table 3.3 A Percent Distribution of Characteristics of Female Sample by Residence and Stratum Reproductive Health Survey: Albania 2002 Table 3.3 B Percent Distribution of Characteristics of Male Sample by Residence and Stratum Reproductive Health Survey: Albania 2002 Table 3.4 A Percent Distribution of Marital Status by Selected Characteristics, for Women Aged 15–44 Years Reproductive Health Survey: Albania 2002 Table 3.4 B Percent Distribution of Marital Status by Selected Characteristics, for Men Aged 15–49 Years Reproductive Health Survey: Albania 2002 Table 4.1 Three-Year Period Age-Speciﬁ c Fertility Rates for Several Time Periods Among All Women Aged 15–44 Reproductive Health Survey: Albania 2002 Table 4.2 Three-Year Period* Age–Speciﬁ c and Total Fertility Rates, Among Women Aged 15–44 Reproductive and Demographic Health Surveys (RHS and DHS) in Selected Eastern European and Former Soviet Union Countries Albania Reproductive Health Survey 2002, Final Report Table 4.3 A Age-Speciﬁ c Fertility Rates and Total Fertility Rates by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Albania 2002 Table 4.3 B Age-Speciﬁ c Fertility Rates and Total Fertility Rates by Selected Characteristics Among All Men Aged 15–49 Reproductive Health Survey: Albania 2002 Table 4.4 A Percent Distribution of Number of Live Births by Current Age of Respondents Among all Women and Among Married Women Aged 15–44 Reproductive Health Survey: Albania 2002 Table 4.4 B Percent Distribution of Number of Live Births by Current Age of Respondents Among All Men and Among Married Men Aged 15–49 Reproductive Health Survey: Albania 2002 Table 4.5 A Percent of Women Aged 15–44 Who Had Their First Sexual Relation, First Marriage, and First Birth Before Selected Ages, and Median Age at These Events, by Current Age Reproductive Health Survey: Albania 2002 Table 4.5 B Percent of Men Aged 15–49 Who Had Their First Sexual Relation and First Marriage Before Selected Ages and Median Age at These Events, by Current Age Reproductive Health Survey: Albania 2002 Table 4.6 Median Age at First Sexual Intercourse, First Marriage and First Birth Among Women Aged 15–44 and Men Aged 15–49 by Selected Characteristics Reproductive Health Survey: Albania 2002 Table 4.7 Sexual Activity Status by Current Marital Status for Women Aged 15–44 and Men Aged 15–49 (Percent Distribution) Reproductive Health Survey: Albania 2002 List of Tables XIV Table 4.8 Abortions * per 1000 Births Reported in Reproductive Health Survey and By Albanian Institute of Statistics (INSTAT)† Three Year Period: 1999–2001 Table 4.9 A Planning Status of the Last Pregnancy Among Women 15–44 Years of Age With at Least One Pregnancy Since January 1997, by Selected Characteristics (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 4.9 B Planning Status of the Last Live Birth Among Men 15–49 Years of Age With Partner Having at Least One Live Birth Since January 1997, by Selected Characteristics (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 4.10 A Fertility Preferences of Currently Married Women Aged 15–44 Years By Number of Living Children and by Age Group (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 4.10 B Fertility Preferences of Currently Married Men Aged 15–49 Years By Number of Living Children and by Age Group (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 4.11 Percentage of Fecund Married Women Reporting They Want no More Children by Number of Living Children and Selected Characteristics Fecund Women 15–44 Years of Age. Reproductive Health Survey: Albania 2002 Table 5.1 Prenatal Care by Pregnancy Trimester of First Visitand Number of Prenatal Visits, for Births in 1997–2002, by Selected Characteristics (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 5.2 Percentage Counseled on Speciﬁ c Topics During Prenatal Care Visits for Births in 1997–2002 by Selected Characteristics, Among Women with Any Prenatal Care Reproductive Health Survey: Albania 2002 Table 5.3 Percentage Experiencing Selected Procedures During Prenatal Care Visits for Births in 1997–2002 by Selected Characteristics, Among Women with Any Prenatal Care. Reproductive Health Survey: Albania 2002 Table 5.4 Percentage with Routine Measurement of Blood Pressure (BP) During Pregnancy, Reported High Blood Pressure (HBP) During Pregnancy, and Hospitalization Rate for HBP, for Births in 1997–2002, Among Women with Any Prenatal Care. Reproductive Health Survey: Albania 2002 Table 5.5 Use of Ultrasound Exams During Pregnancy and Time of First Ultrasound Exam, By Selected Characteristics, for Births in 1997– 2002, Among Women with Any Prenatal Care. Reproductive Health Survey: Albania 2002 Table 5.6 Percentage of Pregnancy Complications that Required Medical Attention, by Selected Characteristics, for Births in 1997–2002, Among Women with Any Prenatal Care. Reproductive Health Survey: Albania 2002 Table 5.7 Place of Delivery for Births in 1996– 2001 by Selected Characteristics (Percent Distribution) Reproductive Health Survey: Albania 2002 Table 5.8 Average Time Between Admission and Delivery and Percent Distribution of Number of Nights Spent in a Medical Facility, for Births in 1997–2002. Reproductive Health Survey: Albania 2002 Table 5.9 Percentage of Cesarean Deliveries by Selected Characteristics, for Births in 1997– 2002, Among Women Currently Aged 15–44. Reproductive Health Survey: Albania 2002 Table 5.10 Percentage of Poor Birth Outcomes by Selected Characteristics, for Births in 1997– 2002, Among Women Currently Aged 15–44. Reproductive Health Survey: Albania 2002 Table 5.11 Percentage Who Attended Postpartum Care Visit within Speciﬁ ed Time Periods by Selected Characteristics, for Births in 1997– 2002, Among Women Currently Aged 15–44. Reproductive Health Survey: Albania 2002 Table 5.12 Percentage of Women with Information Received During Postpartum Care by Selected Characteristics, for Births in 1997–2002. Reproductive Health Survey: Albania 2002 Albania Reproductive Health Survey, 2002 Final Report XV Table 5.13 Time Between Delivery and First Baby Clinic Visit by Selected Characteristics, for Births in 1997–2002. Reproductive Health Survey: Albania 2002 Table 5.14 Percentage of Babies With Birth Certiﬁ cates Issued and Time Between Delivery and Certiﬁ cate Issued for Births in 1997–2002. Reproductive Health Survey: Albania 2002 Table 5.15 Percentage of Women Reporting Postpartum Complications, by Selected Characteristics, for Births in 1997–2002. Reproductive Health Survey: Albania 2002 Table 5.16 Percent of Children Ever Breastfed and Percent Distribution of Initiation of Breastfeeding, by Selected Characteristics, for Births in 1997–2002. Reproductive Health Survey: Albania 2002 Table 5.17 Mean Duration of Breastfeeding in Months, by Type of Breastfeeding and Selected Characteristics, for Births in 1997–2002. Reproductive Health Survey: Albania, 2002 Table 5.18 Infant and Child Mortality Rates (Infant and Child Deaths per 1,000 Live Births) by Selected Characterisitcs, for Children Born August 1992–July 2002. Reproductive Health Survey: Albania 2002 Table 6.1 A Percentage of Women Aged 15– 44 Who Have Heard of Speciﬁ c Methods of Contraception by Selected Characteristics Reproductive Health Survey: Albania, 2002 Table 6.1 B Percentage of Men Aged 15–49 Who Have Heard of Speciﬁ c Methods of Contraception by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 6.2 A Percentage of Women Aged 15–44 Who Say They Know How Speciﬁ c Methods of Contraception Are Used by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 6.2 B Percentage of Men 15–49 Years Who Say They Know How Speciﬁ c Methods of Contraception are Used by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 6.3 A Percentage of Women 15–44 Years Who Say They Know Where to Get Speciﬁ c Contraceptive Methods by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 6.3 B Percentage of Men 15–49 Years Who Say They Know Where to Get Speciﬁ c Contraceptive Methods by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 6.4 A Percent Distribution of Most Important Source of Information about Contraception by Speciﬁ c Method Among Women Aged 15–44 Who Have Heard About Speciﬁ c Methods of Contraception. Reproductive Health Survey: Albania, 2002 Table 6.4 B Percent Distribution of Most Important Source of Information about Contraception by Speciﬁ c Method Among Men Aged 15–49 Who Have Heard About Speciﬁ c Methods of Contraception. Reproductive Health Survey: Albania, 2002 Table 6.5 A Percentage Distribution of Women 15–44 by Their Opinion About Contraceptive Effectiveness if the Method is Used Correctly and Consistently. Reproductive Health Survey: Albania, 2002 Table 6.5 B Percentage Distribution of Men 15–49 by Their Opinion About Contraceptive Effectiveness if the Method is Used Correctly and Consistently. Reproductive Health Survey: Albania, 2002 Table 7.1 Percent of Women Currently Using Any Contraceptive Method by Marital Status Among Women Aged 15–44 Reproductive and Demographic Health Surveys (RHS and DHS) In Selected Eastern European and Former Soviet Union Countries. Albania Reproductive Health Survey 2002, Final Report Table 7.2 A Current Use of Contraception Among Women 15–44 Years of Age, by Marital Status (Percent Distribution). Reproductive Health Survey: Albania, 2002 List of Tables XVI Table 7.2 B Current Use of Contraception Among Men 15–49 Years of Age, by Marital Status (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.3 A Percentage Currently Using Modern and Traditional Methods by Selected Characteristics Currently Married Women Aged 15–44 Years. Reproductive Health Survey: Albania, 2002 Table 7.3 B Percentage Currently Using Modern and Traditional Methods by Selected Characteristics Currently Married Men Aged 15– 49 Years. Reproductive Health Survey: Albania, 2002 Table 7.4 A Current Use of Speciﬁ c Contraceptive Methods by Selected Characteristics Currently Married Women Aged 15–44 Years. Reproductive Health Survey: Albania, 2002 Table 7.4 B Current Use of Speciﬁ c Contraceptive Methods by Selected Characteristics Currently Married Men Aged 15–49 Years. Reproductive Health Survey: Albania, 2002 Table 7.5 Source of Supply for Last Modern Contraceptive Used Among Currently Married Women Aged 15–44 Years Currently Using a Modern Method by Speciﬁ c Methods (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.6 Percent Distribution of Type of Counseling by a Health Care Provider for Current Contraceptive Method Among Married Women Aged 15–44 Currently Using a Modern Method. Reproductive Health Survey: Albania, 2002 Table 7.7 A Percentage of Contraceptive Users Who Stated that Selected Reasons Read to Them Were Very Important or Somewhat Important When Deciding To Use a Non-Supplied Method Instead of a Modern Method, by Selected Characteristics Women Aged 15–44 Currently Using Traditional Methods. Reproductive Health Survey: Albania, 2002 Table 7.7 B Percentage of Contraceptive Users Who Stated That Selected Reasons Read to Them Were Very Important or Somewhat Important When Deciding To Use a Non-Supplied Method Instead of a Modern Method, by Selected Characteristics Men Aged 15–49 Currently Using Traditional Methods. Reproductive Health Survey: Albania, 2002 Table 7.8 A Perceived Effectiveness of Traditional Methods Compared to Modern Methods by Selected Characteristics Women Aged 15–44 Currently Using Traditional Methods (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.8 B Perceived Effectiveness of Traditional Methods Compared to Modern Methods by Selected Characteristics Men Aged 15–49 Currently Using Traditional Methods (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.9 A Most Commonly Cited Reasons for Not Currently Using Contraception Among Currently Married Women Aged 15–44 Years (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.9 B Most Commonly Cited Reasons for Not Currently Using Contraception by Age Group Among Currently Married Men Aged 15– 49 Years (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.10 A Desire to Use Contraception in the Future by Number of Living Children Fecund Currently Married Women Aged 15–44 Years Who Are Not Using Contraception (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 7.10 B Desire to Use Contraception in the Future by Number of Living Children Fecund Currently Married Men Aged 15–49 Years Who Are Not Using Contraception (Percent Distribution). Reproductive Health Survey: Albania, 2002 Albania Reproductive Health Survey, 2002 Final Report XVII Table 7.11 Desire to Use Contraception in the Future by Fertility Preferences Fecund Currently Married Women Aged 15–44 Years Who Are Not Using Contraception (Percent Distribution). Reproductive Health Survey: Albania, 2002 Table 8.1 Potential Demand For Family Planning (FP) Services by Age Group And Marital Status (Percent Distributions and Percentage). Reproductive Health Survey: Albania, 2002 Table 8.2 Percentage of Women Aged 15–44 Years in Need of Any or Modern Contraceptive Methods by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 8.3 Percentage of Unmet Need for Contraception Among Fecund Married Women of Reproductive Age by Future Fertility Preferences *. Reproductive Health Survey: Albania, 2002 Table 8.4 Percentage of Potential Demand for Modern Contraceptive Methods Satisﬁ ed Married Women 15–44 Years of Age At Risk of an Unintended Pregnancy By Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 8.5 Advise on Using Modern Methods by Method and Type of Counseling: Ever Users of Modern Methods. Reproductive Health Survey: Albania, 2002 Table 8.6 Counseling and Contraception Offered at the Time of Legally Performed Abortions. Reproductive Health Survey: Albania, 2002 Table 9.1 Percentage Who Want More Information about Contraception by Selected Characteristics Among Women Aged 15–44 and Men Aged 15– 49. Reproductive Health Survey: Albania, 2002 Table 9.2 A Percent Distribution of Women’s Opinion on the Best Source of Contraceptive Information by Selected Characteristics Among Women 15–44 Who Want More Information About Contraception. Reproductive Health Survey: Albania, 2002 Table 9.2 B Percent Distribution of Men’s Opinion on the Best Source of Contraceptive Information by Selected Characteristics Among Men Aged 15–49 Who Want More Information About Contraception. Reproductive Health Survey: Albania, 2002 Table 9.3 Percentage Who Think That Information about Contraception Should be Broadcast on Radio or Television by Selected Characteristics Among Women Aged 15–44 and Men Aged 15– 49. Reproductive Health Survey: Albania, 2002 Table 9.4 Percentage Who Agree with Selected Statements Concerning Possible Advantages and Disadvantages of Using the Pill, by Residence and Education Among Women Aged 15–44 Who Have Heard of the Pill. Reproductive Health Survey: Albania 2002 Table 9.5 Percentage Who Agree with Selected Statements Concerning Possible Advantages and Disadvantages of Using the IUD, by Residence and Education Among Women Aged 15–44 Who Have Heard of the IUD. Reproductive Health Survey: Albania 2002 Table 9.7 Percent Distribution of Opinion of Degree of Risk to a Woman’s Health From Using the Pill by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 Table 9.8 A Percent Distribution of Opinion of Degree of Risk to a Woman’s Health From Using the Condom by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 Table 9.8 B Percent Distribution of Opinion of Degree of Risk to a Woman’s Health From Using the Condom by Selected Characteristics Among Men Aged 15–49. Reproductive Health Survey: Albania, 2002 Table 9.9 Percent Distribution of Opinion of Degree of Risk to a Woman’s Health from Tubal Ligation by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 List of Tables XVIII Table 9.10 A Percent Distribution of Opinion of Degree of Risk to a Woman’s Health From Abortion by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 Table 9.10 B Percent Distribution of Opinion of Degree of Risk to a Woman’s Health from Abortion by Selected Characteristics Among Men Aged 15– 49. Reproductive Health Survey: Albania, 2002 Table 10.1 Mean Ideal Number of Children for a Young Family in Albania by Selected Characteristics Among Women Aged 15–44 and Men Aged 15–49. Reproductive Health Survey: Albania, 2002 Table 10.2 A Percent Distribution of Women’s Opinion on the Most Likely Time in the Menstrual Cycle for a Woman to Become Pregnant by Selected Characteristics Among Women 15–44. Reproductive Health Survey: Albania, 2002 Table 10.2 B Percent Distribution of Men’s Opinion on the Most Likely Time In the Menstrual Cycle for a Woman to Become Pregnant by Selected Characteristics Among Men Aged 15– 49. Reproductive Health Survey: Albania, 2002 Table 10.3 A Percent Distribution of Women’s Opinion on the Likelihood of Pregnancy While Breastfeeding by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania 2002 Table 10.3 B Percent Distribution of Men’s Opinion on the Likelihood of Pregnancy While Breastfeeding by Selected Characteristics Among Men Aged 15–44. Reproductive Health Survey: Albania 2002 Table 10.4 A Percentage Distribution of Women’s Agreement that Abortion Is a Woman’s Personal Decision by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 Table 10.4 B Percentage Distribution of Men’s Agreement that Abortion Is a Woman’s Personal Decision by Selected Characteristics Among Men Aged 15–49. Reproductive Health Survey: Albania, 2002 Table 10.5 Percent Distribution of Opinion Regarding Abortion Under Selected Circumstances by Selected Characteristics Among Women and Men of Reproductive Age Who Do Not Believe That Abortion Is Always a Woman’s Personal Decision. Reproductive Health Survey: Albania, 2002 Table 10.6 A Percentage Who Agree with the Acceptability of Abortion Under Selected Circumstances by Selected Characteristics Among Women Aged 15–44 Who Do Not Believe That Abortion is Always a Woman’s Personal Decision. Reproductive Health Survey: Albania, 2002 Table 10.6 B Percentage Who Agree with the Acceptability of Abortion Under Selected Circumstances by Selected Characteristics Among Men Aged 15–49 Who Do Not Believe That Abortion Is Always a Woman’s Personal Decision. Reproductive Health Survey: Albania, 2002 Table 10.7 A Percent Distribution of Women’s Opinion on What a Woman Should Do If a Pregnancy is Unwanted by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 Table 10.7 B Percent Distribution of Men’s Opinion on What a Woman Should Do If a Pregnancy is Unwanted by Selected Characteristics Among Men Aged 15–49. Reproductive Health Survey: Albania, 2002 Table 10.8 Percentage Who Agree with Statements on Gender Norms by Residence and Education Among Women Aged 15–44 and Men Aged 15– 49. Reproductive Health Survey: Albania 2002 Table 10.9 A Percentage Who Agree with Statements on Gender Norms by Selected Characteristics Among Women Aged 15–44. Reproductive Health Survey: Albania, 2002 Table 10.9 B Percentage Who Agree with Statements on Gender Norms by Selected Characteristics Among Men Aged 15–49. Reproductive Health Survey: Albania, 2002 Albania Reproductive Health Survey, 2002 Final Report XIX Table 10.10 Percent Distribution of Opinion on Who Should Decide How Many Children A Couple Will Have by Selected Characteristics Among Women Aged 15–44 and Men Aged 15– 49. Reproductive Health Survey: Albania 2002 Table 11.1 A Percentage Visiting Any Health Facility* in the Past 12 Months, by Selected Characteristics Women Aged 15–44 Years. Reproductive Health Survey: Albania 2002 Table 11.1 B Percentage Visiting Any Health Facility* in the Past 12 Months, by Selected Characteristics, Among Men Aged 15–49 Years. Reproductive Health Survey: Albania 2002 Table 11.2 A Percentage of Women Who Visited a Health Facility in the Past 12 Months That Received Counseling For Family Planning Methods by Type of Facility and Selected Characteristics, Women Aged 15–44 Years. Reproductive Health Survey: Albania 2002 Table 11.2 B Percentage of Men Aged 15–49 Years Who Visited a Health Facility in Past 12 Months That Received information/Counseling on Selected Topics, By Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.3 A Percentage Agreeing that Selected Factors May Be a Major Problem Preventing Women From Getting Medical Advice or Treatment for Themselves, by Selected Characteristics, Among Women Aged 15–44 Years. Reproductive Health Survey: Albania 2002 Table 11.3 B Percentage Agreeing that Selected Factors May Be a Major Problem Preventing Men From Getting Medical Advice or Treatment for Themselves, by Selected Characteristics, Among Men Aged 15–49 Years. Reproductive Health Survey: Albania 2002 Table 11.4 Time since Last Routine Gynecologic Examination by Selected Characteristics, Among Women Aged 15–44 Years Who Have Ever Had Sexual Intercourse. Reproductive Health Survey: Albania 2002 Table 11.5 Most Important Reason That Women Have Never Had a Routine Gynecologic Exam, by Selected Characteristics, Among Women Aged 15–44 Years Who Have Ever Had Sexual Intercourse. Reproductive Health Survey: Albania 2002 Table 11.6 Percentage with Awareness of Breast Self-Examination (BSE) and Frequency of BSE, by Selected Characteristics, Among Women Aged 15–44 Years Who Have Ever Had Sexual Intercourse. Reproductive Health Survey: Albania 2002 Table 11.7 Frequency of Cervical Cancer Screening by Selected Characteristics, Among Women Aged 15–44 Years Who Have Ever Had Sexual Intercourse. Reproductive Health Survey: Albania 2002 Table 11.8 Main Reason that Women Have Never Had a Pap Smear, by Selected Characteristics, Among Women Aged 15–44 Years Who Have Ever Had Sexual Intercourse. Reproductive Health Survey: Albania 2002 Table 11.9 A Percentage of Women Aged 15– 44 Years Who Have Been Told by a Doctor That They Have Selected Health Problems, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.9 B Percentage of Men Aged 15–49 Years Who Have Been Told by a Doctor That They Have Selected Health Problems, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.10 Percentage of Currently Married Women Aged 15–44 Years Who Reported Fecundity Impairment, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.11 Percentage of Currently Married Women Aged 15–44 Years Who Reported Fecundity Impairment by Type of Problem and Selected Characteristics. Reproductive Health Survey: Albania 2002 List of Tables XX Table 11.12 A Percentage of Women Aged 15– 44 Who Have Ever Smoked and Who Currently Smoke by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.12 B Percentage of Men Aged 15–49 Who Have Ever Smoked and Who Currently Smoke, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.13 A Percentage of Women Aged 15–44 Who Report Having a Drink Containing Alcohol in past 3 Months, and Frequency of Drinking, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 11.13 B Percentage of Men Aged 15–49 Who Report Having a Drink Containing Alcohol in Past 3 Months, and Frequency of Drinking, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.1 A Percentage of Women Aged 15–44 Who Agree Certain Sex Education Topics Be Taught in School, By Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.1 B Percentage of Men Aged 15–49 Who Agree Certain Sex Education Topics Be Taught in School, By Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.2 A Percent Distribution of Best Age to Start School-Based Courses on Human Reproduction and Contraception, as Reported by Women Aged 15–44 Who Are in Favor of Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.2 B Percent Distribution of Best Age to Start School-Based Courses on Human Reproduction and Contraception, as Reported by Men Aged 15–49 Who Are in Favor of Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.3 A Percent Distribution of Best Age to Start School-Based Courses on Sexually Transmitted Infections, as Reported by Women 15–44 Who are in Favor of Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.3 B Percent Distribution of Best Age to Start School-Based Courses on Sexually Transmitted Infections, as Reported by Men 15– 49 Who are in Favor of Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.4 A Percentage of Young Adult Women Aged 15–24 Who Discussed The Indicated Family Life Education Topics With a Parent Before They reached Age 18, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.4 B Percentage of Young Adult Men Aged 15–24 Who Discussed The Indicated Family Life Education Topics With a Parent Before They Reached Age 18, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.5 A Percentage of Young Adult Women Aged 15–24 Who Were Taught Indicated Family Life Education Topics in School Before They Reached Age 18, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.5 B Percentage of Young Adult Men Aged 15–24 Who Were Taught Indicated Family Life Education Topics in School Before They Reached Age 18, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.6 A Percentage of Young Adult Women Aged 15–24 Who Were Taught in School About Indicated Family Life Education Topics by Speciﬁ c Ages. Reproductive Health Survey: Albania 2002 Table 12.6 B Percentage of Young Adult Men Aged 15–24 Who Were Taught in School About Indicated Family Life Education Topics by Speciﬁ c Ages. Reproductive Health Survey: Albania 2002 Table 12.7 A Percent Distribution of The Most Important Source of Information Related to Sexual Matters, Reported by Young Adult Women 15–24 Who Had Received Any Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Albania Reproductive Health Survey, 2002 Final Report XXI Table 12.7 B Percent Distribution of The Most Important Source of Information Related to Sexual Matters, Reported by Young Adult Men 15–24 Who Had Received Any Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.8 A Percent Distribution of The Most Important Source of Information Related to Sexual Matters, Reported by Young Adult Women 15–24 Who Never Received Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.8 B Percent Distribution of The Most Important Source of Information Related to Sexual Matters, Reported by Young Adult Men 15–24 Who Never Received Sex Education in School, by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 12.9 A Knowledge of Young Adult Women Aged 15–24, on Selected Reproductive Health Issues by Whether or Not Speciﬁ c Topics Were Discussed With a Parent or Taught in School (Percent Distribution). Reproductive Health Survey: Albania 2002 Table 12.9 B Knowledge of Young Adult Men Aged 15–24, on Selected Reproductive Health Issues by Whether or Not Speciﬁ c Topics Were Discussed With a Parent or Taught in School (Percent Distribution). Reproductive Health Survey: Albania 2002 Table 13.1 A Percent Distribution of Reported Sexual Experience by Marital Status at Time of First Sexual Experience by Selected Characteristics Among Young Women Aged 15– 24. Reproductive Health Survey: Albania, 2002 Table 13.1 B Percent Distribution of Reported Sexual Experience by Marital Status at Time of First Experience by Selected Characteristics, Among Young Men Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.2 Percent Distribution of Reported Sexual Experience by Marital Status at Time of First Sexual Experience by Current Age Among Young Women Aged 15–24 Reproductive and Demographic Health Surveys (RHS and DHS) In Selected Eastern European and Former Soviet Union Countries. Albania Reproductive Health Survey 2002, Final Report Table 13.3 A Percent Distribution of Relationship to Partner at First Sexual Intercourse Among Sexually Experienced Young Women Aged 15– 24. Reproductive Health Survey: Albania, 2002 Table 13.3 B Percent Distribution of Relationship to Partner at First Sexual Intercourse Among Sexually Experienced Young Men Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.4 A Percent of Women Aged 15–24 Who Had Their First Sexual Intercourse Before Selected Ages, by Various Characteristics. Reproductive Health Survey: Albania 2002 Table 13.4 B Percent of Men Aged 15–24 Who Had Their First Sexual Intercourse Before Selected Ages, by Various Characteristics. Reproductive Health Survey: Albania 2002 Table 13.5 A Percent Distribution of Age Difference Between Partners at First Sexual Intercourse Among Sexually Experienced Young Women Aged 15–24 by Residence, Age at ﬁ rst Sex and Marital Status at First Sex. Reproductive Health Survey: Albania, 2002 Table 13.5 B Percent Distribution of Age Difference Between Partners at First Sexual Intercourse Among Sexually Experienced Young Men Aged 15–24 by Residence, Age at first Sex and Marital Status at First Sex. Reproductive Health Survey: Albania, 2002 Table 13.6 A Percent Who Used Contraception at First Sexual Intercourse and Percent Distribution of Method Used Among Sexually Experienced Young Women Aged 15–24. Reproductive Health Survey: Albania, 2002 List of Tables XXII Table 13.6 B Percent Who Used Contraception at First Sexual Intercourse And Percent Distribution of Method Used Among Sexual Experienced Young Men Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.7 Percent Distribution of Most Commonly Cited Reasons for Not Using Contraception at First Sexual Intercourse Among Sexually Experienced Young Women Aged 15– 24 by Marital Status at First Sexual Intercourse. Reproductive Health Survey: Albania, 2002 Table 13.8 Percent Distribution of Current Sexual Activity Status by Sex, Current Marital Status and Age Group Among Young Adults Aged 15– 24. Reproductive Health Survey: Albania, 2002 Table 13.9 A Percent Who Used Contraception at Last Sexual Intercourse and Percent Distribution of Methods Used by Current Marital Status and Age Group Among Sexually Experienced Young Women Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.9 B Percent Who Used Contraception at Last Sexual Intercourse and Percent Distribution of Methods Used by Current Marital Status and Age Group Among Sexually Experienced Young Men Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.10 Percent Distribution of Main Reason Not Currently Using Contraception by Sex and Current Marital Status Among Sexually Active Young Adults Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.11 A Percent Distribution of Number of Sexual Partners in Last Three Months and in Lifetime by Current Marital Status and Education Level Among Sexually Experienced Young Women Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.11 B Percent Distribution of Number of Sexual Partners in Last Three Months And in Lifetime by Marital Status and Education Level Among Sexually Experienced Young Men Aged 15–24. Reproductive Health Survey: Albania, 2002 Table 13.12 Percent Agreeing With Statements About Condoms and Condom Use, by Sex and Condom Experience for Sexually Experienced Young Adults Aged 15–24 Years. Reproductive Health Survey: Albania, 2002 Table 13.13 A Percent Agreeing With Hypothetical Responses to a Partner Requesting Condom Use During Sex, by Selected Characteristics, Among Sexually Experienced Young Women 15–24 Years of Age. Reproductive Health Survey: Albania, 2002 Table 13.13 B Percent Agreeing With Hypothetical Responses to a Partner Requesting Condom Use During Sex, by Selected Characteristics, Among Sexually Experienced Young Men 15–24 Years of Age. Reproductive Health Survey: Albania, 2002 Table 13.14 Percent Who Have Ever Talked to a Partner About Using Condoms, by Sex and Selected Characteristics for Sexually Experienced Young Adults 15–24 Years of Age. Reproductive Health Survey: Albania, 2002 Table 14.1 A Percentage of Women Aged 15–44 Who Have Heard of Specified Sexually Transmitted Infections by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.1 B Percentage of Men Aged 15–49 Who Have Heard of Specified Sexually Transmitted Infections by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.2 A Percentage of Women Aged 15–44 With Knowledge of Symptoms Associated With STIs, Other Than HIV/AIDS, in a Woman by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.2 B Percentage of Men Aged 15–49 With Knowledge of Symptoms Associated With STIs, Other Than HIV/AIDS, in a Man by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Albania Reproductive Health Survey, 2002 Final Report XXIII Table 14.3 A Most Important Source of Information About Sexually Transmitted Infections All Women Aged 15–44 Who Have Heard of at Least One STI by Selected Characteristics. Reproductive Health Survey: Albania, 2002 (Percent Distribution) Table 14.3 B Most Important Source of Information on Sexually Transmitted Infections All Men Aged 15–49 Who Have Heard of at Least One STI by Selected Characteristics. Reproductive Health Survey: Albania, 2002 (Percent Distribution) Table 14.4 A Percentage of Women of Reproductive Age Who Had Received Radio And Television Messages About HIV/AIDS and Other STIs During The Past Six Months By Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.4 B Percentage of Men of Reproductive Age Who Had Received Radio And Television Messages About HIV/AIDS and Other STIs During The Past Six Months By Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.5 A Percentage of Women Aged 15–44 Years with a Diagnosis of Specified Sexually Transmitted Infections by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.5 B Percentage Men Aged 15–49 With a Diagnosis of Specified Sexually Transmitted Infections by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.6 A Level of Awareness, Testing, Diagnosis, And Treatment For STIs Among Women Aged 15–44 Years Who Have Ever Had Sexual Intercourse by Specific Sexually Transmitted Infections. Reproductive Health Survey: Albania, 2002 Table 14.6 B Level of Awareness, Testing, Diagnosis, And Treatment For STIs Among Men Aged 15–49 Years Who Have Ever Had Sexual Intercourse by Specific Sexually Transmitted Infections. Reproductive Health Survey: Albania, 2002 Table 14.7 A Percent Distribution of Women Aged 15–44 Who Have Heard of at Least One Sexually Transmitted Infection By Self- Perceived Risk of Acquiring an STI by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.7 B Percent Distribution of Men Aged 15–49 Who Have Heard of at Least One Sexually Transmitted Infection By Self-Perceived Risk of Acquiring an STI by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.8 A Percentage of Women Aged 15–44 Who Have Heard of HIV/AIDS, Who Believe HIV/AIDS Infection Can Be Asymptomatic, and Who Know Where HIV Testing Is Provided by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.8 B Percentage of Men Aged 15–49 Who Have Heard of HIV/AIDS, Who Believe HIV/AIDS Infection Can be Asymptomatic, and Who Know Where HIV Testing is Provided by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.9 A Percentage of Women Aged 15–44 Who Do Not Know Principle Mechanisms of HIV Transmission by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.9 B Percentage of Men Aged 15–49 Who Do Not Know Principle Mechanisms of HIV Transmission by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.10 A Percentage of Women Aged 15– 44 Who Correctly Reject Misconceptions About HIV Transmission by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.10 B Percentage of Men Aged 15–49 Who Correctly Reject Misconception About HIV Transmission by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.11 A Percentage of Women Aged 15–44 Who Know HIV Infection Can Be Asymptomatic, And is Not Spread by Dental Treatment or Mosquito Bite, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 List of Tables XXIV Table 14.11 B Percentage of Men Aged 15–49 Who Know HIV Infection Can Be Asymptomatic, And is Not Spread by Medical Treatment or Mosquito Bite, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.12 A Percent Distribution of Women Aged 15–44 Who Mentioned Possible Means of Preventing HIV/AIDS Spontaneously And After Probing. Reproductive Health Survey: Albania, 2002 Table 14.12 B Percent Distribution of Men Aged 15–49 Who Mentioned Possible Means of Preventing HIV/AIDS Spontaneously and After Probing. Reproductive Health Survey: Albania, 2002 Table 14.13 A Percent of Women Aged 15–44 Who Know Possible Means of Preventing HIV/AIDS Transmission Spontaneously and After Probing, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.13 B Percent of Men Aged 15–49 Who Know Possible Means of Preventing HIV/AIDS Transmission Spontaneously and After Probing, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.14 A Percent of Women Aged 15–44 Who Believe HIV Can Be Prevented By Limiting Number of Sexual Partners, Being Monogomous, And Using Condoms, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.14 B Percent of Men Aged 15–49 Who Believe HIV Can Be Prevented By Limiting Number of Sexual Partners, Being Monogamous, And Using Condoms, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.15 A Percent Distribution of Women Aged 15–44 by Self-Perceived Risk of Contracting HIV/ AIDS by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.15 B Percent Distribution of Men Aged 15–49 by Self-Perceived Risk of Contracting HIV/ AIDS by Selected Characteristics. Reproductive Health Survey: Albania, 2002 Table 14.16 A Opinion About The Main Risk Factor of Contracting HIV/AIDS Among Women 15–44 Who Have Heard About HIV/AIDS And Believe They Have Any Risk of Contracting HIV/ AIDS. Reproductive Health Survey: Albania, 2002 Table 14.16 B Opinion About The Main Risk Factor of Contracting HIV/AIDS Among Men 15–44 Who Have Heard About HIV/AIDS And Believe They Have Any Risk of Contracting HIV/ AIDS. Reproductive Health Survey: Albania, 2002 Table 14.17 A Opinion About The Main Factor That Protects From Contracting HIV/AIDS Among Women Aged 15–44 Who Have Heard of HIV/AIDS And Believe That They Have No Risk of Contracting HIV/AIDS, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 (Percent Distribution) Table 14.17 B Opinion About The Main Factor That Protects From Contracting HIV/AIDS Among Men Aged 15–49 Who Have Heard of HIV/AIDS And Believe That They Have No Risk of Contracting HIV/AIDS, by Selected Characteristics. Reproductive Health Survey: Albania, 2002 (Percent Distribution) Table 15.1 A Percentage of Women Aged 15–44 Who Witnessed or Experienced Parental Abuse by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 15.1 B Percentage of Men Aged 15–49 Who Witnessed or Experienced Parental Abuse by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 15.2 A Percentage Who Reported Intimate Partner Violence (IPV) in Their Lifetime and Percentage Who Reported Intimate Partner Violence in The Last Year, by Type of Abuse and Selected Characteristics, Among Women Aged 15–44 Ever Married or in Union. Reproductive Health Survey: Albania 2002 Albania Reproductive Health Survey, 2002 Final Report XXV Table 15.2 B Percentage of Men Who Reported Perpetration of Intimate Partner Violence (IPV) in Their Lifetime And Percentage Who Perpetrated Intimate Partner Violence in The Last Year by Type of Abuse and Selected Characteristics, Among Men Aged 15–49 Ever Married or in Union. Reproductive Health Survey: Albania 2002 Table 15.3 A Percentage Who Reported Lifetime Physical Violence and Recent Violence by Severity of Violent Act by Selected Characteristics, Among Women Aged 15–44 Ever Married or in Union. Reproductive Health Survey: Albania 2002 Table 15.3 B Percentage Who Reported Inﬂ icting Lifetime Physical Violence And Recent Violence by Severity of Violent Act and Selected Characteristics, Among Men Aged 15–49 Ever Married or in Union. Reproductive Health Survey: Albania 2002 Table 15.4 Percent Distribution of Number of Incidents of Physical Abuse by Type of Abuse and Percentage Resulting in Physical Injuries Among Women Who Were Physically Abused During The Past Year Women Aged 15–44 Ever Married or in Union. Reproductive Health Survey: Albania 2002 Table 15.5 Women Who Were Physically Abused by an Intimate Partner During The Past Year Who Talked to Anyone About This Incident of Violence by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 15.6 Percentage of Women Who Were Physically Abused by an Intimate Partner During The Past Year Who Discussed the Abuse With Other Persons by Type of Person by Selected Characteristics. Reproductive Health Survey: Albania 2002 Table 15.7 Percentage Distribution of Women Who Were Ever Physically Abused by an Intimate Partner Who Did not Report the Abuse to a Health Provider, Police, or Lawyer by reasons for Not Reporting The Abuse by Residence and Socio- Economic Index. Reproductive Health Survey: Albania 2002 Table 15.8 Situations That Make Partner Violent as Reported by Women Who Were Physically Abused by an Intimate Partner During The Past Year by Residence. Reproductive Health Survey: Albania 2002 Table 15.9 Percentage of Women Aged 15–44 Ever Married or in Union Who Ever Experienced Any Form of Abuse Who Want to Know of The Tirana Hotline Number Where They Can Ask Questions About Violence Against Women. Reproductive Health Survey: Albania 2002 Table 15.10 Percentage of Women Age 15–44, Who Stated That a Man Has a Right to Hit or Beat His Wife Under The Following Situations by Residence and Education. Reproductive Health Survey: Albania 2002 List of Tables XXVI Albania Reproductive Health Survey, 2002 Final Report XXIX LIST O F FIG U R E S List of Figures Figure 4.1 Three-year period age-speciﬁ c fertility rates for several time periods among all women Figure 4.2 Median age at ﬁ rst sexual intercourse, ﬁ rst marriage, and ﬁ rst birth by education level Figure 5.1 Adequacy of prenatal care utilization index, births in the 5 years prior to the survey, across Eastern European countries Figure 5.2 Adequacy of prenatal care utilization index, births in the 5 years prior to the survey Figure 5.3 Infant mortality rates by district in 1995 and in 2000 Figure 5.4 Distribution of neonatal and post-neonatal deaths in Albania, 1995 and 2000 Figure 6.1 Awareness and knowledge of how to use contraceptive methods among women aged 15-44 years Figure 6.2 Awareness and knowledge of how to use contraceptive methods among men aged 15-49 years Figure 7.1 Currently married women and contraceptive use status Figure 7.2 Currently married women who are using modern, traditional, or no contraceptive method by educational level Figure 7.3 Percentage of contraceptive users who stated that selected reasons read to them were very important or somewhat important when deciding to use a non-supplied method instead of a modern method Figure 8.1 Unmet need for modern contraception among fecund married women of reproductive age by future fertility preferences Figure 8.2 Counseling and contraception offered at the time of last legally performed abortion Figure 9.1 Percentage who want more information about contraception Figure 9.2 Opinions on the best source of contraceptive information Figure 11.1 Percentage of respondents visiting any health facility in the past 12 months by residence Figure 11.2 Reproductive health behaviors among women who have ever had sex Figure 12.1 Best age to start school- based courses on human reproduction, contraception, and STIs in the opinions of female respondents Figure 12.2 Best age to start school- based courses on human reproduction, contraception, and STIs in the opinions of male respondents Figure 12.3 Young adult women who discussed or were taught about various family life education topics before they reached age 18 Figure 12.4 Young adult men who discussed or were taught about various family life education topics before they reached age 18 Figure 13.1 Marital status at time of ﬁ rst sexual experience among young adults List of Figures XXX Figure 13.2 Contraception used at first sexual intercourse Figure 13 3.Percent of sexually experienced young adults who have ever talked to a partner about using condoms Figure 14.1 Awareness of certain sexually transmitted infections among men and women 14-44 Figure 14.2 Recent exposure to mass media messages on HIV/AIDS and other STIs, all women and men of reproductive age Figure 15.1 Lifetime and recent physical violence, CDC-assisted Reproductive Health Surveys, selected countries in Eastern Europe and NIS Figure 15.2 Percentage of respondents who witnessed or experienced parental abuse Figure 15.3 Questions asked using modified Conflict Tactics Scale (CTS) Figure 15.4 Percentage of women ever married or in union who reported lifetime intimate partner violence (IPV), by marital status Figure 15.5 Women’s and men’s reports of IPV in lifetime and past year Albania Reproductive Health Survey, 2002 Final Report 1 B ack gro und Chapter 1 BACKGROUND Albania is a small country of about 28,748 km2, situated in southeastern Europe. It borders on Greece to the south, the Former Yugoslav Republic of Macedonia to the east, the UN administered province of Kosova and Republic of Serbia and Montenegro to the north and the Adriatic and Ionian Seas to the west. There are 720 km of land borders and 362 km of coastline. The terrain is mountainous except along the central coast. About 42% of the 3.1 million people of Albania live in urban areas and approximately 20% of the population live in the capital of Tirana (INSTAT, 2002). Albanians are the majority ethnic group, representing over 95% of the population. Albania is a multi-religious country and three major religions, Muslim, Orthodox Christian, and Roman Catholic, have been important in contributing to the Albanian heritage and culture. All religious practice was outlawed and mosques and churches closed in 1967. However, private religious practice was again legalized in 1990, with a separation of religion and state functions. There are no ofﬁ cial data on the prevalence of religious identity among Albanians. A recent unofﬁ cial study indicated that about 72% of the country identiﬁ es themselves as Muslim, 18% as Orthodox Christian, and 10% as Roman Catholic (Neza, 2000), but religious afﬁ liation is relative and linked mainly with inheritance from the past and not with current practice and beliefs. Albania is administratively divided into 36 districts, 12 prefectures, 311 communes, and 64 municipalities (INSTAT, 2002). The population distribution between districts is quite different; there are districts with less than 10,000 inhabitants and there are districts with as many as 200,000 inhabitants. Seven cities with more than 50,000 inhabitants represent 62% of the total urban population. This diversity is reﬂ ected in the average number of persons per square kilometer. There are districts with as low as 21 persons per km2 while there are a number of districts with more than 400 persons per km2 (INSTAT, 2001). The modern history of the Albanian state starts at the beginning of the last century when it gained independence from the Ottoman Empire in November 1912. Between the two world wars Albania was ﬁ rst a parliamentary democracy, then a monarchy. After the end of World War II, the National Liberation Front (NLF) led by the Communist Party, controlled the country and a one party system headed by the Workers’ Party was established. At that time Albania was part of the socialist bloc but gradually became isolated not only from the capitalist West but from almost all other Communist countries. This isolation was complete after 1978 when the country broke ties with China. The collapse of Communism across Eastern Europe in 1990–1991 brought a number of social, economic, and political changes to the region. Albania began a transition toward a democratic government and new, market-oriented economy, which has presented formidable challenges. The current Constitution of Albania was ratiﬁ ed in 1998 and established the government as a parliamentary republic, with the capital in Tirana. During the past 12 years Albania has faced continuous political and social changes, and after a period of transition, interrupted many times by social crises such as those of the years 1991–1992 and 1997 (the collapse of pyramid schemes) and the Kosovo crisis in 1999, Albania is now a country undergoing profound economic and structural reforms. Chapter 1 2 Background The economy of the country is changing from a central economic planning system to a free-market system; many questions related to privatization, property ownership claims, and the appropriate regulation of business still remain unresolved. The country has experienced slow but steady economic progress; however, according to poverty baseline statistics, 25.4% of the population is poor and 5% of Albanian citizens live in extreme poverty. The rates of poverty are higher in rural and remote areas of the country (UNDP, 2004). The ofﬁ cial unemployment rate is 16%, with two-thirds of all workers employed in agriculture, mostly at the subsistence level. Remittances from citizens working abroad remain extremely important, as does foreign assistance. Albania is a lower middle income country with a Gross National Income (GNI) per capita of US$ 1,380. The agricultural sector accounts for 34% of Gross Domestic Product (GDP). Workers’ remittances account for an additional 12% of GDP, with industry and services contributing 13% and 32%, respectively. While economic growth in Albania has ﬂ uctuated during the last ﬁ ve years, it is now on a positive track for growth. The government is projecting that economic growth will increase to 6% from 2003- 2005, with inﬂ ation rates of 2-4% (Ministry of Finance, 2002). The country has good potential for growth in agriculture, livestock, ﬁ sheries, forestry, tourism, mining, and light industry. Nonetheless, the country faces considerable challenges as it remains one of the poorest countries in Europe. According to available data, as mentioned above, about one out of four Albanians is poor and lack access to basic services. A weak and deteriorating infrastructure and related services have left up to 40% of households without access to necessities such as basic education, water, sanitation, and heating. The Government of Albania has developed a National Strategy for Social and Economic Development (NSSED) to lower the level of poverty and improve social and economic development. The main objectives of the NSSED for the three-year period, 2002-2004, are the following: (i) real GDP growth of 22- 25 percent; (ii) reduction of number of people living in poverty, particularly for the worst-affected social groups and areas; (iii) tangible improvement of infrastructure and related services, e.g. supply of potable water and electricity, particularly for the impoverished populations; (iv) reduction of infant and maternal mortality rates and disease incidence; and (v) increase in the level of elementary and secondary education school enrollment (Ministry of Finance, 2002). Reductions in infant and maternal mortality are one of the objectives of the Strategy and it follows that the health sector is responsible for this objective. Public spending on health is low compared to the average of 3.0% of GDP for lower middle income countries. As a consequence, one of the strategic priorities for public expenditures is to increase the share of GDP allocated to the health sector. The government planned to increase the share of GDP in 2005 to 4% compared with 1.85% in 2001. The percentage of total public expenditures has increased to 11% in 2004 from 7.4% in 1998. Albania started negotiations in January 2003 with the European Union for a Stabilization and Association Agreement (SAA). Negotiations have so far focused on political issues. The Albanian Government committed to Albania Reproductive Health Survey, 2002 Final Report 3 achieve Millennium Development Goals (MDG) following the July 2003 parliament resolution in support of MDGs, and recently prepared a MDG Progress Report as a result of the work of national consensus building groups comprising all partners and stakeholders. The Albania relevant MDG targets and indicators have been identiﬁ ed at the national level and regional and local levels, adopting different regional strategies consistent with local and national indicators (UNDP 2004). An Albanian-European Partnership Action Plan document has also been prepared by the Government with clearly identiﬁ ed measures to improve food safety, the environment and control and surveillance of communicable diseases, including process and outcome indicators. Also, the Government, in collaboration with donor agencies and other partners, is coordinating the MDG process and strategy using the objectives of the NSSED as well as related long term development efforts towards European and regional integration through the Stabilization and Association Agreement process. Strong links have been formed between global, national and local development agendas emphasizing national ownership of the process, uniﬁ cation of stakeholders and common advocacy campaigns, and establishing strong mechanisms for monitoring and reporting. During the years 1992–1993 there was a huge wave of emigration, mainly to neighboring European countries (Greece and Italy). During the period 1990– 1995, it is estimated that the number of emigrants ﬂ uctuated between 300,000 and 600,000, representing 9%–11% of the total population in 1995. Around 40% of them are estimated to be women and a new pattern of women emigrating alone without family members has been seen in recent years. Female trafﬁ cking and their exploitation as sex workers has appeared in the aftermath of the fall of old regime and in the vacuum of legislation (National Equity Committee, 2002; Lesko et al., 2003). The social changes have also been associated with the internal migration of the population towards the big cities and particularly towards the capital city of Tirana. The internal migration during these years brought changes in the ratio of the urban/rural population. In 1989, the urban population was 36% of the total population and by the year 2001, the percentage had increased to 42% (INSTAT, 2002). The demographic changes and the urbanization process are directly reﬂ ected in the decrease of the average household size. While in 1979 the average household size was 5.6 persons with 4.6 in the urban zones and 6.2 in the rural areas, the same indicator for 1989 was 4.7, 3.9, and 5.3 persons, respectively, and in the 2001 Census was 4.2, 3.9, and 4.5 persons, respectively (INSTAT, 2002). It appears that the tendency toward a family with two parents and two children is the new norm in Albania, as in many other countries. Internal migration has affected the lives of both women and children due to difﬁ cult access of services, unemployment and dependence on the male as the workers in the family. Life expectancy for females in 2001 was estimated to be 77.5 compared with 72.5 for males. Women typically marry and begin families at a relatively young age; the average age at marriage for women is 23 years (INSTAT, 2002). The provisions of the Albanian Constitution of 1946 sanctioned for the ﬁ rst time basic rights for women. However, Albanian women tend to follow a traditional model where women defer to the men in the family and the society has been very conservative Chapter 1 4 Background in preserving traditional family structures and inequalities in the family. The Albanian Parliament ratiﬁ ed in December 1993 the Convention on the Elimination of all Forms of Discrimination Against Women (AFPA et al, 2002). However, during the transition period, due to lack of work and high unemployment, women became more vulnerable and male or family support was necessary to survive. Many social services helping women in the past were eliminated due to lack of funding. In the northern parts of Albania the inﬂ uence of the Kanun, a code of traditional law dating back several centuries, is still practiced although it was prohibited by the state after the second world war. In the aftermath of the fall of the hard-line Communist regime, the Kanun is reported to have regained strength in the north of the country (National Equity Committee, 2002). The Kanun declares a woman to be property transferable from her father to her husband. When Albania was a Communist country, the healthcare system was centrally controlled and based on the Semashko model as in other countries of Eastern Europe and the Former Soviet Union. Health care was free to all with emphasis on infectious disease prevention and some health education programs, but an important percentage of the budget went to medical treatment. A variety of changes in the health legislation have been proposed very recently with the drafting or revision of important laws related to the ﬁ nancing and organization of the health care systems, and the creation of a health insurance fund and the patient rights card. Also, Albania has recently developed a new national ten-year strategy for healthcare reform. The implementation of a National Health Promotion Strategy has been discussed, consistent with the objectives of the health sector reform (under The National Strategy for Social-Economic Development) and includes the following goals: 1) increased effectiveness and efﬁ ciency in use of resources; 2) increased access to quality health services nationwide; and 3) improvement of health indicators through speciﬁ c targeted interventions. The increased effectiveness and efﬁ cient use of resources will be achieved through: (i) improvement of the planning process and needs assessment with improved management and fairer distribution of resources; (ii) decentralization of management functions to local institutions, including regional health authorities, and strengthening of the role of professional organizations; (iii) reduction in corruption; (iv) the gradual establishment of information systems; and (v) support for the privatization process in providing health services and monitoring of the private sector (Ministry of Health, 2004) The Primary Health Care Policy adopted in 1997 aims to offer accessible and ﬁ nancially affordable healthcare to all. Ofﬁ cially, health care still remains free, but while physicians are still employed by the state, many people pay for healthcare services in the form of gifts or unofﬁ cial fees for service. This unofﬁ cial expense comes out of limited household budgets. Very recently, user fees were introduced in hospitals and some primary health care facilities which are meant to limit and prevent “unofﬁ cial expenses.” Even though many health care facilities were rehabilitated since 1997 there are still facilities that urgently need basic repairs. Also, due to the closed nature of the country until 1990, physicians may not have the most up-to-date information and skills. In addition to Ministry of Health operated clinics, there are now private providers of healthcare and clinics operated by international organizations. Infant and under ﬁ ve mortality are ofﬁ cially reported as 23 deaths per 1,000 live births and 32 deaths per 1,000 live births, respectively, as of 2000, the Albania Reproductive Health Survey, 2002 Final Report 5 highest officially reported rate in Europe (INSTAT, 2002). Although these rates have both declined considerably from rates in the late 1950s and early 1960s, and the official statistics appear to show improvement in infant mortality since the transition, the rates may in fact be affected by problems such as non- registration of births in which the infant dies shortly thereafter and the definition of early neonatal deaths and early deaths of premature infants as stillbirths. Mortality rates are estimated to be more than twice as high among children in the more rural northern areas of the country than in the more urban central and coastal areas (World Bank, 1997). For 50 years Albania had a pronatalist population policy; modern family planning was forbidden and it was taboo to speak about sexuality and contraception in public. Reproductive health care and basic family planning services were introduced into the country in 1992 after a Decision of the Council of the Ministers that declared family planning should be seen as a basic human right from which all citizens should be able to benefit on their own free will. Eleven services are now provided with three levels of care, starting with primary healthcare services (health centers, ambulances in villages, and consulting centers for women and children in cities), maternity and pediatric hospitals at the secondary level, and the Hospital of Obstetrics and Gynecology in Tirana and the University Hospital Center “Mother Teresa” in Tirana at the tertiary level of care. Also, national and international NGOs provide family planning services in addition to advocacy on this issue. However, women often have limited access to information and services regarding reproductive health, especially in rural areas. Abortion, prior to 1991, was also forbidden and about half of the maternal deaths during the decade of the 1980’s were due to complications following illegal abortion. In April 1991, through the “order of the Minister of Health” and the “Decision of the Council of Ministers for the approval of activities of Family Planning in Albania,” abortion was legalized and modern methods of contraception were introduced in the public health services. The “Law for the Voluntary Interruption of Pregnancy until 12 Weeks Gestation” passed the Parliament in May 1995. Following its legalization in 1991, abortion declined as a cause of maternal mortality from 50% in 1989 to 25% in 1993 and to 6% in 1997 (unpublished paper, Population in Europe and North America on the Eve of the Millenium: Dynamic and Policy Responses, presented at the UNFPA Regional Population Meeting, December 1998, Budapest, Hungary). During the past 12 years, the ﬁ gures for maternal and infant mortality remain relatively high despite the fact that they had declined by about 50% compared with the years before 1990. A national law on reproductive health passed the parliament in June 2001 which regulates the management, administration, functioning and supervision of all reproductive health services and activities in public and private health institutions. The law protects the reproductive rights of individuals and couples in accordance with national policies and laws as well as known and accepted international principles. According to the law, the overall goals of reproductive healthcare services are to offer good access and quality reproductive healthcare; to improve the health status of women during their reproductive years, especially during childbearing and delivery; to improve the health status of newborns, infants, and children; and to improve the health of adolescents and young adults. Chapter 1 6 Background In addition to the striking similarities in socioeconomic conditions inherited from the Communist era, there have also been demographic and health similarities among countries in the region, in particular a heavy reliance on abortion rather than on modern contraception as a means of preventing unintended births. Therefore, reproductive health is an issue of critical importance for the countries of this region (CDC and ORC MACRO, 2004). Also, reproductive health has been considered as one of the priorities of the national health promotion and public health strategy (MOH, 2003) Beginning in 1993, several surveys on family planning and reproductive health attitudes and behaviors were conducted in Eastern Europe (CDC and MACRO, 2003). To this end, the Division of Reproductive Health of the U.S. Centers for Disease Control and Prevention (CDC/DRH) in Atlanta has provided technical assistance for Reproductive Health Surveys (RHS) in collaboration with local counterparts. Between 1993 and 2001, ten Reproductive Health Surveys were conducted in seven countries in Eastern Europe. A Reproductive Health Survey (RHS) was conducted in Albania in 2002 making it the 8th country in the region to conduct this type of survey. This survey represents the first systematic effort to gather representative national data on population and reproductive health issues in Albania. Population-based surveys of women of reproductive age using nationally representative samples are an effective mechanism for collecting information on topics such as family planning, fertility, contraceptive use, knowledge about HIV/ AIDS, and other reproductive health issues. Until recently, relatively little detailed and reliable population-based information was available about the situation in the country with regard to important reproductive health topics. The RHS, supported by USAID, UNFPA and UNICEF, examines patterns and levels of fertility, family planning, contraceptive use and method selection, health behaviors, knowledge of HIV/AIDS, as well as attitudes towards specific contraceptive methods and abortion. These issues are of particular importance in Albania, since for many years women and healthcare providers had limited access to up-to- date and reliable information on these topics. The survey also provides data on key maternal and child health indicators, infant feeding, and the extent to which mothers receive medical care during pregnancy and at delivery. A principal objective of the survey is to examine the reproductive health status and needs that can be used to help direct or modify program interventions. These data are particularly useful in assisting policy makers and health planners in evaluating health service needs, and identifying reproductive health behaviors associated with poor health outcomes. They could also play a significant role in designing programs better targeted to meet the needs of population subgroups. A key programmatic difference between policy objectives in Albania and other countries in Eastern Europe, compared with those in some developing countries, is that the emphasis is not on promoting a decline in fertility and population growth, but on bringing about improvements in women’s health through increased availability and improved use of modern contraceptive methods and reduced reliance on abortion. Until now, a comprehensive comparison of key family planning and reproductive Albania Reproductive Health Survey, 2002 Final Report 7 health indicators had never been compiled in Albania. The nationally representative data on key indicators presented in this report can be used to design or modify health interventions, identify high-risk behaviors amenable to change and highlight reproductive health areas that warrant greater attention. These data can be translated into policy and programmatic activities to improve services and ﬁ ndings may be combined with other existing information to contribute to a more profound understanding of reproductive health in Albania. Chapter 1 8 Background Albania Reproductive Health Survey, 2002 Final Report M etho do lo gy 9 CHAPTER 2 METHODOLOGY Sampling Design The Albania RHS 2002 is based on in- person, face-to-face interviews with 5,697 women and 1,740 men in their homes. The household-based survey was designed to collect information from a representative sample of men and women of reproductive age throughout Albania. Respondents were selected from the universe of all females aged 15–44 years and all males aged 15– 49 years, regardless of marital status, who were living in Albania when the survey was conducted. Male and female samples were selected independently. For analysis purposes, three strata were constructed for the sampling design: Metro Tirana, other urban areas and other rural areas. Metro Tirana includes 6 of the 19 communes in Tirana district: Bashkia Tirane (capital city of Tirana) , Kamez, Vore, Farke, Kashar and Paskuqan. These six communes include 85% of the District population and an estimated 92% of the urban population in the District. The “Other Urban Area” stratum includes urban areas outside of Metro Tirana and the “Other Rural Area” stratum includes all rural areas outside of Metro Tirana. As in other countries in Eastern Europe with Reproductive Health Surveys, the survey had a three-stage sampling design, which allows independent estimates for the female and male samples. The ﬁ rst stage of the sample design was a selection of census sectors with probability proportional to the number of households recorded in the 2001 Census. During this stage, 300 census sectors, 100 in each of the strata deﬁ ned above, were selected as primary sampling units (PSUs) throughout Albania. This step was accomplished by using a systematic sample with a random start in each strata for the female sample. A 33% sub-sample (every third PSU) of the census sectors selected in the female sample constituted the ﬁ rst stage of the male sample. Thus, the ﬁ rst-stage selection included 300 sectors for the female sample and 100 sectors for the male sample. In the second stage of sampling, clusters of households were randomly selected in each PSU that was chosen in the ﬁ rst stage (separate households were selected for the female and male samples). Finally, in the third stage of sampling, in each of the households in the female sample, one woman aged 15–44 years was selected at random for interview and in the male sample one man aged 15–49 years was randomly selected for interview. Metro Tirana and Other Urban Areas were over-sampled, and rural areas were under- sampled, so that more precise estimates could be made for the two mostly urban strata. Two variables are used in this report: STRATA, including metro Tirana, other urban areas and other rural areas as deﬁ ned above and RESIDENCE representing urban or rural residence independent of strata. Urban residence includes the 100 PSUs in the “other urban areas” stratum and 86 of the 100 PSUs in Metro Tirana. Rural residence includes the 100 PSUs in the “other rural areas” stratum and 14 of the 100 sectors in Metro Tirana. Some PSUs intended for both the male and female samples were not large enough to provide non–overlapping clusters. In these cases, an adjacent enumeration area in the same location was identiﬁ ed for the male sample, and in a few instances the male sample was drawn from a combination of both areas due to small population size. Chapter 2 10 Methodology Because only one respondent was selected from each household with women (or men) of reproductive age, all results have been weighted to compensate for the fact that some households included more than one eligible respondent. Survey results were also weighted to adjust for over-sampling of the metro Tirana stratum and other urban areas and under-sampling of rural areas. A review of the sample data compared with results from the 2001 census showed that there was differential non-response in certain age groups for both females and males and also differential non-response by marital status among females. Thus, a third weight was added to adjust for differential non-response. Response rates were lowest for unmarried women 30–44 years of age but they represent only 4% of all women of reproductive age (WRA). For women 15– 19, married women were underrepresented and unmarried women overrepresented in the sample; however, married teenagers represent only 2% of all WRA. Thus, the differential non-response weight for females is not a signiﬁ cant adjustment. For males, teenagers 15–19 were over-represented in the sample and older working age men from 20–49 years of age slightly under- represented. The third weight for males adjusted for this differential non-response. Presentation of Tables All tables in this report represent weighted results. However, the un-weighted number of cases, used for variance estimates, is shown in each table (see Appendix A on sampling errors). Thus, the survey can be used to make national and sub-national estimates because of the process to “weight” the data —that is, to determine how many women in the population were represented by each woman in the sample. Another note concerning data presented in tables in this report relates to percent distributions; although all percent distributions are shown to add to 100.0%, they may actually add to 99.9% or 100.1% due to rounding. Also tables for females (A) and males (B) that relate to the same topic are positioned to face each other for easier comparisons by the reader. Tables labeled A (female) will always be on an even- numbered page and corresponding B tables will be on the following odd-numbered page. To maintain these comparisons, there sometimes will be blank numbered pages in the table sections of the report. Questionnaire The individual questionnaire included information on each respondent’s education, employment, living arrangements, and other background characteristics, as well as histories of marriage, divorce and cohabitation, sexual experience, pregnancy and contraceptive use. Additional questions investigated health risk behaviors that may affect reproductive health (smoking and drinking habits), women’s health screening practices, young adult sexual and contraceptive behavior, knowledge and attitudes related to HIV/AIDS, and intimate partner violence. The questionnaire was developed in English and translated into Albanian and underwent two pretests. The second pretest, in May 2002, was performed to test changes in the questionnaire made after the ﬁ rst pretest. Data Collection The interviews were performed by 25 female and 8 male interviewers specially trained in interview techniques, survey procedures, and questionnaire content before the beginning of ﬁ eldwork. Interviewer training took place in the Health Authority Training Center, a facility next to the headquarters of the Albanian National Institute of Public Health (IPH), just before data collection began and consisted of one week of classroom Albania Reproductive Health Survey, 2002 Final Report 11 training in ﬁ eldwork procedures and proper administration of the questionnaire and one week of practical training in the ﬁ eld with close monitoring by the trainers. At the end of the training period, ﬁ ve female and two male teams were selected for the ﬁ eldwork. Each team consisted of one Supervisor, four Interviewers, and a Driver. Fieldwork was managed by staff of IPH with technical assistance from CDC/DRH. The overall ﬁ eldwork implementation was supervised by two ﬁ eldwork coordinators. Fieldwork lasted from August through December 2002. Each team was assigned to visit a number of primary sampling units in all regions of the country and traveled by car throughout the country on planned itineraries. Interviews were conducted at the homes of the respondents and lasted on average about 35 minutes for both men and women. Interviews were conducted in Albanian. Completed questionnaires were ﬁ rst reviewed in the ﬁ eld by team supervisors and then were taken by the ﬁ eldwork coordinators, who also reviewed them, to the National Institute for Statistics (INSTAT) headquarters where they were reviewed again by a data quality consultant before data processing. Response Rates Of the 10,316 households selected in the female household sample, 5,866 (57%) included at least one eligible woman (age 15–44 years) (Table 2.1A). One-third (34%) of households did not include an eligible woman and 8% of households were unoccupied, principally in rural areas (12%). Of the identiﬁ ed respondents, 5,697 were successfully interviewed, yielding an individual response rate of 97% for an overall response rate of 97% for women. Virtually all respondents who were selected to participate in the sample agreed to be interviewed and were very cooperative. Less than one percent refused to be interviewed. Response rates were similar in all three strata. The male sample totaled 3,965 households with 1,831 (46%) including at least one eligible man (age 15–49 years) (Table 2.1B). A lower percentage of households included an eligible male than did the female sample (include an eligible female) due, in part, to the emigration of males of working age. A total of 1,740 eligible males were interviewed for a 95% individual response rate, yielding an overall response rate of 94% (.95 x 99%). As with the female sample, refusals were less than one percent and response rates in the three strata were similar. M et ho do lo gy T ab le s 12 Chapter 2 Methodology Table 2.1 A Results of Household Visits and Interview Status of Eligible Women by Stratum (Percent Distribution) Reproductive Health Survey: Albania 2002 Households Visits Total Strata Metro Tirana Other Urban Rural Identiﬁ ed eligible women* 56.9 59.7 52.5 58.6 No eligible woman lives in household 34.0 35.5 37.0 28.8 Residents not at home 0.8 0.3 1.4 0.6 Household refusal 0.0 0.0 0.0 0.0 Unoccupied house 8.4 4.5 9.1 12.0 Total 100.0 100.0 100.0 100.0 No. of Households Visited 10,316 3,594 3,593 3,129 Eligible Women Completed interview 97.1 98.2 96.3 96.7 Selected respondent not home 1.5 0.7 2.3 1.7 Selected respondent refusal 0.1 0.1 0.2 0.0 Other reasons** 0.2 0.4 0.2 0.0 Total 100.0 100.0 100.0 100.0 No. of Eligible Women Identiﬁ ed 5,866 2,146 1,886 1,834 No. of Completed Interviews 5,697 2,108 1,816 1,773 * Includes women 15–44 years of age who had complete or incomplete interviews, who were absent or handicapped, or who refused to be interviewed. **Includes women with a handicap preventing them to be interviewed and women having incomplete interviews. Albania Reproductive Health Survey, 2002 Final Report M etho do lo gy Tab les 13 Table 2.1 B Results of Household Visits and Interview Status of Eligible Men by Stratum (Percent Distribution) Reproductive Health Survey: Albania 2002 Households Visits Total Strata Metro Tirana Other Urban Other Rural Identiﬁ ed eligible men* 46.2 54.3 42.2 41.2 No eligible man lives in household 42.0 34.7 45.5 46.5 Residents not at home 1.3 1.6 1.1 1.5 Household refusal 0.1 0.1 0.1 0.0 Unoccupied house 10.4 9.3 11.1 10.8 Total 100.0 100.0 100.0 100.0 No. of Households Visited 3,965 1,402 1,380 1,183 Eligible Men Completed interview 95.0 94.3 93.8 97.5 Selected respondent not home 4.4 4.3 6.2 2.5 Selected respondent refusal 0.2 0.5 0.0 0.0 Other reasons** 0.3 0.8 0.0 0.0 Total 100.0 100.0 100.0 100.0 No. of Eligible Men Identiﬁ ed 1,831 761 583 487 No. of Completed Interviews 1,740 718 547 475 * Includes men 15–49 years of age who had complete or incomplete interview, who were absent or handicapped, or who refused to be interviewed. **Includes men with a handicap preventing them to be interviewed and men having incompleted interviews. Chapter 2 14 Methodology Albania Reproductive Health Survey, 2002 Final Report 15 C haracteristics o f the Sam ple CHAPTER 3 CHARACTERISTICS OF THE SAMPLE Household characteristics In the 2002 Albania Reproductive Health Survey, the household questionnaire included a roster for the interviewer to list all members of the household who met the criteria to be eligible for the sample. From this list, one eligible respondent was randomly selected for the female sample or one eligible man was randomly selected for the male sample. The household questionnaire also listed the total number of persons living in the household. In addition, the individual questionnaire collected data on amenities and durable consumer goods belonging to the household, which would later be used to construct a socioeconomic scale to allow assignment of a socioeconomic status indicator to women and men in the sample. In this way, we would be able to examine the association of socioeconomic status with reproductive health indicators or behaviors measured in the survey. Tables 3.1 (A & B) and 3.2 (A & B) present data from the household questionnaire. In Tables 3.1 (A & B), the average size of Albanian households can be seen to be 5.1 persons in the female sample and 4.6 persons in the male sample. The most frequent household sizes are four- and ﬁ ve-person households. More than half of all the households, for the total country and for speciﬁ c geographic strata in both female and male samples, have an average size of four or ﬁ ve persons. Households of one or two persons are relatively rare, with less than 1% of households being single- person households and less than 4% being two-person households in both the female and male samples. However, the percentage of one- or two-person households may be understated due to the greater likelihood of the interviewer ﬁ nding no one at home for the household interview visit compared to households having three or more members. As would be expected, rural areas have a slightly larger household size than urban areas, especially in the female sample. Household amenities and consumer goods are shown in Tables 3.2A and 3.2B. Roughly one-quarter of Albanian households in 2002 had a telephone line, and 63% had ﬂ ush toilets. Less than 10% had access to 24-hour electricity. Dramatic differences in these amenities can be seen between the urban and rural strata. This is particularly so for telephone lines and ﬂ ush toilets. Almost half of the households in urban areas had telephone lines, whereas less than 10% of rural households had these lines. However, in both samples, approximately 60% of respondents (females-62%, males-58%) reported having cell phones; about two- thirds of households in urban areas and approximately half of households in rural areas. While more than three quarters of urban households had ﬂ ush toilets, less than half of rural households reported having them. There is strong consistency between the female and male samples. Among the durable goods possessed by households, the most frequent are TVs and refrigerators, with more than 90% of all households possessing these items. Ownership of these items appears to be geographically ubiquitous, with only minor differences between urban and rural areas. Seventy-eight percent of Albanian households have a gas or electric stove, roughly 60% have cell phones, and 21% have a working automobile. These three possessions vary markedly by strata, with their presence more common among the urban compared to the rural population. Computers and air-conditioning are rare. Less than 5% of households outside of Metro Tirana have these modern goods, and in Tirana only 12% of the households reported having them. Vegetable gardens, Characteristics of the Sample Chapter 3 16 on the other hand, are quite common, with 90% of rural households and 20 to 40% of urban households reporting access to a vegetable garden. Again, as with household amenities, there is strong consistency in percentages of durable goods between the female and male samples. Characteristics of the Respondents Tables 3.3A and 3.3B present selected sociodemographic characteristics of the samples. Regarding the age distribution, 38% of female respondents and 33% of male respondents were young adults (15–24 years of age). The age distribution is slightly younger in rural areas for both females and males. Overall, the age distributions are similar to those found in ofﬁ cial statistics (Instituti I Statistikes, 2002). Sixty-ﬁ ve percent of women and 60% of men reported that they were currently married. Divorce and widowhood are very infrequent in Albania. Only 2% of women and less than 1% of men reported themselves in either of these categories. There is no signiﬁ cant urban-rural difference in marital status. More than a third of both women and men reported being childless, and among those with children, the modal number of children is two. Although the percentage of childless respondents did not signiﬁ cantly differ between urban and rural areas, more women and men reported three or more children in rural areas than in Tirana or other urban areas. Among women in rural areas, 28% had 3 or more children compared to 15% in Tirana and 16% in other urban areas. The corresponding percentages for men were 25% in rural areas, 13% in Tirana, and 11% in other urban areas. Eight percent of women and 9% of men have had post-secondary education. Respondents in urban areas were signiﬁ cantly more likely to have post-secondary education than those in rural areas (17% vs. 2%). Most women (54%) and men (48%) have had only primary or no schooling. In rural areas, three-quarters of the female population and two-thirds of the male population fall into this latter category. The majority of respondents reported that they were Muslim; 80% of women and 84% of men. This is somewhat higher than the 72% reported in the census, but this difference may be affected by differential emigration patterns. Another 8% of women and 9% of men said they were Orthodox, and Catholics made up 12% of the women and 4% of the men. Ethnically, the population is almost 100% Albanian. As for religiosity — measured by frequency of attendance at religious services, less than 50% of respondents reported that they attend services at least once a month. The one exception to this norm is Catholic men living in rural areas. Among the latter group, two-thirds (67%) report they attend church once a month or more frequently. Otherwise, only 5% of all Muslim women and men report attending religious services at least once a month, and the comparable percentages for the other religions are 34% and 25% for Orthodox women and men, respectively, and 44% for Catholic women and 43% for Catholic men. Only 49% of men and 15% of women reported that they were working outside the home for 20 or more hours per week. These percentages rise to 60% for men and 25% for women in urban areas, and drop to 39% for men and 8% for women in rural areas. As for geographic mobility, the women report more mobility than the men. More than half of the women (53%) reported to have ever migrated, with only 22% of the men reporting the same. As would be Albania Reproductive Health Survey, 2002 Final Report 17 expected, the Metro Tirana population has a much higher percentage of migrants than other urban or other rural places. Male- female differences in migration history are greatest in the rural population. Only 3% of rural men have ever migrated, whereas 51% of rural women report having migrated. Tables 3.4A and 3.4B show the marital status distribution controlling for various sociodemographic characteristics. There is little to no variation in marital status by residence for both women and men. The positive association between age and marriage occurs before the age of 35 for both sexes, although women appear to marry at younger ages than men. By age 20–24, half of the women are married, whereas for men this proportion is not married until age 25–29. None of the men in the sample are married at ages 15–19, while 10% of women are married in these young ages. On the other hand, at ages 40–44, 4% of women and less than 1% of men have remained never married. The median age at ﬁ rst marriage is 21.9 years for the women and 26.5 years for the men (see Chapter 4). An association for number of living children with marital status is observed only between no children and any children. Once there are any living children present, currently married status reaches 95% or higher. The relation of educational level with marital status appears to be linked in part with school attendance. Women and men with secondary incomplete and post- secondary educational levels are more likely to be still in school (data not shown) and, consequently, less likely to be married. For both sexes, those with completed secondary education are more likely to be married than those with primary or less. At the same time socioeconomic status has no effect for women and a very modest effect for men, with men at the lowest status level somewhat more likely to be married than those at the other two levels. Employed women and men have higher percentages married than those not working (74% vs. 64% for women and 76% vs. 45% for men), also likely reﬂ ecting current school attendance and young age among those not working. Chapter 3 18 C ha ra ct er is ti cs o f th e Sa m pl e Ta b le s Characteristics of the Sample Table 3.1 A Size of Households with at Least One Eligible Respondent by Stratum (Percent Distribution) Female Sample, Reproductive Health Survey: Albania 2002 No. Persons per Household Strata Total Tirana Other Urban Rural 1 0.2 0.9 0.2 0.0 2 2.5 3.5 3.7 1.5 3 10.7 14.4 11.4 9.3 4 28.6 34.8 36.8 22.3 5 24.0 22.1 25.9 23.4 6 16.5 12.5 12.8 19.8 7 8.7 4.8 4.8 12.0 8 + 8.8 7.0 4.3 11.7 Total 100.0 100.0 100.0 100.0 Average No. of Persons 5.1 4.7 4.6 5.4 No. of Cases 5,788* 2,125 1,859 1,804 * Exludes 15 households whose number of inhabitants was unknown. Albania Reproductive Health Survey, 2002 Final Report 19 C haracteristics o f the Sam ple Tab les Table 3.1 B Size of Households with at Least One Eligible Respondent by Stratum (Percent Distribution) Male Sample, Reproductive Health Survey: Albania 2002 No. Persons Per Household Total Strata Metro Tirana Other Urban Other Rural 1 0.5 0.9 0.7 0.2 2 3.9 5.3 4.6 2.9 3 14.4 15.6 19.7 10.8 4 30.8 32.1 40.3 24.6 5 27.4 21.9 24.1 31.4 6 12.6 13.2 8.2 15.0 7 6.7 6.0 2.0 9.7 8 + 3.8 4.9 0.3 5.4 Total 100.0 100.0 100.0 100.0 Average No. of Persons 4.6 4.6 4.1 4.9 No. of Cases 1825* 755 583 487 * Excludes 6 households whose number of inhabitants was unknown Chapter 3 20 C ha ra ct er is ti cs o f th e Sa m pl e Ta b le s Characteristics of the Sample Table 3.2 A Percentage of Households with Basic Household Amenities and Goods, by Stratum, for Women Aged 15–44 Years Reproductive Health Survey: Albania 2002 Household Amenities Total Strata Metro Tirana Other Urban Other Rural Flush Toilet 62.9 77.4 80.9 48.8 Cell Phone 61.6 69.5 66.5 56.7 Telephone Line 24.7 47.6 48.6 4.9 Electricity (24 Hours) 9.5 31.5 5.3 5.3 Vacation Home 1.5 5.6 1.1 0.5 Household Goods TV 96.4 97.7 98.5 94.9 Refrigerator 90.0 97.3 96.3 84.5 Gas/Electric Stove 78.1 84.0 93.7 67.9 Family Has Access to Vegetable Garden 60.7 33.9 22.9 89.0 VCR 31.8 44.6 42.4 22.3 Satellite Antenna 30.2 22.2 33.3 30.8 Auto 20.9 29.9 25.1 15.9 Computer 3.7 12.1 5.1 0.6 Air Conditioner 2.9 11.2 2.6 0.6 Percentage of Households With Crowded Conditions* 92.6 92.1 94.1 92.0 No. of Cases 5,697 2,108 1,816 1,773 * Total number of persons living in the household divided by total number rooms in the house (not including kitchen and bathroom) was higher than one Albania Reproductive Health Survey, 2002 Final Report 21 C haracteristics o f the Sam ple Tab les Table 3.2 B Percentage of Households with Basic Household Amenities and Goods, by Stratum, for Men Aged 15–49 Years Reproductive Health Survey: Albania 2002 Households Amenities Total Strata Metro Tirana Other Urban Other Rural Flush Toilet 62.9 83.2 76.5 46.9 Cell Phone 58.3 73.6 68.9 46.0 Telephone Line 24.0 46.8 39.9 5.6 Electricity (24 Hours) 5.3 19.2 3.3 1.1 Vacation Home 1.3 2.8 1.4 0.6 Household Goods TV 98.4 99.2 99.7 97.4 Refrigerator 92.7 98.4 98.7 86.9 Gas/Electric Stove 77.6 93.5 94.5 61.3 Family Has Access to Vegetable Garden 60.2 39.4 19.4 92.6 VCR 32.5 51.1 40.0 20.8 Auto 20.8 35.8 29.8 9.6 Satellite Antenna 17.3 18.7 16.1 17.5 Computer 3.9 12.7 4.1 0.4 Air Conditioner 3.2 12.2 2.2 0.3 Percentages of Households With Crowded Conditions* 88.5 86.9 87.6 89.6 No. of Cases 1,740 718 547 475 * Total number of persons living in the household divided by total number rooms in the house (not including kitchen and bathroom) was higher than one Chapter 3 22 C ha ra ct er is ti cs o f th e Sa m pl e Ta b le s Characteristics of the Sample Table 3.3 A Percent Distribution of Characteristics of Female Sample by Residence and Stratum Reproductive Health Survey: Albania 2002 Characteristics Total Residence Strata Urban Rural Metro Tirana Other Urban Other Rural Age Group 15–19 21.0 18.5 22.9 18.3 18.8 23.0 20–24 17.0 15.5 18.1 18.2 14.7 17.9 25–29 15.6 15.3 15.8 16.7 14.8 15.7 30–34 15.7 17.4 14.5 16.1 18.1 14.4 35–39 15.6 17.9 13.9 15.7 18.5 14.0 40–44 15.0 15.4 14.7 15.0 15.1 15.0 Marital Status Currently Married 65.1 66.3 64.2 63.1 68.0 64.1 Previously Married 2.1 2.4 1.8 2.9 2.1 1.9 Never Married 32.8 31.3 34.0 34.0 30.0 34.0 Living Children 0 37.8 36.7 38.6 39.6 35.4 38.6 1 12.8 13.8 12.0 16.3 12.6 11.9 2 27.1 34.1 21.9 29.3 35.7 21.8 3 14.9 11.5 17.4 10.6 12.2 17.5 4 + 7.4 3.8 10.1 4.3 4.0 10.2 Education Level Primary or Less 53.9 27.5 73.7 33.8 27.7 74.0 Secondary Incomplete 10.2 14.3 7.2 12.0 15.1 7.1 Secondary Complete 27.7 41.3 17.6 35.9 42.3 17.4 Post-Secondary 8.1 16.8 1.6 18.2 14.9 1.5 Socioeconomic Index Low 42.2 20.0 58.8 22.1 21.4 59.4 Medium 49.5 63.0 39.5 53.9 66.6 39.0 High 8.2 17.0 1.7 24.0 12.0 1.6 Religion* Muslim 79.6 76.6 81.8 84.5 74.1 81.1 Orthodox 8.1 12.7 4.7 7.9 14.1 4.9 Catholic 11.5 9.2 13.2 5.7 10.7 13.6 Other/Undeclared 0.8 1.5 0.3 2.0 1.1 0.3 Employment Working 15.3 25.7 7.6 27.8 23.5 7.3 Not Working 84.7 74.3 92.4 72.2 76.5 92.7 Migration Status Ever Migrated 52.8 53.1 52.6 67.5 48.3 51.0 Never Migrated 47.0 46.7 47.3 31.7 51.7 48.9 Do Not Know 0.1 0.3 0.0 0.7 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 5,697 3,572 2,125 2,108 1,816 1,773 *With regard to religious service attendance, the percentages of women who attend religious services at least once a month are: Muslim Total Urban Rural Metro Tirana Other Urban Other Rural 5.4 6.5 4.6 6.3 6.7 4.5 Orthodox 33.7 34.9 31.2 37.3 34.2 31.3 Catholic 43.8 36.1 47.8 44.6 34.2 47.9 Albania Reproductive Health Survey, 2002 Final Report 23 C haracteristics o f the Sam ple Tab les Table 3.3 B Percent Distribution of Characteristics of Male Sample by Residence and Stratum Reproductive Health Survey: Albania 2002 Characteristics Total Residence Strata Urban Rural Metro Tirana Other Urban Other Rural Age Group 15–19 18.9 16.6 20.9 16.3 16.9 21.0 20–24 14.5 13.2 15.6 14.9 13.3 15.0 25–29 13.3 12.9 13.7 14.2 12.0 13.8 30–34 13.6 14.6 12.8 12.4 15.8 12.8 35–39 14.1 14.6 13.7 11.7 16.3 13.8 40–44 14.2 15.6 12.9 16.2 14.8 13.0 45–49 11.4 12.4 10.6 14.3 11.0 10.6 Marital Status Married 60.3 59.6 61.0 59.8 59.8 60.9 Previously Married 0.6 0.9 0.4 1.2 0.5 0.4 Never Married 39.0 39.5 38.6 39.0 39.7 38.7 Living Children 0 45.5 45.5 45.5 47.4 45.0 45.1 1 11.5 13.4 9.8 13.5 12.8 9.9 2 24.9 30.0 20.5 26.6 31.5 20.3 3 11.8 8.5 14.7 7.7 8.9 15.1 4 + 6.3 2.6 9.5 4.8 1.8 9.5 Education Level Primary or Less 48.4 28.4 65.7 30.0 30.5 66.1 Secondary Incomplete 8.7 10.6 7.1 11.8 9.7 6.9 Secondary Complete 33.9 43.6 25.5 39.6 44.4 25.4 Post-Secondary 9.1 17.4 1.8 18.7 15.4 1.6 Socioeconomic Index Low 47.2 25.1 66.4 20.9 29.2 68.2 Medium 42.2 53.6 32.3 52.3 54.8 30.9 High 10.6 21.3 1.2 26.8 16.0 1.0 Religion* Muslim 84.0 75.9 91.1 84.0 71.6 91.4 Orthodox 8.8 15.0 3.4 7.6 18.4 3.6 Catholic 4.3 5.6 3.1 3.4 7.3 2.8 Other/Undeclared 2.9 3.5 2.4 5.0 2.7 2.2 Employment Working 48.9 60.3 39.1 63.7 57.1 38.3 Not Working 51.1 39.7 60.9 36.3 42.9 61.7 Migration Status Ever Migrated 21.7 38.3 7.2 58.8 29.4 2.6 Never Migrated 78.1 61.2 92.7 39.8 70.6 97.4 Do Not Know 0.3 0.5 0.0 1.3 0.0 0.0 Total 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,740 1,155 585 718 547 475 *With regard to religious service attendance, the percentages of men who attend religious services at least once a month are: Muslim Total Urban Rural Metro Tirana Other Urban Other Rural 5.4 3.1 7.2 4.9 2.8 6.9 Orthodox 25.0 23.6 30.5 23.0 23.7 30.5 Catholic 42.7 27.0 67.0 36.1 23.1 76.0 Chapter 3 24 C ha ra ct er is ti cs o f th e Sa m pl e Ta b le s Characteristics of the Sample Table 3.4 A Percent Distribution of Marital Status by Selected Characteristics, for Women Aged 15–44 Years Reproductive Health Survey: Albania 2002 Characteristics Marital Status Total No. of CasesMarried Previously Married Never Married Total 65.1 2.1 32.8 100.0 5,697 Strata Metro Tirana 63.1 2.9 34.0 100.0 2,108 Other Urban 68.0 2.1 30.0 100.0 1,816 Other Rural 64.1 1.9 34.0 100.0 1,773 Residence Urban 66.3 2.4 31.3 100.0 3,572 Rural 64.2 1.8 34.0 100.0 2,125 Age Group 15–19 9.5 0.0 90.5 100.0 1,094 20–24 49.5 0.3 50.2 100.0 936 25–29 78.9 2.8 18.3 100.0 946 30–34 89.5 1.8 8.6 100.0 1,067 35–39 92.3 3.9 3.8 100.0 958 40–44 92.5 4.6 2.8 100.0 696 Living Children 0 12.9 0.3 86.8 100.0 1,943 1 94.8 5.2 0.0 100.0 828 2 96.9 3.1 0.0 100.0 1,840 3 + 97.9 2.1 0.0 100.0 1,086 Education Level Primary or Less 66.8 2.2 31.0 100.0 2,519 Secondary Incomplete 35.2 1.9 62.9 100.0 653 Secondary Complete 75.1 2.2 22.7 100.0 1,830 Post-Secondary 57.5 1.0 41.5 100.0 695 Socioeconomic Index Low 67.3 2.1 30.6 100.0 1,940 Medium 63.0 2.2 34.8 100.0 2,985 High 66.7 1.1 32.2 100.0 772 Employment Working 73.6 4.2 22.2 100.0 1,118 Not Working 63.6 1.7 34.7 100.0 4,579 Albania Reproductive Health Survey, 2002 Final Report 25 C haracteristics o f the Sam ple Tab les Table 3.4 B Percent Distribution of Marital Status by Selected Characteristics, for Men Aged 15–49 Years Reproductive Health Survey: Albania 2002 Characteristics Marital Status Total No. of CasesMarried Previously Married Never Married Total 60.3 0.6 39.0 100.0 1740 Strata Metro Tirana 59.8 1.2 39.0 100.0 718 Other Urban 59.8 0.5 39.7 100.0 547 Other Rural 60.9 0.4 38.7 100.0 475 Residence Urban 59.6 0.9 39.5 100.0 1155 Rural 61.0 0.4 38.6 100.0 585 Age Group 15–19 0.0 0.0 100.0 100.0 401 20–24 13.3 0.4 86.3 100.0 189 25–29 60.2 1.0 38.8 100.0 218 30–34 87.3 0.4 12.3 100.0 253 35–39 94.9 0.7 4.5 100.0 255 40–44 98.7 0.7 0.6 100.0 277 45–49 97.4 1.5 1.0 100.0 147 Living Children 0 13.7 0.5 85.8 100.0 815 1 99.2 0.8 0.0 100.0 221 2 98.8 1.2 0.0 100.0 468 3 + 100.0 0.0 0.0 100.0 236 Education Level Primary or Less 60.9 0.6 38.5 100.0 689 Secondary Incomplete 13.9 0.3 85.9 100.0 199 Secondary Complete 72.1 0.6 27.2 100.0 626 Post-Secondary 58.0 0.8 41.2 100.0 226 Socioeconomic Index Low 63.6 0.5 35.9 100.0 638 Medium 57.4 0.5 42.1 100.0 814 High 57.3 1.8 40.8 100.0 288 Employment Working 75.9 0.8 23.3 100.0 913 Not Working 45.4 0.4 54.2 100.0 827 Chapter 3 26 Characteristics of the Sample Albania Reproductive Health Survey, 2002 Final Report 27 Fertility and P regnancy CHAPTER 4 FERTILITY AND PREGNANCY survey and grouping them (in five-year age groups) by the age of the mother at the time of the reported date of birth. The denominators for the rates represent the number of woman-years lived in each five-year age group during the specified three-year period. Table 4.1 and Figure 4.1 present age- specific fertility rates calculated from the live birth history asked of every woman in the survey. These rates were calculated for three three-year periods over the last decade, 1993–1996, 1996–1999, and 1999–2002. As can be observed in the Table, the total fertility rate has declined substantially over the 10-year period, from 3.3 to 2.6 children per woman. This was due to pronounced declines in the most fertile ages of 20–24 and 25–29. Fertility Experience Current levels of fertility presented in Tables 4.1, 4.2, 4.3A and 4.3B were estimated with the use of five-year age- specific fertility rates (ASFR) calculated from information collected through the respondents’ lifetime pregnancy histories. ASFRs are expressed per 1000 women. The total fertility rate (TFR) is computed by multiplying the age-specific fertility rates by five (the number of years in each age group) and summing them over the reproductive ages. When this number is divided by 1000, the TFR can be defined as the average number of live births a women would have during her reproductive lifetime (15–44) if she experienced the observed ASFRs of a given time period. Numerators for the ASFRs were calculated by selecting live births that occurred during the 36-month period preceding the Figure 4.1 Three-Year Period Age-Specific Fertility Rates for Several Time Periods Among All Women 0 40 80 120 160 200 240 1993-1996 1996-1999 1999-2002 40-4435-3930-3425-2920-2415-19 Chapter 4 28 Fertility and Pregnancy As with women in other countries of the region (Table 4.2), Albanian women initiate and complete childbearing at an early age. The highest fertility rates in Albania are among women 20–24 and 25–29 years of age, accounting for 33% and 32%, respectively, of the TFR of 2.6. Women aged 35–44 make a minimal contribution to total fertility of only 8% of the TFR. The adolescent fertility rate is very low, only 35 live births per 1000 women 15–19 years of age, representing 7% of the total fertility rate. The estimated TFR of 2.6 is a bit higher than the rate published by WHO for 2001 (2.4) and the rate of 2.3 published by the UN population Division (WHO, 2003; UN, 2003). The TFR of 2.6 is the highest in Europe and higher than the TFR in 9 of the 13 countries in Eastern Europe and the Former Soviet Union that have conducted similar Reproductive Health Surveys (CDC and MACRO, 2003). There is no difference in the TFR in Albania by urban or rural residence, although the rate is slightly lower in Metropolitan Tirana than in the rest of the country (Table 4.3A). The TFR for women with a post- secondary education (2.0) is lower than the TFR for those with a primary (2.7) or secondary (2.5) education. Also, although the principal childbearing years for all women are 20–29 years of age, those with a post-secondary education tend to bear their children somewhat later at ages 25–34. There is also a tendency for age at childbearing to increase as SES increases. Fertility rates for men are shown in Table 4.3B. These rates are based upon the responses of men to questions about children fathered by them. The male TFRs are universally lower than the female TFRs, due to very low fertility rates at ages 15– 24 reflecting a later age at marriage and possibly indicating a tendency for men to underreport children fathered by them. Also, because of the smaller sample size for males with a small number of births reported by men, many of the male ASFRs are considered to be unstable. Nevertheless, the male rates show the same relationship with the selected characteristics as were observed for females in Table 4.3A. The male ASFRs also differ from the female in that they reveal older ages for childbearing, reflecting age differences between partners engaging in sexual intercourse. Cumulative fertility of Albanian women and men is shown in Tables 4.4A and B. The number of live births (also known as “children ever born”) in Table 4.4A shows that 38% of Albanian women in the reproductive years had not had a live birth at the time of the survey, but only 8% of women in union were without a live birth. By age 40–44, only 1% of married women reported never having had a live birth. The median number of live births for married women was 2, and for women at the end of their reproductive years the median increased to 3 live births. Cumulative fertility levels observed for married men are similar to those of the women. Among all men, however, lower levels of fertility are reported, with 46% stating that they were childless. It is probable that single men are less knowledgeable about the number of children they may have fathered. It is worth noting that all men at ages 45– 49 report completed fertility at similar levels to married women, most likely because most men in this age group are married. Albania Reproductive Health Survey, 2002 Final Report 29 Age at First Intercourse, Union and Birth Tables 4.5A and B present data on age at first sexual intercourse, first union and first live birth for women and first sexual intercourse and first union for men, respectively, according to their age cohort at the time of the survey. By examining the percentages that have experienced sexual intercourse or marriage or a live birth by current age cohort, it is possible to determine whether the ages at which these events first take place are changing over time. For example, in Table 4.5A, the percentage of women who experienced sexual intercourse before age 18 increased from 10% among current 40–44 year olds to 16% among current 20–24 year olds. Similarly, the percentage of 40–44 year olds who married before age 18 is 7%, whereas 11% of 20–24 year olds married before age 18. In turn, a higher percentage of first live births before age 18 and before age 20 result from the younger ages of first intercourse and first union. Of course, these data cannot reveal the temporal relationship between marriage and intercourse – that is, which of these events preceded the other. It is also important to note that less than half of the women had had intercourse (47%) or had been married (41%) before age 22 and only a quarter had had a live birth (26%) before reaching 22 years of age. These findings are reflected in an average age 21.1 years at first intercourse, 21.9 years at first marriage, and 23.4 years at first live birth. These averages show little change across the age cohorts, suggesting little change over the last two decades in the timing of these events in a woman’s life cycle. Data for the men are shown in Table 4.5B. Here we see a more dramatic change in age at first intercourse across time. Only 5% of men currently aged 45–49 reported having had first sexual intercourse before age 18, compared to 22% of men currently aged 20–24. This substantial increase is also seen for percentages that had first intercourse by the age of 20. However, these increases in sexual experience at younger ages are not reflected in the average age at first intercourse for all ages and cohorts, which remained relatively stable over time. Also, age at first sexual intercourse for men does not correspond as closely to age at first marriage as it does for women. Thus, while the median age at first intercourse for all men is 21.5 years, the median age at first marriage for men is 26.5 years. When observed by residence (Table 4.6), age at first intercourse for women is rather stable. The median age at first intercourse does not vary between urban and rural areas. However, on average, women in urban areas marry and have their first births a year later than those in rural areas. Educational level shows an even stronger and consistent effect on ages of these three events, resulting in a three-year difference in average age at first intercourse (20.5 vs. 23.3), a four-year difference in age at first marriage (21.0 vs. 25.1) and a four- year difference in age at first birth (22.5 vs. 26.6), when comparing the lowest and highest educational categories. (See also Figure 4.2.) The patterns of age at first intercourse for men are somewhat different from those of women (Table 4.6). In contrast to women, the average age at first intercourse for men is higher in rural areas and inversely affected by educational level. For men in rural areas, the median age at first intercourse is 22.2 years compared to 20.6 years for men in urban areas. Likewise, Chapter 4 30 Fertility and Pregnancy men with primary or lower levels of education have a median age of 22.0 years at first intercourse compared to 20.3 years for men with post-secondary education. Urbanization and education have the opposite effect on age at marriage for men. The median age at first marriage increases from 25.8 years for men living in rural areas to 27.4 years for those residing in urban areas. Similarly, men with the lowest educational levels marry, on average, at 26.0 years of age compared to 28.6 years of age for men with the highest level of education. The education effects for men are shown also in Figure 4.2. Current Sexual Activity Current sexual activity is an important measure for determining the women who are risk of an unintended pregnancy and thus in need of contraceptive services. Table 4.7 shows that 70% of Albanian women in their reproductive years have had sexual intercourse. This percentage comprises all married and previously married women and 8% of never married women. Seventy-five percent of currently married women had intercourse within the last month, and another 13% had last intercourse 1–3 months prior to the survey. Another 7% reported a pregnancy-related reason for no current sexual activity. Among previously married women, 76% last had intercourse one or more years ago, presumably when they were still married. Almost half (48%) of the sexually experienced never married women have had intercourse within the last month (3.9%/8.2%) and another 23% had their last intercourse 1–3 months ago (1.9%/8.2%). Current sexual activity among men is higher than that of women. Seventy-six percent of all men have ever had sexual intercourse, including 38% of never married men. The percentage of men who had Figure 4.2 Median Age at First Sexual Intercourse, First Marriage and First Birth by Education Level 0 5 10 15 20 25 30 Age at first birthAge at first marriageAge at first intercourse Post- secondary Secondary complete Secondary incomplete Primary or less Post- secondary Secondary complete Secondary incomplete Primary or less Ag e Women Men Albania Reproductive Health Survey, 2002 Final Report 31 intercourse in the last month was 83% of the currently married and 14% of the never married men. Among the sexually experienced never married men, 38% (14.4%/37.5%) had sex in the last month and another 29% (11.0%/37.5%) had sex 1–3 months prior to the survey. Induced Abortion For several decades one of the most outstanding demographic features of most of the Eastern European countries has been the high reliance on induced abortion as a means of birth prevention (David, 1992). Induced abortion was the single most important means of controlling fertility. In recent years, abortion rates and ratios in many of these countries have been among the highest in the world. Among the factors frequently cited as contributing to the reliance on abortion has been the limited availability of modern contraceptive methods, poor quality of methods available, fears about possible side effects, and easy access to and low cost of induced abortion. However, since 1990, data show that an increase in use of modern contraception has been associated with a decline in abortion in many countries of the region (C Westoff et al., 1998, 2000, 2002; CDC and MACRO, 2003). As with the calculation of the total fertility rate, age-specific induced abortion rates are calculated by using the age of the woman at age of pregnancy termination and then summed over the ages 15–44 to produce a total abortion rate. In Table 4.8, the number of induced abortions per 1000 live births reported in the reproductive health survey for the three years prior to the survey is compared with the official data reported to the Institute of Statistics (INSTAT) for 1999–2001. The survey rate of 73 abortions per 1,000 live births is 64% lower than the official data of 200 per 1,000 live births (three-year average) reported to INSTAT. Over the last three-year period, the official ratio reported to INSTAT has declined from 241 per 1,000 live births to 172 per 1,000, a 29% decrease (Instituti I Statistikes, 2003). In Romania and the countries of the Former Soviet Union that have conducted Reproductive Health Surveys or Demographic and Health Surveys, reporting of induced abortion by survey respondents has been close to, and in some cases, has exceeded official reporting. (CDC and MACRO, 2003). Only in the Czech Republic has there been severe under-reporting of induced abortion by respondents as appears to be the case in Albania. It is estimated that respondents in the Czech survey only reported between 45% and 50% of induced abortions they underwent (Czech Statistical Office et al., 1995). There are three principal factors that may affect the under-reporting of induced abortions, even in a country where they are legal, by survey respondents: (1) Under-reporting of unwanted pregnancies that have a higher probability of being terminated by the voluntary interruption of the pregnancy (see next section of this chapter); (2) Under-reporting of clandestine abortions outside of the medical system; and (3) a tendency to declare induced abortion as spontaneous abortions or miscarriages (see next section of this chapter). Since the apparent underreporting of abortion by survey respondents is at least 50% and may be as high as 77%, and since the underreporting is most likely not a random event but associated with characteristics of the respondent, data from the survey on abortion is probably unreliable. For this reason, the further analysis of abortion data is considered beyond the scope of this report. Chapter 4 32 Fertility and Pregnancy Planning Status of the Last Pregnancy For every pregnancy ended since January 1997, respondents were asked the planning status of their pregnancies at the time of conception. Each pregnancy was classified as either intended (wanted at the time it occurred), mistimed (occurring earlier than intended), unwanted (the respondent did not want any more children), or the respondent was unsure. Mistimed and unwanted pregnancies together constitute unintended pregnancies (Westoff, 1976). Despite the under-reporting of induced abortions, strongly associated with unwanted pregnancies, the results in Table 4.9A are somewhat useful for examining relative levels of the planning status of the last pregnancy among the various population sub-groups. The sharp differential between pregnancies ending in induced abortion and a live birth (or a current pregnancy) is obvious. Almost two-thirds (65%) of pregnancies ending in induced abortion were reported as unwanted compared with only 3% of current pregnancies and live births. Also, 11% of pregnancies ending in stillbirth, spontaneous abortion, or an ectopic pregnancy, were reported as unwanted, although the proportion would not be expected to be significantly higher than the 3% of live births reported as unwanted. This suggests that some women who experienced an induced abortion reported their pregnancy outcome as a spontaneous abortion. The proportion of unwanted pregnancies increases as age group and number of living children, two correlated variables, increase, reaching 20% for 35–44 year old women and 28% for women with four or more living children. Mistimed pregnancies are highest for young adults 15–24 years of age and women with no living children. No major differences are seen by residence or by education. A rough adjustment for the underreporting of abortions puts the percentage of unwanted pregnancies closer to 12% (one out every eight pregnancies) compared with the 7% shown in the table. Among men, for whom there is no pregnancy data, Table 4.9B shows men reporting 98% of last live births as intended, with no differentials observed by residence, age, number of living children or educational level. Future Fertility Preferences Data on fertility preferences are needed so that a determination can be made of the appropriate forms of contraception required by couples in the society. Tables 4.10A and B present future fertility preferences of currently married women and men. Approximately two-thirds (63%) of married women want no more children (Table 4.10A). Another 12% want a child after two or more years. The desire for no more children increases with parity from 2% of married women with no living children to 92% of women who have four or more children. The desire to delay the next birth for two years or longer is highest (45%) among women with one child. Age shows the same direct relationship with wanting no more children as observed for parity, with a low of 5% among women 15–19 and a high of 90% among women 40–44 years of age. Wanting to postpone the birth of a child for two or more years is inversely related to age, with 54% of 15–19 year olds and 1% of 35–39 year olds reporting a desire to postpone the next birth by two years or longer. In Table 4.10B the percentage of married men who want no more children (58%) is similar to that of women, with a corresponding increase with parity and Albania Reproductive Health Survey, 2002 Final Report 33 age. However, compared to women, smaller percentages of men report wanting to postpone the next birth for two or more years (6% vs. 12% for women) and a larger percentage is undecided (13% of men compared to 7% of women). The differences between men and women appear to be most pronounced at parity one. Nineteen percent of men with one living child compared to 45% of women in that category want to postpone the next birth for two or more years. Furthermore, at parity one, 19% of men are undecided about having any more children and another 11% say they want more but do not know when. This contrasts to lower percentages for women at parity one, where the corresponding percentages are 9% and 5%, respectively. In order to better understand the relationship between number of living children and desire for no more births, Table 4.11 shows this association controlling for fecundity and selected demographic characteristics. While in the aggregate, there appears to be no affect of residence on desire for more children, the trend by parity indicates that urban low-parity women are more likely to want no more births than rural low-parity women. Urban women with 0, 1, and 2 living children report wanting no more children at levels of 5%, 16% and 80%, respectively, compared to rural women at 0%, 5% and 67%, respectively. When the correlation between parity and age is controlled, both variables appear to have strong independent effects on desire for no more children. This is most noticeable at parities one and two. Only 3% of women 15–24 years of age with one living child state they want no more children, whereas 64% of women 35–44 years of age want no more children. Similarly, 47% of 15–24 year old women with two living children want no more births, and 90% of 35–44 year olds at the same parity want no more births. Education, while in the aggregate appears to have no effect, at parities one and two there is a direct relationship between wanting no more children and level of education. Chapter 4 34 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.1 Three-Year Period Age-Specific Fertility Rates for Several Time Periods Among All Women Aged 15–44 Reproductive Health Survey: Albania 2002 Age Group Albania Albania Albania 1993–1996 * 1996–1999 ** 1999–2002 *** 15–19 41 38 35 20–24 207 182 170 25–29 221 185 167 30–34 120 92 105 35–39 76 43 34 40–44 0 10 8 Total Fertility Rate 3.3 2.8 2.6 *Period from August 1993 – July 1996 **Period from August 1996 – July 1999 ***Period from August 1999 – July 2002 Albania Reproductive Health Survey, 2002 Final Report 35 Fertility and P regnancy Tab les Table 4.2 Three-Year Period* Age–Specific and Total Fertility Rates, Among Women Aged 15–44 Reproductive and Demographic Health Surveys (RHS and DHS) in Selected Eastern European and Former Soviet Union Countries Albania Reproductive Health Survey 2002, Final Report Region and Country Time Period Age–Specific Fertility Rates (per 1,000 women) † TFR ‡ 15–44 GFR § 15–4415–19 20–24 25–29 30–34 35–39 40–44 Eastern Europe Albania, 2002 1999–2001 35 170 167 105 34 8 2.6 89 Czech Rep., 1993 1990–1992 49 176 92 41 11 4 1.9 62 Moldova, 1997 1994–1996 57 158 88 40 17 6 1.8 64 Romania, 1999 1997–1999 36 100 83 29 13 2 1.3 49 Russia (three oblasts), 1999 ¶ 1996–1998 39 101 73 28 11 7 1.3 44 Ukraine, 1999 1997–1999 49 115 66 36 14 4 1.4 49 Caucasus Armenia, 2000 1998–2000 50 149 88 35 16 3 1.7 56 Azerbaijan, 2001 1998–2000 44 151 133 58 19 9 2.1 71 Georgia, 1999 1997–1999 64 113 92 48 21 7 1.7 61 Central Asia Kazakhstan, 1999 1997–1999 40 167 106 64 24 9 2.1 67 Kyrgyz Rep., 1997 1995–1997 75 246 179 113 47 13 3.4 118 Turkmenistan, 2000 1998–2000 30 184 195 105 48 14 2.9 103 Uzbekistan, 1996 1994–1996 61 266 176 114 39 9 3.3 123 * Three years prior to the interview. † Age at pregnancy outcome. ‡ TFR: Total Fertility Rate (number of births per woman). § GFR: General Fertility Rate (births divided by the number of women age 15–44), expressed per 1,000 women ¶ Yekaterinburg, Perm, and Ivanovo, respectively (predominantly urban sample). Chapter 4 36 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.3 A Age-Specific Fertility Rates and Total Fertility Rates by Selected Characteristics Among All Women Aged 15–44 Reproductive Health Survey: Albania 2002 Characteristics Age-Specific Fertility Rate (per 1000) (ASFR) Total Fertility Rate * GFR †15–19 20–24 25–29 30–34 35–39 40–44 Total 35 170 167 105 34 8 2.6 89 Strata Metro Tirana 37 143 170 98 30 (5) 2.4 85 Other Urban 38 184 159 100 45 (4) 2.7 92 Other Rural 33 172 171 111 27 (11) 2.6 89 Residence Urban 37 167 164 100 41 (4) 2.6 89 Rural 33 172 169 109 27 (11) 2.6 90 Education Level Primary or Less 51 187 171 105 28 (6) 2.7 96 Secondary 14 180 169 99 34 11 2.5 83 Post-Secondary (6) 54 136 134 67 (4) 2.0 75 Socioeconomic Index Low 37 196 194 103 34 (9) 2.9 98 Medium 31 153 142 105 30 (8) 2.3 80 High 50 147 181 116 51 (0) 2.7 100 Note: All rates in this table are calculated based on births in the last three years (August 1999–July 2002) and ages of mothers at time of birth. * The total fertility rate (TFR) is calculated as the sum of ASFR’s for each year of age from age 15 to 44. † The general fertility rate (GFR) is calculated as the number of births per 1000 women 15–44. ( ) Rates considered unstable due to numerators of less than 15 cases. Albania Reproductive Health Survey, 2002 Final Report 37 Fertility and P regnancy Tab les Table 4.3 B Age-Specific Fertility Rates and Total Fertility Rates by Selected Characteristics Among All Men Aged 15–49 Reproductive Health Survey: Albania 2002 Characteristics Age-Specific Fertility Rate (per 1000) (ASFR) Total Fertility Rate * GFR †15–19 20–24 25–29 30–34 35–39 40–44 45–49 Total (1) 31 134 137 58 30 (8) 2.0 59 Strata Metro Tirana (3) 36 125 125 46 (19) (15) 1.8 52 Other Urban (0) (14) 109 163 52 38 (12) 2.0 62 Other Rural (0) 38 152 122 68 29 (0) 2.1 60 Residence Urban (0) 25 111 150 51 32 (15) 1.9 58 Rural (1) 36 154 123 66 28 (0) 2.0 60 Education Level Primary or Less (1) 61 142 143 70 28 (10) 2.3 65 Secondary (1) (59) 144 127 49 30 (9) 1.8 61 Post-Secondary (0) (4) 65 144 (53) (43) (0) 1.5 50 Socioeconomic Index Low (0) 41 134 156 63 31 (3) 2.1 59 Medium (1) 20 141 114 54 (10) (8) 1.7 55 High (0) (45) 108 155 (54) 93 (40) 2.5 77 Note: All rates in this table area calculated based on births in the last three years (August 1999–July 2002) and ages of fathers at time of birth. * The total fertility rate (TFR) is calculated as the sum of ASFR’s for each year of age from ages 15 to 49. † The general fertility rate (GFR) is calculated as the number of births per 1000 men 15-49. ( ) Rates caonsidered unstable due to numerators of less than 15 cases. Chapter 4 38 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.4 A Percent Distribution of Number of Live Births by Current Age of Respondents Among all Women and Among Married Women Aged 15–44 Reproductive Health Survey: Albania 2002 Number of Live Births All Women Total Age Group (Current Age) 15–19 20–24 25–29 30–34 35–39 40–44 0 37.8 95.8 64.0 23.0 9.6 6.6 4.1 1 12.8 3.8 25.0 28.3 10.9 5.8 4.6 2 27.1 0.4 9.7 39.0 47.5 41.7 35.5 3 14.9 0.0 1.3 9.5 25.4 31.6 28.2 4 + 7.4 0.0 0.0 0.2 6.7 14.3 27.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 5,697 1,094 936 946 1,067 958 696 Number of Live Births Married Women Total Age Group (Current Age) 15–19 20–24 25–29 30–34 35–39 40–44 0 7.5 55.6 27.5 5.7 1.1 2.9 1.2 1 18.6 40.0 50.3 34.0 11.8 5.1 3.7 2 40.4 4.5 19.5 48.4 51.4 43.6 36.4 3 22.4 0.0 2.6 11.7 28.3 33.4 29.9 4 + 11.1 0.0 0.0 0.2 7.4 15.0 28.8 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 3,965 97 502 800 1,004 906 656 Albania Reproductive Health Survey, 2002 Final Report 39 Fertility and P regnancy Tab les Table 4.4 B Percent Distribution of Number of Live Births by Current Age of Respondents Among All Men and Among Married Men Aged 15–49 Reproductive Health Survey: Albania 2002 Number of Live Births All Men Total Age Group (Current Age) 15–19 20–24 25–29 30–34 35–39 40–44 45–49 0 45.5 100.0 94.9 63.4 21.4 7.0 1.6 2.7 1 11.5 0.0 2.6 22.9 33.5 15.4 6.8 3.2 2 24.9 0.0 1.5 12.0 36.8 51.3 45.8 38.0 3 11.8 0.0 1.0 1.6 6.8 20.0 32.3 27.6 4 + 6.3 0.0 0.0 0.2 1.6 6.3 13.5 28.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,740 401 189 218 253 255 277 147 Number of Live Births Married Men Total Age Group (Current Age) 15–19 20–24 25–29 30–34 35–39 40–44 45–49 0 10.3 ** 61.7 39.1 10.4 2.7 1.0 1.4 1 18.9 ** 19.2 38.0 38.3 16.2 6.2 3.3 2 40.8 ** 11.5 20.0 41.7 53.4 46.4 37.6 3 19.6 ** 7.6 2.6 7.8 21.1 32.7 28.3 4 + 10.4 ** 0.0 0.3 1.8 6.6 13.7 29.3 Total 100.0 ** 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,023 0 32 123 215 242 270 141 **Percentages are not shown when base is less than 25 cases. Chapter 4 40 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.5 A Percent of Women Aged 15–44 Who Had Their First Sexual Relation, First Marriage, and First Birth Before Selected Ages, and Median Age at These Events, by Current Age Reproductive Health Survey: Albania 2002 Current Age Age at First Sexual Intercourse Has Had Intercourse Never Had Intercourse Median Age † No. of Cases <15 <18 <20 <22 <25 15–19 1.2 (10.8) (13.8) NA NA 13.8 86.2 ** 1,094 20–24 1.6 16.3 35.1 (50.2) (55.2) 55.2 44.8 21.5 935 25–29 0.3 12.4 36.9 61.0 80.7 85.1 14.9 20.7 945 30–34 0.3 8.7 30.8 59.4 82.3 92.4 7.6 21.0 1,066 35–39 0.4 10.8 32.2 55.2 82.9 97.2 2.8 21.3 957 40–44 0.6 9.6 31.4 56.6 83.4 97.2 2.8 21.1 696 Total 0.8 11.5 29.2 47.4 63.3 69.9 30.1 21.1 5693* Current Age Age at First Marriage Ever in Union Never in Union Median Age † No. of Cases <15 <18 <20 <22 <25 15–19 0.6 (6.8) (9.5) NA NA 9.5 90.5 ** 1,094 20–24 0.9 11.2 27.8 (43.6) (49.8) 49.8 50.2 22.2 936 25–29 0.1 7.9 28.0 51.8 75.6 81.7 18.3 21.8 946 30–34 0.6 6.7 23.5 51.4 79.1 91.4 8.6 21.9 1,067 35–39 0.4 7.7 24.6 47.6 76.9 96.2 3.8 22.2 958 40–44 0.2 6.8 25.4 51.5 79.0 97.2 2.8 21.9 696 Total 0.5 7.8 22.4 40.7 58.5 67.2 32.8 21.9 5,697 Current Age Age at First Live Birth Has Had Live Birth Never Had Live Birth Median Age† No. of Cases <15 <18 <20 <22 <25 15–19 0.2 (2.5) (4.2) NA NA 4.2 95.8 ** 1,094 20–24 0.2 3.8 15.1 (28.3) (36.0) 36.0 64.0 23.6 936 25–29 0.0 1.6 13.7 37.0 65.8 77.0 23.0 23.3 946 30–34 0.5 2.7 9.7 31.9 69.2 90.4 9.6 23.3 1,066 35–39 0.2 2.1 11.7 31.0 65.3 93.4 6.6 23.7 955 40–44 0.0 2.6 9.8 33.2 66.5 95.9 4.1 23.5 696 Total 0.2 2.6 10.4 26.3 48.3 62.2 37.8 23.4 5693* * Excludes 4 cases not reporting the date at first sexual intercourse and 4 cases not reporting date at first birth ** Omitted because less than 50% in that age group reported the variable of interest by the end of the interval ( ) Time exposed partially truncated because not all cases have exposure throughout the period of analysis NA. Not applicable † Life table method used in calculation of median age at first intercourse, first marriage and first birth to control for truncated cases Albania Reproductive Health Survey, 2002 Final Report 41 Fertility and P regnancy Tab les Table 4.5 B Percent of Men Aged 15–49 Who Had Their First Sexual Relation and First Marriage Before Selected Ages and Median Age at These Events, by Current Age Reproductive Health Survey: Albania 2002 Current Age Age at First Sexual Intercourse Has Had Intercourse Never Had Intercourse Median Age No. of Cases <15 <18 <20 <22 <25 15–19 0.6 (4.5) (4.8) N/A N/A 4.8 95.2 ** 401 20–24 1.5 21.5 40.9 (56.1) (61.3) 61.3 38.7 21.5 188 25–29 2.1 15.3 38.6 56.1 80.4 93.6 6.4 20.9 209 30–34 0.4 8.3 39.2 53.8 76.1 99.4 0.6 20.9 241 35–39 0.2 8.3 26.7 48.1 72.2 99.8 0.2 21.9 235 40–44 0.0 8.3 30.8 53.8 74.5 100.0 0.0 21.3 247 45–49 0.0 5.4 22.1 51.3 75.4 100.0 0.0 21.7 132 Total 0.7 10.2 27.9 43.7 59.5 74.3 25.7 21.5 1,653* Current Age Age at First Marriage Ever in Union Never in Union Median Age No. of Cases <15 <18 <20 <22 <25 15–19 0.0 (0.0) (0.0) N/A N/A 0.0 100.0 ** 401 20–24 0.0 1.0 4.3 (7.7) (13.7) 13.7 86.3 ** 189 25–29 0.0 0.0 3.1 11.1 28.7 61.2 38.8 26.4 218 30–34 0.0 0.0 2.1 6.0 31.6 87.7 12.3 26.9 253 35–39 0.0 0.7 1.0 6.4 30.8 95.5 4.5 26.7 255 40–44 0.0 1.1 5.1 11.0 33.6 99.4 0.6 26.6 277 45–49 0.0 0.5 1.5 13.8 35.8 99.0 1.0 25.8 147 Total 0.0 0.5 2.4 7.4 23.3 61.0 39.0 26.5 1,740 * Excludes 87 cases not reporting the date at first sexual intercourse. ** Omitted because less than 50% in that age group reported the variable of interest by the end of the interval. ( ) Time exposed partially truncated because not all cases have exposure throughout the period analisys NA. Not applicable † Life table method used in calculation of median age at first intercourse, first marriage and first birth to control for truncated cases. Chapter 4 42 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.6 Median Age at First Sexual Intercourse, First Marriage and First Birth Among Women Aged 15–44 and Men Aged 15–49 by Selected Characteristics Reproductive Health Survey: Albania 2002 Characteristics Women Men Median Age at First Intercourse Median Age at First Marriage Median Age at First Birth Median Age at First Intercourse Median Age at First Marriage Total 21.1 21.9 23.4 21.5 26.5 Strata Metro Tirana 21.1 22.5 24.1 20.3 27.0 Other Urban 21.4 22.7 24.0 20.8 27.4 Other Rural 21.0 21.5 22.9 22.3 25.9 Residence Urban 21.3 22.7 24.1 20.6 27.4 Rural 21.0 21.5 22.9 22.2 25.8 Education Level Primary or Less 20.5 21.0 22.5 22.0 26.0 Secondary Incomplete 20.7 22.1 23.5 21.5 25.2 Secondary Complete 21.7 22.7 24.0 21.2 26.7 Post-Secondary 23.3 25.1 26.6 20.3 28.6 Albania Reproductive Health Survey, 2002 Final Report 43 Fertility and P regnancy Tab les Table 4.7 Sexual Activity Status by Current Marital Status for Women Aged 15–44 and Men Aged 15–49 (Percent Distribution) Reproductive Health Survey: Albania 2002 Sexual Activity Status Total Women Marital Status Married Previously Married Never Married Never Had Intercourse 30.1 0.0 0.0 91.8 Ever Had Intercourse 69.9 100.0 100.0 8.2 Within The Last Month 50.3 75.3 2.7 3.9 1–3 Months Ago 8.9 12.5 2.7 1.9 Over 3 Months But Within Last Year 2.6 3.2 9.9 0.8 One Year or Longer 3.7 2.5 76.4 1.4 Currently Pregnant 3.6 5.4 2.5 0.0 Postpartum 0.7 1.1 0.0 0.0 Unknown Interval 0.2 0.1 5.8 0.1 Total 100.0 100.0 100.0 100.0 No. of Cases 5,697 3,965 88 1,644 Sexual Activity Status Total Men Marital Status Married Previously Married Never Married Never Had Intercourse 24.4 0.0 ** 62.5 Ever Had Intercourse 75.6 100.0 ** 37.5 Within The Last Month 55.6 82.5 ** 14.4 1–3 Months Ago 8.1 6.2 ** 11.0 Over 3 Months But Within Last Year 2.7 0.8 ** 5.5 One Year or Longer 2.9 1.4 ** 4.9 Partner Currently Pregnant 2.4 3.9 ** 0.0 Partner Postpartum 0.9 1.5 ** 0.0 Unknown Interval 3.0 3.7 ** 1.8 Total 100.0 100.0 ** 100.0 No. of Cases 1,740 1,023 14 703 ** Percentages are not shown when base is less than 25 cases. Table 4.8 Abortions * per 1000 Births Reported in Reproductive Health Survey and By Albanian Institute of Statistics (INSTAT)† Three Year Period: 1999–2001 INSTAT RHS (CI)‡ Under-Reporting in RHS (CI)‡ Abortion/1000 Births 200 73 (46 to 100) 64% (-77% to -50%) * Arborteve me Nderprerje (Induced Abortions) † Instituti I Statistikes (2003): Http:/www.Instat.gov.Al/graphics/doc/tablelat/shno1.html ‡ 95% confidence interval Chapter 4 44 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.9 A Planning Status of the Last Pregnancy Among Women 15–44 Years of Age With at Least One Pregnancy Since January 1997, by Selected Characteristics (Percent Distribution) Reproductive Health Survey: Albania 2002 Characteristics Planning Status of Last Pregnancy Total No. of CasesIntended Mistimed Unwanted Not Sure Total 86.7 5.8 7.0 0.5 100.0 2,275 Last Pregnancy Outcome Current Pregnancy 86.7 9.3 3.0 1.0 100.0 222 Live Birth 91.7 4.8 3.2 0.3 100.0 1,811 Induced Abortion 22.2 11.6 64.7 1.5 100.0 149 Other Pregnancy Outcomes * 78.8 8.9 11.4 0.8 100.0 93 Strata Metro Tirana 83.3 7.9 8.5 0.3 100.0 844 Other Urban 85.3 7.1 7.3 0.3 100.0 730 Other Rural 88.5 4.5 6.4 0.6 100.0 701 Residence Urban 84.5 7.6 7.6 0.3 100.0 1,410 Rural 88.4 4.5 6.5 0.6 100.0 865 Age at The Time of The Last Pregnancy Outcome† < 20 88.5 10.4 1.1 0.0 100.0 135 20–24 92.0 6.6 1.4 0.1 100.0 653 25–29 87.1 6.7 5.6 0.5 100.0 798 30–34 82.0 3.5 13.2 1.3 100.0 498 35+ 78.2 1.7 20.1 0.0 100.0 191 Marital Status at Last Pregnancy Currently Married 86.7 5.7 7.1 0.5 100.0 2,171 Not Currently Married 86.7 8.2 5.2 0.0 100.0 104 Living Children 0 87.4 11.3 1.3 0.0 100.0 105 1 93.7 5.0 1.0 0.2 100.0 679 2 87.6 6.7 5.6 0.0 100.0 934 3 80.1 5.9 12.1 2.0 100.0 419 4 + 71.2 0.9 27.9 0.0 100.0 138 Education Level Primary or Less 87.5 5.4 6.7 0.4 100.0 1,072 Secondary Incomplete 84.4 8.5 7.1 0.0 100.0 158 Secondary Complete 86.5 5.0 7.8 0.8 100.0 795 Post-Secondary 84.1 10.0 5.9 0.0 100.0 250 * Includes pregnancies resulting in stillbirth, miscarriage or ectopic pregnancy. † Age of the woman at the time of pregnancy outcome. Albania Reproductive Health Survey, 2002 Final Report 45 Fertility and P regnancy Tab les Table 4.9 B Planning Status of the Last Live Birth Among Men 15–49 Years of Age With Partner Having at Least One Live Birth Since January 1997, by Selected Characteristics (Percent Distribution) Reproductive Health Survey: Albania 2002 Characteristics Planning Status of Last Pregnancy Total No. of CasesIntended Mistimed Unwanted Not Sure Total 98.4 1.0 0.1 0.5 100.0 488 Strata Metro Tirana 96.4 3.1 0.5 0.0 100.0 181 Other Urban 98.8 0.6 0.0 0.6 100.0 162 Other Rural 98.7 0.7 0.0 0.6 100.0 145 Residence Urban 98.3 1.2 0.2 0.4 100.0 312 Rural 98.5 0.9 0.0 0.6 100.0 176 Age at Time of The Last Live Birth* < 25 98.6 1.4 0.0 0.0 100.0 27 25–29 97.9 2.1 0.0 0.0 100.0 152 30–34 99.3 0.7 0.0 0.0 100.0 189 35+ 97.4 0.0 0.4 2.2 100.0 120 Living Children 0–1 98.9 1.1 0.0 0.0 100.0 164 2 98.0 1.6 0.0 0.4 100.0 227 3 + 98.2 0.0 0.4 1.4 100.0 97 Education Level Primary or Less 99.0 0.3 0.0 0.6 100.0 212 Secondary Incomplete ** ** ** ** ** 6 Secondary Complete 97.6 1.8 0.2 0.5 100.0 214 Post-Secondary 97.8 2.2 0.0 0.0 100.0 56 * Age of the man at the time of live birth outcome **Percentages are not shown when base is less than 25 cases. Chapter 4 46 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.10 A Fertility Preferences of Currently Married Women Aged 15–44 Years By Number of Living Children and by Age Group (Percent Distribution) Reproductive Health Survey: Albania 2002 Preference for Children Total Number of Living Children† 0 1 2 3 4 + Want a Child Now 3.4 29.2 6.5 1.4 0.3 0.3 Want a Child Within a Year 3.1 21.0 6.1 1.4 1.0 0.3 Want a Child in 1–2 Years 5.8 14.1 17.7 3.6 1.0 0.3 Want a Child After 2 or More Years 12.4 8.7 44.6 7.6 1.9 0.1 Want More But Do Not Know When 2.7 3.5 4.8 2.9 1.3 0.9 Want No (no more) Children 62.5 2.0 10.0 72.5 86.7 91.5 Undecided 7.3 6.6 8.5 8.6 5.8 3.6 Subfecund, Infecund 2.8 14.9 1.8 2.1 1.9 2.9 Total 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 3,961* 211 783 1,864 809 294 Preference for Children Total Age Group 15–19 20–24 25–29 30–34 35–39 40–44 Want a Child Now 3.4 11.3 7.8 4.5 2.8 1.7 1.2 Want a Child Within a Year 3.1 5.1 9.6 3.7 2.9 1.1 0.5 Want a Child in 1–2 Years 5.8 6.4 15.0 12.1 5.1 1.1 0.3 Want a Child After 2 or More Years 12.4 53.6 38.4 23.2 5.5 1.1 0.0 Want More But Do Not Know When 2.7 5.7 3.9 3.7 3.1 2.2 0.8 Want No (no more) Children 62.5 5.1 15.2 41.1 68.4 84.2 89.9 Undecided 7.3 12.9 9.5 10.6 11.1 4.8 0.9 Subfecund, Infecund 2.8 0.0 0.6 1.1 1.1 3.8 6.5 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 3,961* 96 501 800 1,003 906 655 * Excludes 4 women with missing information. † Women who were pregnant at the time of interview are classified as having one more child than their actual number of living children. Albania Reproductive Health Survey, 2002 Final Report 47 Fertility and P regnancy Tab les Table 4.10 B Fertility Preferences of Currently Married Men Aged 15–49 Years By Number of Living Children and by Age Group (Percent Distribution) Reproductive Health Survey: Albania 2002 Preference for Children Total Number of Living Children † 0 1 2 3 4 + Want a Child Now 4.1 26.2 8.2 0.7 0.0 0.0 Want a Child Within a Year 4.3 25.6 8.6 0.5 0.8 0.4 Want a Child in 1–2 Years 6.2 9.1 21.5 2.9 0.0 0.0 Want a Child After 2 or More Years 5.6 3.2 18.6 4.1 0.0 0.0 Want More But Do Not Know When 3.7 6.9 10.9 2.0 1.0 0.0 Want No (no more) Children 58.2 4.5 9.9 74.7 85.5 76.2 Undecided 12.9 3.8 18.8 13.4 9.4 14.1 Subfecund, Infecund 4.9 20.7 3.5 1.7 3.4 9.3 Total 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,022* 88 221 473 170 70 Preference for Children Total Age Group 20–24 25–29 30–34 35–39 40–44 45–49 Want a Child Now 4.1 15.6 14.6 5.7 2.1 0.3 0.3 Want a Child Within a Year 4.3 19.1 12.0 6.9 1.4 1.6 0.3 Want a Child in 1–2 Years 6.2 8.9 15.2 13.9 3.4 1.7 0.3 Want a Child After 2 or More Years 5.6 17.8 14.6 12.7 2.7 0.2 0.0 Want More But Do Not Know When 3.7 5.1 8.9 6.6 4.0 0.5 0.6 Want No (no more) Children 58.2 14.0 15.3 32.0 64.7 84.0 84.2 Undecided 12.9 19.5 11.6 19.4 18.2 7.8 6.0 Subfecund, Infecund 4.9 0.0 7.8 2.9 3.5 4.0 8.4 Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 No. of Cases 1,022* 32 122 215 242 270 141 * Excludes 1 man with missing information. † Men whose partner was pregnant at the time of interview are clasified as having one more child than their actual number of living children. Chapter 4 48 Fe rt il it y an d P re gn an cy Ta b le s Fertility and Pregnancy Table 4.11 Percentage of Fecund Married Women Reporting They Want no More Children by Number of Living Children and Selected Characteristics Fecund Women 15–44 Years of Age Reproductive Health Survey: Albania 2002 Characteristics Total Number of Living Children† 0 1 2 3 4 + Total 64.3 2.3 10.1 74.0 88.5 94.2 No. of Cases 3,866* 183 769 1,833 795 286 Strata Metro Tirana 62.6 0.0 17.5 78.8 90.3 94.1 Other Urban 66.9 7.2 13.8 79.7 87.2 93.3 Other Rural 63.3 0.0 5.3 66.9 88.6 94.5 Residence Urban 65.8 4.8 16.1 79.8 87.9 93.8 Rural 63.1 0.0 5.2 67.2 88.8 94.4 Age Group 15–24 13.3 2.5 2.7 46.8 69.4 ** 25–34 56.3 0.0 7.7 65.4 78.1 81.2 35–44 91.7 ** 63.7 90.3 95.6 96.8 Education Level Primary or Less 61.1 0.8 4.9 66.3 87.5 94.0 Secondary Incomplete 58.4 ** 16.0 66.0 90.5 ‡ Secondary Complete 71.0 8.5 15.3 81.7 90.3 94.3 Post-Secondary 63.1 0.0 20.9 85.6 85.1 ‡ * Excludes 4 women with missing information. † Women who were pregnant at the time of interview are clasified as having one more child than their actual number of living children. ‡ Percentages are not shown when base is less than 25 cases. Albania Reproductive Health Survey, 2002 Final Report 49 M A T E R N A L A N D C H ILD H E A LT H Chapter 5 Maternal and Child health Adequate perinatal care is an essential approach in identifying and addressing risk factors that may affect the health of mothers and their babies. In Albania, perinatal care has been organized as a vertical program controlled by the Ministry of Health and for many years women have had free access. Currently, under the new health reform, it is included in all three sub systems: primary health care, secondary health care and tertiary health care. Perinatal care consists of three components: preconception care, prenatal care and postnatal care. Preconceptional counseling and prenatal care are generally offered by primary care providers and consists of a wide range of information. Information includes risks associated with pregnancies, health risk factors that can affect the development of the fetus (e.g. tobacco and alcohol), maternal infection (e.g. rubella, toxoplasma, HIV and other sexually transmitted diseases), risks associated with maternal health conditions, and risks associated with genetic conditions. Efforts are being made by the Ministry of Health of Albania to organize preconception counseling, especially in addressing the high prevalence of genetic conditions in some areas of the country. Nevertheless, preconception counseling is not routinely provided during health care visits in spite of the essential role the primary care provider plays in modifying women’s health behaviors (many healthy behaviors must be in place before the pregnancy is recognized) and in identifying medical conditions that require special attention during pregnancy. The use of timely and periodic prenatal care can assist in the identiﬁ cation and/ or prevention of perinatal morbidity and prevention of mortality. In Albania, public prenatal care is organized within the primary health care subsystem, and in urban areas, it is offered in women’s clinics (policlinics), and in both urban and rural areas the service is provided by family doctors (GP’s) in their health centers. There are 95 women’s clinics and 582 health centers in the urban areas. Prenatal care includes a general risk assessment, consisting of a medical examination and a series of laboratory tests, such as blood, urine, vaginal bacteriological exams, screening for sexually transmitted infections, and isoimmunization Rh. Pregnant women in Albania are entitled to use these public services free of charge. In urban areas, mainly in Tirana, there are an increasing number of private clinics that offer prenatal services, especially the use of ultrasound exams during pregnancy. Although women’s clinics are now separated from well baby clinics in urban areas, postpartum care is performed jointly with infant care visits during the ﬁ rst year postpartum. The Albanian Reproductive Health Survey looked at a number of factors which can have a considerable impact on the health of a woman, the health of her baby, and the outcome of her pregnancy. The instrument used for the survey covered issues such as: the use of health care services related to pregnancy; health related behaviors during pregnancy; the place of delivery; type and assistance at delivery; and postpartum behaviors, including infant feeding practices. However, the sample size allows the ability to estimate infant and child mortality indicators for only the ten year period prior to the survey. In this chapter selected aspects of maternal and child care in Albania will be examined. Such aspects include sources of health care, 50 Chapter 5 Maternal and Child Health utilization of maternal health care clinics, quality of care, etc. The aim is to identify subgroups with speciﬁ c needs of care and to investigate maternal and child outcomes, which may be related to the availability and quality of maternity care services. All this information will be used to help direct or modify program interventions. Prenatal care Prenatal care is most effective when it is initiated in the early stages of pregnancy, is continued throughout gestation, and is comprehensive. For the optimal health of the mother and child, it is recommended that every pregnant woman starts seeing a health care provider for prenatal care examinations during her ﬁ rst trimester of pregnancy. This section describes the use of prenatal care for all pregnancies ending in a live birth since January 1997. Women participating in the survey were asked about the total number of prenatal care visits they have had during their pregnancy (information did not include visits made just to conﬁ rm pregnancy or the use of health care services for the delivery only). Another question regarded the week or month of gestation when they had their ﬁ rst visit for prenatal care. Table 5.1 displays prenatal care which is distributed by pregnancy trimester of ﬁ rst visit and number of prenatal visits by selected categories. Nineteen percent of all pregnancies ending in a live birth since January 1997 have not received any prenatal care by health professionals. The ﬁ gure is the highest when compared with Eastern European countries and it is among the highest even when compared with the Caucasus Region and Central Asian countries (CDC and ORC MACRO, 2004). Although there is a considerable amount of variation between countries on how many prenatal visits a pregnant woman should make and when they should make their ﬁ rst visit, it is generally accepted that the ﬁ rst visit should take place within the ﬁ rst three months after conception. Among pregnant women who had a live birth since January 1997, including those who have not had any prenatal visits, only 59% received their ﬁ rst prenatal care during the ﬁ rst trimester. During the second trimester the ﬁ rst visit was made by 18 % of pregnant women, and the remaining 3% had their ﬁ rst prenatal visit only during the third trimester. Almost one-ﬁ fth of women (19%) reported no prenatal care. While there are virtually no differences between women living in Tirana and women living in other urban areas in Albania, rural women are by far, more likely (two and a half times more) to carry their birth to term without having any prenatal visits. In addition to rural women there are two additional socio-economic factors, which increases the risk of not having any prenatal visits: level of education and socio economic index. One out of four women among those with only a primary education or less have not had any visits, compared to 7% for women who have had their university studies. The picture is similar when considering the socioeconomic index; women with a low socioeconomic index are almost two and a half times more likely to not have had any prenatal care visits. Other characteristics that inﬂ uence not having any prenatal care visits are the age of the mothers and the birth order. Table 5.1 shows a steady trend; women of older ages are more inclined to not receive any prenatal care and among those in the 35–44 age group the likelihood of not receiving prenatal care is almost twice as high as those under 20 years old. Almost 30% of women who have had three or more births made no prenatal visits. Albania Reproductive Health Survey, 2002 Final Report 51 The place of residence, education, and socioeconomic index are also three important factors which inﬂ uence the early starting of prenatal care. More women living in an urban area started their prenatal care earlier compared to women living in a rural area: 71% versus 51%. Differences among various educational and socio-economic groups are even higher. Only one-fourth of women with a post-secondary education had their ﬁ rst visit after the ﬁ rst trimester or no visits, while almost half of the women with a primary education do so. When analyzing the socioeconomic index, the picture is the same: 79% of women classiﬁ ed in the high socioeconomic index start their prenatal care during the ﬁ rst trimester versus only 49 % of those classiﬁ ed in the low index. Prenatal care should not only start early but also continue throughout pregnancy, according to the recommended standards of periodicity. To asses the adequacy of prenatal care it is necessary to monitor both the time of the ﬁ rst visit and the number of prenatal care visits. In our study the relative majority of women (slightly less than half of those who had some prenatal care) have had only 1–3 visits. The average number of prenatal visits among all pregnant women was around 3 ranging from no visits at all to 27 visits. Women living in urban areas, women with higher education, and those with a higher socioeconomic status use the prenatal care services more frequently compared to the women living in rural areas, with less education and a lower socioeconomic status. When compared to other countries in the sub-region, the same differences between areas of residence and education of mothers are noticed, but the range of differences is more similar to the Caucasus countries than Eastern Europe. Generally, in all of these countries, urban living and better educated women use the health services more frequently for prenatal care, compared to women living in rural areas and having a lower educational status. Nevertheless, only among countries such as Georgia, Azerbaijan or Armenia are differences as high as those seen in Albania (CDC and ORC MACRO, 2004). The baby’s weight at birth does not seem to be associated with onset of prenatal care. The proportions of the two categories – under 2500 kg and 2500 kg and above– are quite similar. Prenatal care is inadequate in some of the countries of Eastern Europe and the former Soviet Union (successor states of USSR). In recent reproductive health surveys (RHS) and demographic and health surveys (DHS) conducted in the region, the proportion of pregnant women with no prenatal care was less than 1% in Czech Republic, 1% in Moldova, 4% in Russia, 8% in Armenia, 9% in Ukraine and Georgia, between 2% and 55% in Central Asian Republics, 11% in Romania, and 30% in Azerbaijan (CDC and ORC MACRO, 2004). Late prenatal care is also common. With the exception of Czech Republic, where more than 90% of women began receiving care in the ﬁ rst trimester, in all other countries less than three-fourths of women entered prenatal care early. Late prenatal care was more prevalent in the Caucasus region than in other regions. In the United States, in 2000, 83% of pregnant women began prenatal care in the ﬁ rst trimester, while only 4% had no prenatal care or late care (third trimester) (CDC, 2002). In Albania there are no ofﬁ cial indicators to measure the adequacy of prenatal care. In the United States the adequacy of prenatal care is assessed by using the Adequacy of Prenatal Care Utilization Index (APNCU), also known as the Kotelchuck index (Kotelchuck, 1994). This index is based 52 Chapter 5 Maternal and Child Health Figure 5.2 Adequacy of Prenatal Care Utilization Index* Births in the 5 Years Prior to the Survey Inadequate 69% Unknown 2% Adequate Plus 2% Adequate 7% Intermediate 20% on the recommendation of the American College of Obstetricians and Gynecologists, and it is used in all similar reproductive surveys, which makes it a good comparison indicator. It combines the month when prenatal care begins with the number of visits received. Inadequate care is deﬁ ned as no or late prenatal care or less than 50% of recommended visits. The three remaining levels (intermediate, adequate and adequate plus) require an early initiation of care by the fourth month of gestation. Intermediate care requires 50%–79% of the recommended number of visits; adequate care requires 80–109%; and adequate plus level requires 110% or more of the recommended number of visits. Using the recommendations of the American College of Obstetricians and Gynecologists for number of visits, as has been used in other reproductive health surveys in Eastern Europe, the adequacy of prenatal care in Albania assessed by the Kotelchuck Index compared with four other countries is shown below. The percentage of women in each category is shown across multiple countries (ﬁ gure 5.1) and for Albania (ﬁ gure 5.2) 0 20 40 60 80 100 Unknown Inadequate Intermediate Adequate Adequate Plus RomaniaMoldovaGeorgiaAzerbaijanAlbania Figure 5.1 Adequacy of Prenatal Care Utilization Index*, Selected Countries in Eastern Europe *Also known as the Kotelchuck Index, it is a measure of adequacy of prenatal care based on initiation of such care (no prenatal care automatically warrants “Inadequate” level) and the number of required visits adjusted for the length of gestation and the gestational age at first visit. Albania Reproductive Health Survey, 2002 Final Report 53 Inadequate care ranges from 13% in Moldova to 81% in Azerbaijan. For Albania, inadequate care is estimated at 70% of the women eligible for prenatal care with live births since 1997. Adequate and Adequate Plus care ranges from 6% in Azerbaijan to 68% in Moldova. The percentage of women with adequate or adequate plus care in Albania is estimated at 9%, somewhat higher than Azerbaijan and somewhat lower than Romania. In the prenatal health care package an important component is the dissemination of health information. Especially when preconception care is missing, the ﬁ rst prenatal visit is a critical opportunity to screen women for behavioral risk factors such as tobacco or alcohol use, medical and genetical risks, occupational risks and to provide comprehensive counseling. Counseling should include information about maternal behaviors and exposures that may affect the health of the fetus, nutrition, rest, and early signs and symptoms of pregnancy complications. In addition, approaching the time of delivery, counseling should prepare women for what they will face when giving birth, distribute accurate information regarding labor and delivery, and advise about techniques to reduce pain and anxiety during labor. Also, counseling about breastfeeding and family planning after birth should be initiated during the prenatal period and reinforced during post partum care. The majority of the women (37%) had most of their prenatal care visits in a district hospital or in the Tirana maternity hospital. A similar proportion (33%) used policlinics, especially in Tirana or in another city, for most of their prenatal care visits and 23% of pregnant women used health centers or health posts for their visits (data not shown). It seems that some proportion of women living in rural areas prefer to use health services located in Tirana or other urban areas instead of going to the nearest health center or health post for examinations and counseling. Only 7% of pregnant women sought prenatal care in private clinics, ranging from 13% in Tirana to 5% in rural areas. To complete the picture of the quality of prenatal care, besides the utilization of services discussed above, the reproductive health survey included additional questions aimed at assessing information received and measurements performed during the prenatal visit; that is the adequacy of the content of prenatal care. Table 5.2 shows the percentage of pregnant women who received some information about speciﬁ c educational topics during their prenatal care visit. Only 60% of women who attended prenatal care clinics received some counseling about nutrition during pregnancy. The proportion of women who received counseling on breastfeeding and delivery is approximately the same, slightly over 58%. These three topics are, nevertheless, the most discussed during the prenatal visits among pregnant women in Albania. Other topics, like postnatal care, pregnancy complications, effects of smoking and alcohol, are remembered to have been discussed with a health professional by roughly half of the pregnant women. Contraception was less frequently mentioned as a counseling topic during prenatal care visits; less than 40% of women reported it. Maternal characteristics that appear to be associated with lower levels of counseling for almost all the topics include rural residence, low levels of education (less than secondary education), and a low socioeconomic index. Other maternal characteristics related with poor counseling practices during prenatal care are age of the 54 Chapter 5 Maternal and Child Health mother, under 20 years old, and having two or more previous pregnancies. The number of prenatal visits was directly related to the proportion of women receiving information during their prenatal care visits. In addition to counseling, the ﬁ rst prenatal visit should include a detailed medical history of the women and her family, including information about risk factors and genetic disorders, a detailed obstetrical history, a comprehensive physical examination, measurement of blood pressure, urine tests, basic blood tests, an ultrasound, and tests for various types of infection. Monitoring of mothers weight, blood pressure, and basic blood tests are extended during the follow up visits. The proportion of women who have received examinations such as blood tests, urine tests and measurement of blood pressure is above 80% (Table 5.3). About three-fourths (77%) of women had an ultrasound examination during their prenatal care visit, while only 62% stated that they received a tetanus immunization. Only one in four pregnant women received iron supplements as part of their prenatal care. Residing in a rural area, a low educational level and a low socioeconomic status remains associated with lower proportions of exposure to most of the selected procedures presented in table 5.3. On the other hand, having more than three prenatal care visits increases the chances of receiving an ultrasound examination. A private clinic, as a source of prenatal care, raised the odds for having an ultrasound exam and blood and urine tests but not for the measurement of blood pressure or other selected procedures. Routine measurement of blood pressure is an essential component of health risk assessment during prenatal visits. Table 5.4 clearly shows that the majority of women who gave birth during the 1997–2002 period had routine measurements of their blood pressure during pregnancy (83.3%). Among them, more than one in ten has been told by a doctor that they have high blood pressure. The proportion of those hospitalized exclusively for this condition was very low (only 0.5%), while more than half of the pregnant women diagnosed with high blood pressure received treatment for it. Although blood pressure was measured more frequently among more educated, higher socioeconomic status women and those living in urban areas, high blood pressure was found at a higher prevalence among rural women and women with lower educational and socioeconomic level. Treatment and hospitalization for high blood pressure among pregnant women followed the same proﬁ le. The number of prenatal visits steadily increases the identiﬁ cation rate of high blood pressure. As a result, the prevalence of high blood pressure among women, having more than 10 prenatal care visits, is almost three times higher compared to women who have attended only one to three prenatal visits. Table 5.5 shows the prevalence of ultrasound exams during pregnancies, carried to term, between 1997 and 2002. Overall, about three in four pregnant women (77%) had at least one ultrasound exam. This prevalence is lower than that observed in the Czech Republic in 1993, similar to the more recent data of the Ukraine (78%) and Moldova (75%), but much higher than the prevalence observed in Romania (47%) and some Caucasus Countries; Georgia (54%) and Azerbaijan (26%). Ultrasound exam rates in Albania, similarly to those observed elsewhere, are higher in urban areas, among better educated and higher socioeconomic status women, and among women having their ﬁ rst Albania Reproductive Health Survey, 2002 Final Report 55 child. Ultrasound examinations rates are positively associated with the number of prenatal visits. Almost one in three women (30%) had their ﬁ rst ultrasound exam very early in their pregnancy (less than 14 weeks) while the relative majority of ﬁ rst exams occurred between 14 and 26 weeks of pregnancy (44%). The three characteristics mentioned before (urban residence, a high educational level and a high socioeconomic status) are associated to starting an ultrasound examination early among pregnant women. The utilization of a private clinic for prenatal care visits is another important factor that is positively associated to the starting ultrasound examinations early; around 43% of pregnant women using a private clinic as a source of prenatal care receive their ﬁ rst ultrasound exam within the ﬁ rst 14 weeks of pregnancy. The reproductive health survey data does not allow differentiation between selected speciﬁ c indications (e.g. conﬁ rmation of gestational age, assessment of fetal viability, fetal malformations, fetal growth, fetal presentation and multiple pregnancy, examination of the placenta, assessment of amniotic ﬂ uid) or for routine ultrasound screening, either during early pregnancy (less than 14 weeks) or in late pregnancy (after 27 weeks). Almost one in three women had their ﬁ rst ultrasound exam very early in their pregnancy (less than 14 weeks) while the relative majority of ﬁ rst exams occurred between 14 and 26 weeks of pregnancy (43.8%). The three characteristics mentioned before (urban residence, a high educational level and a high socioeconomic status) are associated with having an ultrasound examination early among pregnant women. The utilization of a private clinic for prenatal care visits is another important factor that is positively associated with starting ultrasound examinations early; around 43% of pregnant women using a private clinic as a source of prenatal care receive their ﬁ rst ultrasound exam within the ﬁ rst 14 weeks of pregnancy. Pregnancy complications Table 5.6 presents pregnancy complications that required medical attention distributed by selected characteristics. Among all pregnancies brought to term since January 1997 and that have some prenatal care, almost one in four were reported to have some kind of pregnancy complication. The most frequently mentioned complication was the risk of preterm delivery (10%), followed by anemia related to pregnancy (7%), a weak cervix, water retention or edema, an urinary tract infection (around 6% each), followed by high blood pressure related to pregnancy, bleeding, and Rh isoimunisation. There are no signiﬁ cant differences among the different subgroups, based on background characteristics of the mothers. Intrapartum care In Albania all births are recommended to occur in medical facilities where adequately trained personnel can monitor the progress of labor and delivery. The reproductive health survey data demonstrates that 85% of births in the country are occurring in a district maternity hospital or in Tirana maternity (Table 5.7). Only around 8% of deliveries take place in “birth houses”; 13% in rural areas. Births delivered outside medical facilities or at home are rare but still represent a signiﬁ cant 6% of total births in the country. The proportion of births occurring outside a hospital or in birth houses become even higher in several subgroups of the population reaching 22% in rural 56 Chapter 5 Maternal and Child Health areas, 19% among women with primary education, and almost 21% among those of low socioeconomic status. Giving birth at home is highly associated with inadequate prenatal care; women who had no prenatal care visits have a four times higher risk of delivering their baby at home, compared to those who have had some prenatal care visits. The rate of giving birth at home is more than 15% among this subgroup. Other characteristics which are likely to increase the risk of giving birth at home are age of the women (those 35–44 years have a rate of 11%) and birth order (10% for women who already have two children) Delivery at a birth house is affected by the same factors as the delivery at home. The phenomenon of giving birth in a private clinic or hospital remains extremely rare in Albania; only among women of higher socioeconomic status does this proportion reach 2.5%. Table 5.8 shows the time spent in a medical facility prior to delivery and the length of stay after delivery. The average time spent prior to delivery in the hospital was about 7 hours (shorter than the times observed in Romania and Georgia, but similar to that observed in Azerbaijan) (CDC and ORC MACRO, 2004). The average duration of labor generally ranges from 6 hours (for multiparous women) to 10 hours (for nulliparous women). Thus, many women, particularly those giving birth for the ﬁ rst time were admitted for delivery during or right after the onset of labor. The average time spent in the medical facilities prior to delivery was slightly shorter for women living in urban areas, and those of higher socioeconomic status, probably indicating better access to hospitals by women of these subgroups. The time spent in the hospital prior to delivery was longer for nulliparous women (almost 10 hours), those who deliver by C-section and those who gave birth to babies weighing less than 2500 g. The majority of Albanian women (59%) stay in the medical premises less than three days after giving birth. Less than 20% stay in the hospital for more than four days and most of these are women who delivered by C-section. Only low birth weight babies and C-section deliveries are factors which highly increase the period of stay in the hospital after delivery. Other characteristics do not seem to be associated with period of stay in the hospital after delivery. Table 5.9 shows the percentage of births delivered by C-section by selected characteristics. The Caesarian section (C- section) rate varies considerably among countries, from about 5% to more than 20% of all deliveries. The optimal rate is not known, but little improvement in birth outcomes has been demonstrated if the rate is higher that 7%. In addition to unequivocal obstetrical indications, a C-section is often performed in less clear situations (e.g. prolonged labor) and often if a previous C- section was performed, which is rarely an adequate indication by itself. The reproductive health survey shows that although most births are delivered vaginally, in Albania, between 1997 and 2002, the rate of C-section deliveries was 13.4% and this ﬁ gure is only slightly higher than those reported by several Eastern European countries and the Caucasus region, where similar surveys were carried out. The C- section rate in those countries ranges from 3% in Azerbaijan to 11% in Romania and 12% in Russian areas with surveys (CDC and ORC MACRO, 2004). Women residing in Tirana were almost twice as likely to have a C-section delivery compared to women in rural areas, demonstrating that the bases of decision for a C-section may include other reasons apart from medical ones. The socioeconomic index was another factor seemingly associated with this type of delivery. Women of a Albania Reproductive Health Survey, 2002 Final Report 57 high socioeconomic status are more than twice as likely to have a C-section delivery. Factors which might increase the chances of having a C-section are the age of the mother (especially over 35 years), prolonged labor, pregnancy complications, low weight of the baby at birth, and to a lesser extent, being a ﬁ rst time mother. The Albania RHS also included a question directed to women who gave birth during the study period on the most important reasons for a C-section delivery. The most frequent reasons given by them included mainly clinical factors like malpresentation of fetus (35%), prolonged labor or baby started to suffer (22%), and baby too big for vaginal delivery (7%). Having had a previous C-section is also mentioned quite frequently as a reason for the actual C-section (22%). There were only 6% of women that requested a C-section delivery. Although small numbers do not allow important conclusions to be made, this last reason is more frequently found in urban areas compared to rural areas (9% versus 2%). Poor birth outcomes Poor birth outcomes are considered stillbirths, preterm births (live births within 37 weeks of gestation) and infants weighting less than 2500 grams at birth (low birth rate- LBW). Selected poor birth outcomes in the ﬁ ve years preceding the survey are shown in table 5.10. The incidence of low birth weight (LBW) for infants born alive during the study period was 4.6%. It is only slightly higher than the rate reported by a recent survey in Albania (UNICEF and INSTAT, 2000). Nevertheless, it is lower than the rates produced by similar studies in some Eastern European countries and the former Soviet Union. There are no clear trends in low birth rate among selected background categories of women apart from age and birth order; LBW rate was respectively 5.7% and 6.7% among women younger than 20 years and ﬁ rst time mothers, while only 1.5% among the 35–44 age group and 2.4% among women who have had three or more births. The preterm birth rate is slightly lower than the LBW rate (3.6%) but the birth order characteristic has the same proﬁ le as the LBW rate. Prolonged labor increases more than twofold the risk of LBW (slightly less that of prematurity birth), and this fact is consistent with other ﬁ ndings in other similar studies. Postnatal care After the birth of the child, it is important to provide appropriate postnatal care for both the health of the mother and the child, which must include counseling about breastfeeding, nutrition, and family planning. The postnatal period is a critical time that allows the health care provider to evaluate the physical and psychological health of the new mother and her infant, to detect and treat possible postpartum complications and to provide the support needed to address any speciﬁ c problems related to child care. The Albania RHS provided information on the use of postnatal care and the content of postnatal counseling. As it is clearly demonstrated by Table 5.11, the percentage of women who attended a postpartum care visit within a speciﬁ ed time period is only a fraction of those who have been receiving some kind of prenatal care. Less than one in ﬁ ve women (19%), currently aged 15–44, who delivered live birth babies during the 1997–2002 period, had at least one postnatal care visit. Furthermore, only 36% had their ﬁ rst postnatal visit within the ﬁ rst week after the delivery. About 61% of women had their ﬁ rst visit within the ﬁ rst two weeks after the delivery. Urban residency, high 58 Chapter 5 Maternal and Child Health level of education and high socioeconomic category were the main factors inﬂ uencing a higher rate of postpartum care. Those giving birth at the Tirana Maternity Hospital, ﬁ rst time mothers, and those with postpartum complications were also more inclined to use the postnatal care services than other women. Information on whether women received a postpartum examination following their most recent live births was collected by the RHS or DHS surveys in ﬁ ve other countries in Eastern Europe and the Caucasus Region. There was a high variation in the proportion of women across these countries who received postpartum care, raging from 74% in Moldova down to 11% in Georgia. Except in Moldova, postpartum care coverage was always higher in urban areas than in rural areas. Coverage also tended to increase with education. During the postnatal care visits more than 70% of the women received information on immunization, child care, nutrition, breastfeeding and breast care by a health professional (Table 5.12). Although less frequent, contraception counseling was also received by slightly more than half of the women (55%). The differences, regarding this topic, between selected categories are not very sharp but proportions are always lower among women living in the rural areas, with lower education, and a lower socioeconomic category. The Albania RHS questionnaire included questions regarding healthcare for the baby after the delivery. Table 5.13 shows the proportion of live births followed by pos

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Albania: Reproductive Health Survey, 2002 Final Report

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