Contraceptive patterns among women and men in León, Nicaragua

ELSEVIER

Contraceptive Patterns Among Women and Men in Leh, Nicaragua Elmer Zelaya,*t Rodolfo Per’la,*t Jairo Garcia,* Jerker Liljehrand$

The aim was to study the contraceptive patterns among men and women in Le6n, Nicaragua. A questionnaire about sexual, contraceptive, reproductive and socioeconomic issues was directed to 7,789 households including 22% of all women of the municipality aged 15-49 years (n = 10,867). A subsample of 388 men and 413 women aged 15-49 years was drawn at random. Refusals were less than 2%. Private interviews revealed that among fertile women who had been sexually active within the last three months, non-pregnant and wishing to avoid pregnancy, 77% were contracepting. Female sterilization was the most common contraceptive method [39%), followed by intrauterine device (16%). Even though around 60% of women at some time had tried oral contraceptives, only 13% of contraceptars used them currently. The rhythm and interruption methods together constituted only 4%. Condom use was low and mainly occasional. Contraceptive use in sexually active women aged IS-44 years was lower among those having lower education, living in rural areas, and living under poverty conditions. The predominance of female sterilization and the occasional condom use--mainly reported by men-reflects a situation of relative male control over contraception and reproduction. This probably originates from “machista” values where men having many children with different women are considered strong. There was also a significantly higher use of contraceptives among the better-off women and men compared with the extremely poor. The situation of many poor women, in a country with limited contraceptive services, is worrying considering that abortion is illegal and the threat of HIV epidemic is growing. The situation for adolescents is partitularly problematic with low experience in contraceptive use. 0 1996Elsevier ScienceInc. All rights reserved. CONTRACEPTION

KEY

WORDS:

1996;54:359-365 Nicaragua, contraception, gender

*Department of Preventive Medicine, UNAN, Le6n, Nicaragua, tDepartment of Epidemiology and Public Health, Umed University, S-901 85 UmeB, Sweden, and *Baltic International School of Public Health, S-371 85, Karlskrona, Sweden Name and address for correspondence: Lit. Elmer Zelaya Bland6n, Department of Epidemiology and Public Health, Ume& University, S-901 85 Ume& Sweden. Tel:46-90-102931; Fax: 46-90-138977 Submitted for publication February 16, 1996 Revised August 16. 1996 Accepted for publication August 16, 1996

0 1996 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010

Staffan Berglund,t

Lars Ake Persson,t

and

Introduction

A

ccess to good quality contraceptive services, with adequate counseling and a reasonable choice of contraceptive methods, contributes to the prevention of unwanted pregnancy and reduces the number of provoked abortions in any society.’ In Latin America and the Caribbean, the estimated contraceptive prevalence among married women aged 15-49 years is 59%,‘13 and the total fertility rate is 3.0.3 The main contraceptive methods are female sterilization (20%) and oral contraceptives (16%).’ About 44% of Latin American women and men of reproductive age do not use any type of contraceptive and regular condom use is very low.’ Traditional cultural factors, conservative political powers, and the Catholic church influence contraceptive use negatively. There is a widespread practice of induced abortion,4 which, being illegal in most countries in the region, therefore, is clandestine and unsafe. Nicaragua, with an estimated population of 4 million, has a total fertility rate of 5.0,3 one of the highest in Latin America. Forty-six percent of the population are children under 15 years of age, and 23% are women in reproductive age groups (15-49 years).5 For the larger part of the population, family economy is barely at survival level, 70% of the population being below the poverty line.6 The number of contraceptive users grew rapidly during the 1980s and in the last three years of that decade, significant efforts were made to promote condom use.’ However, men have long been resistant to using condoms, perhaps because the machista culture8 prejudices against contraceptives given that they reduce the potential number of one’s offspring and, therefore, sons.’ Although the Sandinista government never legalized abortion, access and availability increased during their administration.’ Formal sex education was, however, only minimally promoted.’ Under the new and conservative government, in power since 1990, the opinions of the Catholic church have gained greater influence, its message equating all contraception with abortion and, specifiISSN 0010.7824/96/$15.00 PII SOOIO-7824(96)00203-X

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tally, condemning condom use.’ Currently, abortion is illegal and clandestine abortions are common.‘f9 The present study is part of a larger investigation on reproductive and child health performed in 1993 in the municipality of Leon, the second largest city in Nicaragua. The aim of this article is to describe and analyze the contraceptive patterns among men and women in Leon as a basis for further interventions.

Materials

and Methods

The survey was carried out in the municipality of Leon, Nicaragua, which has an estimated population of 195,000 people, 80% of whom live in the urban area. It is situated in the northwest of Nicaragua about 100 kilometers from the capital city of Managua. Cotton used to be the main source of income in the Leon area; however, in recent years cotton production has been discontinued with severe consequences for the local economy. Unemployment rates have been found in some studies to be as high as 49%, affecting women in a higher proportion than men.” A cross-sectional community-based study was performed in the last quarter of 1993, involving a sample of 7,950 households in 50 randomly selected clusters in urban and rural areas. As 2% of the selected households declined to take part, the net sample consisted of 7,789 households, containing 10,867 women and 9,558 men aged 15-49 years. All of the women (n = 10,867; 22% of all women of the same age group in LebnJ, were asked about socioeconomic, child health, and reproductive issues. They were also asked if they had had sexual intercourse during the last four weeks, and, if so, were they contracepting or sterilized. The interviews were carried out at home by trained female field workers. In the analysis, formal education was defined as completion of primary school or more at the time of the interview and non-formal education as being illiterate or having less than completed primary school. To estimate the socioeconomic status of the study population, we used a social measure, the Unsatisfied Basic Needs Assessment. This measure includes four indicators which measure housing quality, school enrollment among minors, dependency ratio, and availability of sanitary services.” In a substudy, subsamples of women (n = 413) and men (n = 388), aged 15-49 years, were selected at random from the household lists acquired in the crosssectional study. These individuals were interviewed in private about sexual intercourse and contraceptive use during the past three months, and also in detail about all previous contraceptive experience. The interviewers were specially trained medical doctors of the same sex. Efforts were made to create a comfortable and undisturbed interview environment. In these

Contraception 1996;54:359-365

substudies, 1.5% of the selected men declined to participate while all selected women accepted. Further details of study setting, sampling, field work, and validity control have been described elsewhere.” The data entry, cleaning procedures, and descriptive analysis were performed using EPI-INFO 6.02 (Epidemiological software, CDC, Atlanta, GA and WHO). Logistic regression analysis was performed with the EGRET software (Epidemiological Research Corporation, Seattle, WA) and SPSS for Windows 61.2 (SPSS Inc., Chicago, IL). In the next section, all results are presented within a 95% confidence interval and p-values are Yates corrected.

Results Of the 10,867 women in the main study, 653 were above 44 years and excluded from analysis because menopausal situation had not been asked. Also, 4,610 had been sexually inactive during the past month, and of the remainder, 559 were pregnant, 202 desired pregnancy, and 200 reported infertility. Among the remaining 4,643 women between 15 and 44 years, who thus were sexually active, fertile, non-pregnant, and wishing to avoid pregnancy, 74% were contracepting. Among them, contraceptive use was more common when living in the urban area, having higher education and better socioeconomic status (Table 1). As expected, there was a positive relationship between contraception and women’s parity. We hypothesized that women’s education as well as living area and socioeconomic status were independently associated with contraceptive use/non-use, even when adjusting for parity. In a logistic regression model this was tested, and a strong relationship between educational level and contraception was found (Table 1). Women with lower educational attainment were less prone to use contraceptives. Living in the rural area and living under poverty conditions were also associated with low contraceptive use, even after adjustment for parity in the model, However, there was no significant interaction between education and poverty and between zone and poverty in the multivariable model. In the subsamples, among women aged 15-49 years who had been sexually active, living in fertile relationships, non-pregnant, and wishing to avoid pregnancy, 77% were contracepting (Table 2). The most prevalent method was female sterilization (39%), followed by intrauterine device (16% ), and oral contraceptives (13%). There was a significantly higher use of contraceptives among urban (83%) than rural women (66%), p = 0.005. With increasing age, sterilization accounted for an increasing proportion of total use, being the most common method among women aged 25-34 and 35-49 years. However, there was no

Contraception 1996;54:359-365

Contraceptive

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361

Table 1. Association of background factors to use of contraceptive methods among sexually active, fertile, non-pregnant women aged 15-44 years who wished to avoid pregnancy, (n = 4,643); odds ratio (95% CI) for not using contraception are given in bivariate analysis and multiple logistic regressionanalysis Bivariate OR Education

Formal No formal Urban Rural Three or more Two children One child No children Non-poor Poor Extremely poor

Zone Live children

Poverty

‘Likelihood

ratio

significant

statistics

on 8 DF = 1,311.5,

1.0

sterilization. contraceptive

1.72 (1.51-1.96)

::;2(1.47-2.01)

;:;4(1.65-2.28)

::98 (1.32-1.90)

1.0 1.18 (1.00-1.40)

:::S (l-22-1.73) 2.10(1.75-2.52) 4.24 (3.07-5.84)

1.59 (1.34-1.88) 3.34 (2.45-4.56)

1.0 1.71 (1.40-2.08) 1.90 (1.59-2.27)

::94(1.26-1.89)

1.63 (1.36-1.96)

p < 0.001.

active in fertile relationships, whose partner was not pregnant and wishing to avoid pregnancy, 72% reported using contraception with their partners (Table 2). The most prevalent methods were female sterilization (22%), followed by oral contraceptives (18%), condom (16%), and IUD (9%). There was a significantly higher use of contraceptives among urban men (78%) than rural ones (57%), p = 0.0006, and among the better-off men (86%) compared with the ex-

difference between urban and rural wo-

men, and between

Multivariate OR*

socioeconomic

groups as regards

There was a significant difference in use among the extremely poor women

(69%) and the economically better-off women (93%), p = 0.001 (Table 3). The use of methods such as withdrawal, rhythm, and injectables was very low in both the urban and the rural area. Among men aged 15-49 years who were sexually

Table 2. Proportion of current contraceptive use among sexually active, fertile, non-pregnant (their partner non-pregnant) women and men 15-49 years who wish to avoid pregnancy; results shown for urban and rural residency, and different age groups in Leon, Nicaragua, 1993 Sex Female

Male

Note:

Other

methods

Method

Total

Urban

Rural

15-24

Currently using Female sterilization IUD Pills Condom Others Not currently using Total Number of cases

77

83

66

39

42

32

16 13

19 12

11 15

4 5

4 6

4 4

205

131

74

47

Method

Total

Urban

Rural

15-24

Currently using Female sterilization IUD Pills Condom Others Not currently using Total Number of cases

72

78

57

22 9

22 9

22 7

18 16

18 21

19

19

7

8

5 4

31 60

include

injectables,

rhythm,

'

25-34

35-49

70

80

78

6

33 24 14 6 3

65 5 3 5 5

19 28 6

11

23

17

34

30

20

22

100

100

100

100

100

100

84

74

25-34

35-49

67

74

73

3 8

19 11 26 17

42 6

1

10 5

10

28

22

43

33

26

27

100

100

100

100

100

100

244

170

74

72

94

78

withdrawal,

and

male

sterilization.

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Zetaya et al.

Contraception 1996:54:359-365

Table 3. Proportion of current contraceptive use among sexually active, fertile, non-pregnant (their partner non-pregnant) women and men 15-49 years who wish to avoid pregnancy; results shown for education and basic needsin Leon, Nicaragua, 1993

Sex Female

Method Cuml;tly using sterilization IUD Pills Condom Others Not currently using Total Number of cases Method

Male

Total

Primary Incomplete

aPrimary Complete

Non-Poor

Poor

Extremely Poor

77

68

87

93

80

69

39 16 13 4 5

45 5 11 5 2

31 28 16 3 9

43 24 12 ;

39 22 10 4 5

37

23 100

32 100

13 100

7 100

20 100

31 100

205

110

95

42

51

112

Total

Primary Incomplete

aPrimary Complete

Non-Poor

Poor

10

15 4 3

Extremely Poor

;zm19”,“’ using

72

58

85

86

75

67

sterilization IUD Pills Condom Others Not currently using Total Number of cases

22 9 18 16 7

25 7 18 7 1

19 11 22 27 6

20 9 11 39 7

23 10 25 11 6

22 8 21 14 2

28 100

42 100

15 100

14 100

25 100

33 100

244

120

124

44

51

148

tremely poor (67%), p = 0.01 (Table 3). There was a striking difference in condom use in relation to socioeconomic status, being 39% for the better-off group and around 13% for the poor and extremely poor, p = 0.0003. The main reasons for non-use in both men (n = 67) and women (n = 45 ) were dislike of contraceptives (n = 85; 76%), current breast-feeding (n = 9; 8%), fear of side effects (n = 7; 6%), irregular sex (n = 4; 4%) and religious motives (n = 3; 2%). When asked about their contraceptive experience, among women aged 15-49 years, sexually active, nonpregnant, and wishing to avoid pregnancy, 59% had at some time used pills, 36% had ever used IUD, and 39% were sterilized. Around 25% had ever used a condom, but use was mainly reported as occasional. There was a significantly higher ever use of contraceptives (IUDs, pills) among urban as compared to rural women, p = 0.03. Both men and women reported that male sterilization was very rare (0.6%) and the use of methods like withdrawal and rhythm was very low. Among men and women aged 15-49 years who had gone through their sexual debut, 47% and 25%, respectively, had at some time used condoms, p = 0.001.

In both men and women, there was a significantly higher ever use of condoms in the urban than in the rural area, p = 0.04. There had been a higher use of condoms among the men aged 25-34 years than among the oldest ones, p = 0.002. Ninety-one percent of the men who had ever used condoms reported that they had only used them occasionally. Of men and women who had gone through their sexual debut, 53% and 75%, respectively, reported that they had never used a condom in their lives.

Discussion This study showed that a large proportion of sexually active women and men in the Leon area do not use contraceptives in spite of reportedly not desiring pregnancy. Female sterilization was the most prevalent method followed by IUD and pills, whereas condom use was low and mainly occasional. Low education, residence in a rural area, and living under poverty conditions increased the probability of non-contraception. Over one-fifth of all the women in the municipality of Leon were investigated as regards sexual, contraceptive, and socioeconomic patterns, and random

Contraception 1996;54:359-365

subsamples of men and women were carefully interviewed by medical doctors of the same sex with low refusal rates. The results of our study correspond well with a recent nationwide study,l’ and there are no reasons to believe that our results are not representative at least for the Pacific regions of Nicaragua. In both substudies, three very effective methods (female sterilization, IUD, and pills) account for over 75% of the current use among contraceptors. It is quite worrying that contraceptive use is lowest in the youngest age group, and the high risk of premature pregnancy in the study area has been shown elsewhere.il Limited contraceptive access implies also increased risks of STDs, including HIV/AIDS. Use of reversible contraceptives is much more common among urban than in rural areas, which corresponds well with an almost doubled number of living children per woman in rural areas. l1 However, no differences were found between urban/rural use of female sterilization. Thus, it appears as if many urban couples try various contraceptives during their fertile life period, before finally ending fertility with female sterilization. Rural couples, on the other hand, are to a high extent non-contraceptors until they also end fertility with female sterilization, but then at a much higher average parity. ‘i This may partly be due to less availability of contraceptive services and counseling in the rural area but also to less cultural acceptance of modern contraception. There is also a covariation between rural residence, poverty, and less education. The poor are almost twice as likely to be illiterate as the non-poor in Nicaragua. 6 Thus, apart from the Unsatisfied Basic Needs measure, education can also be seen as an indicator of access to social and economic resources which in turn influences the lifestyle of the people. Lack of education may, among other things, mean lack of access to information about non-permanent effective contraceptives, and more likelihood for a woman to be married to a man who is less disposed to contraceptive usage. Poverty, on the other hand, implies lack of affordability for modern reversible contraceptives, and also giving more priority to survival issues rather than health. Currently, unemployment is significantly higher among women compared to men.6!10,11t13 The feminization of poverty leads to a more difficult situation for women depending economically on men who are less worried about contraception for cultural reasons8 For rural women the situation is even worse given the current situation of agriculture and economy in the study area,l’ and because of constraints in the rural public transport system. Strategies to promote contraception must give consideration to these socioeconomic differences.i4 The cultural capital of the different social strata,

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meaning the ability to gather information,14 should be taken into account leading to a differentiated message and strategy according to the different social strata, living area, economic, and cultural background. Otherwise, a uniform and general strategy for prevention of unwanted pregnancies could, in turn, widen the gap on contraceptive use between the poor and the better-off. The differences in contraceptive use as reported by men and women, e.g., shown in the female sterilization figures, suggest a lack of communication on contraceptive use among the couples. It could also be due to different age distributions of the sexual partners of the interviewees, however; for instance, by men tending to have younger sexual partners. Female sterilization starts before 25 years and is the main method above the age of 30, whereas male sterilization is very rare. The dominance of female sterilization may be seen as just another indicator of the highly limited possibilities of the woman to negotiate more flexible forms of contraception, and possibly lack of functional contraceptive counseling and access to contraceptives. Getting sterilized seems to be the final way for the woman to exert control over her own body and reproduction. On the other hand, early sterilization, in a society where marital breakdown is common and consensual union is on the rise, may have a negative impact on young women. Many women starting a new union in their late 20s or early 30s might regret an earlier and sometimes desperate decision to be sterilized.15 But why do not men get sterilized themselves? One explanation for this could be the common idea that sterilized men lose their potency and that having many children with different women is an expression of virility and manhood. ‘19 Additionally, men want to preserve their fertility for the eventuality of divorce or separation. Men commonly refer to their offspring with a specific woman, using the expression, she has three of my children, which implies not only that there may be many more children with other women, but also establishes a clear distinction between the act of producing children, which constitutes the man’s badge of honor, and raising children, which is considered virtually the exclusive domain of women.9J’6 The use of condoms reportedly differs significantly between men and women. This can at least partly be explained by the fact that men are much more likely to engage in short-term sexual encounters, for instance, with occasional mistresses or prostitutes. In cases of insecurity regarding the sexual health status of his partner, men have the option of choosing the discomfort of a condom to risk of catching an STD, while women are rarely able to control this possibil-

364

ZeIaya et al

ity. As suggested in a qualitative study from the same area, sexual coercion of men over women based on cultural conventions, social norms, and economic dependency relations, makes it practically impossible for the majority of women to negotiate condom use.l’ In this context, it is worth noting the striking difference of condom use between the better-off men and the poor and extremely poor. Thus, gender and socioeconomic inequity in Nicaragua is clearly reflected by our data which suggest that poor women, rural women, very young women, and women with low education have the least power over their bodies, contraception, and reproduction. The health care system does not attend the rural and adolescent population as priority groups and does not make access to contraception any easier for them. Family planning services primarily target urban women who are in formal or common-law marriages. Thus, single women and adolescents may not approach family planning services because they fear being perceived as sexually active or being refused services because they are “unmarried” or “too young.“18 Additionally, health care services generally exclude men in the promotion of sexual and reproductive health, which is reflected in the very low rate of male sterilization. Apart from cultural reasons underlying this very low figure, it seems that very little emphasis is placed on the promotion of vasectomy and male responsibility regarding sexuality and reproduction. If a man is not actually opposed to the use of contraception, he is still likely to regard it as “her problem.” This points to the urgent need to expand contraceptive services in general, with special attention given to younger age groups, rural areas, and lower-educated population including men, regardless of marital status. However, the development of special adolescent health services is much needed, where counseling, health education, and provision of contraceptives could be given in confidentiality and with positive attitudes on the part of staff. A difficulty in promoting a good contraceptive mix is the general condemnation of artificial contraceptives by the church, and by conservative forces within the society and its educational system. This influence is expressed by exaggerated propaganda about the risks of artificial contraception designed to produce ’ l9 and the continuous cultivation of the notion panic that the disclosure of sexual activity through the act of buying contraceptives is shameful. In spite of the position of the church, 8 of 10 women at risk of unintended pregnancy are protecting themselves, however, and only 1% of women are using methods approved by the church. In conclusion, our findings underscore the need to increase the coverage of formal education, giving pri-

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ority to women and supporting all social, economic, and cultural activities and strategies reducing gender imbalance. Otherwise, the total material dependency of women on the income of men in combination with the wide gap of educational levels will preserve unequal gender relations, expressed in this report as inequalities in contraceptive opportunities. The very limited use of condoms should be taken seriously considering the increasing exposure to sexually transmitted diseases including HIV.” In 1988, the Ministry of Health developed a campaign to convince men and couples to use condoms. All motels provided condoms to clients, condoms were distributed widely, and women were encouraged to carry and use condoms to protect themselves from STDs.’ This campaign was stopped in 1990, but given the threat of the HIV epidemic and the spread of STDs,” such a strategy should be reconsidered. A particularly important group to protect is adolescents, at present with little real access to contraceptive counseling and provision, and with very limited sexual education.“lzl

Acknowledgments This research was jointly sponsored by the Swedish Agency for Research Collaboration with Developing Countries (SAREC) and the Nicaraguan Autonomous National University in Leon. We would like to thank the Ministry of Health of Nicaragua, the Local Government of Leon, and Movimiento Comunal for their valuable support. Special thanks to Dr. Paola Osejo and Dr. And&s Herrera for their committed effort in performing the substudy interviews and to Mary Car011 Ellsberg for her valuable comments and language revision.

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