KAP SURVEY regarding REPRODUCTIVE HEALTH ppt

K K A A P P S S U U R R V V E E Y Y r r e e g g a a r r d d i i n n g g R R E E P P R R O O D D U U C C T T I I V V E E H H E E A A L L T T H H KABUL, 15 to 31 October 2002 Conducted by: IbnSina Public Health Program for Afghanistan, Afghanistan ICRH International Centre for Reproductive Health, University of Ghent, Belgium Dr. Kathia van Egmond Funded by: VLIR Flemish Inter-University Board, Belgium DGIC Directorate-General for International Cooperation, Belgium LIST OF ABBREVIATIONS DGIC Directorate-General for International Cooperation, Belgium FP Family Planning ICPD International Conference on Population and Development, Cairo 1994 ICPD+5 5-year Review and Appraisal of Implementation of the ICPD Programme of Action, 1999 ICRH International Centre for Reproductive Health, University Ghent IUD Intra Uterine Device KAP Knowledge, Attitudes and Practices MCH Mother and Child Health RH Reproductive Health STI Sexually Transmitted Infections TBA Traditional Birth Attendant UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund VLIR Flemish Inter-University Board WHO World Health Organisation 2 TABLE OF CONTENTS EXECUTIVE SUMMARY p 5 INTRODUCTION p 11 SURVEY OBJECTIVES p 11 METHODOLOGY p 11 SURVEY RESULTS p 13 1. Characteristics of the Survey population p 13 2. Obstetrical indicators p 18 3. Antenatal Care p 22 4. Safe delivery p 23 5. Maternal mortality p 29 6. Family planning p 30 7. Sexually Transmitted Infections p 36 8. Health and Gender issues p 37 FACTORS DETERMINING SOME RH INDICATORS p 41 A. Factors associated with the use of RH services p 41 B. Influence of formal education on RH parameters p 47 LIMITATIONS / BIASES p 49 CONCLUSION p 51 RECOMMENDATIONS p 53 ACKNOWLEDGEMENT p 57 3 4 EXECUTIVE SUMMARY A. Introduction Nearly any one is aware of the extremely bad reproductive health (RH) situation in Afghanistan. The needs for RH care are enormous. However improvement of reproductive health care is not an easy objective in Afghanistan of today. A socially integrated and culturally well-accepted approach is essential for any initiative in the reproductive health care sector. In this perspective, we need a far better understanding of what women’s position in society currently is and what women actually want. The main objective of this KAP study (Knowledge, Attitudes and Practices) therefore consists in contributing to a better understanding of the way Afghan women perceive their reproductive health and reproductive health needs. A total of 468 Afghan women of reproductive age (15 to 49 years) have been interviewed. They have been selected through systematic sampling of adult women attending four different health clinics in Kabul city (2 general outpatient clinics and 2 MCH clinics). B. Summary of the results 1. Characteristics of the survey population and health care seeking behaviour • The mean age of women interviewed was 28 years. The age category 15 to 19 years was underrepresented at all clinics. • 62 % of the interviewed women were illiterate and 64% never attended a regular school. Among their husbands 31% appeared to be illiterate. • 86% of the women were married and among them, the mean age of marriage was 17.2 years old. About one out of six women married at the age of 14 years or younger. • About 49% of the husbands had a more or less permanent and regular job, mostly in the private sector (small business). • Near half of the women interviewed - all living in Kabul – were not born in Kabul. And 25% of all women interviewed had arrived in Kabul over the past year, after the fall of the taleban regime. • In case of illness, more than half of the women went to the public health sector. Another 42% went to seek care in the private health sector. In average, women lived at 25 minutes walking distance from the respective health centres. • Almost 90% of all women interviewed had to ask permission of their husband or of a male relative to go to a health centre. 2. Obstetrical history • 29% of the women said to be pregnant at the moment of interview. • 95% of all ever-married women had been pregnant before. • The average number of previous pregnancies per married woman was nearly 5. For women above the age of 35 years, the mean number of previous pregnancies exceeded 7. • About 86% of all previous pregnancies were reported to have resulted in live births. • In average, women were 18.8 years old when they delivered their first child. 5 • The average interval between two deliveries has been estimated at 2.5 years. The younger the women, the shorter the average duration was. • Of the total number of reported deliveries (n= 1777), two third had occurred at home. The other third in a health facility. • Only 16 % of all women said they had learned “how babies were made” when they were 15 years old. • In total, 29% of all interviewed women had lost at least one live born child. The calculated neonatal and infant mortality rates were high within the surveyed population, but lower than the national estimates. Average number of previous pregnancies, living children and children desired 0.8 2.4 4.1 6.5 7.0 7.6 7.6 0.7 1.9 3.2 4.8 5.6 5.9 6.1 3.9 4.2 4.9 5.5 6.5 6.7 6.6 15 – 19 years 20 – 24 years 25 – 29 years 30 – 34 years 35 – 39 years 40 – 44 years 45 – 49 years 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 Mean number of previous pregnancies Mean number of children currently alive Mean number of total children desired 3. Antenatal Care (only women who gave birth at least once) • 79% of the women attended antenatal consultations during their last pregnancy. Most of them (86%) went to see a gynaecologist. • The first antenatal visit took place on average at 5 months pregnancy and the mean number of antenatal visits was 3.7. • 70% of the women reported to have received a tetanus vaccination at least once during their last pregnancy and on average 2.7 doses were administered. • The acceptability of antenatal care seemed good. Almost all women said they would attend antenatal consultations again next time they were pregnant. Only 1.3% reported accessibility to be an obstacle to antenatal care. • The three main reasons reported by the women for attending antenatal services were: 1) check the health of their unborn baby (39%), 2) medical treatment because of illness (28%) and 3) free vaccination (13%) 6 4. Safe delivery (only women included who gave birth at least once) • Regarding their last delivery place, 59% of the women delivered at home. From the 41% of the women who have given birth in a health structure, 87% went to a public health structure (hospital or health centre). Most of the women (83.5%) were satisfied with the care they had received in the health structure • The reasons why the women delivered at home were various. Geographic inaccessibility counted for 32%, cultural barriers for 18%, financial barriers for 17% and the bad security situation for 11% of all mentioned obstacles. Even if the women did not mention that they preferred to deliver at home, we presume this is an important factor, since 36% of the women said they would deliver at home again next time they were pregnant. • About 55% of the women reported to be involved in the decision-making regarding the place of birth of their children. • 56% of the last deliveries were assisted by skilled health personnel. Logically almost all institutional deliveries were assisted by skilled staff, most often by a (gynaecologic) doctor (75%). But also 26% of all home deliveries were attended by skilled personnel, mainly midwifes. • Among the unskilled attendants, female relatives were most popular (48% of all home deliveries). Traditional Birth Attendants assisted in 17,5% of all reported last home deliveries. • Only 1.6% of the interviewed women delivered through caesarean section. This percentage is low as according to ICPD+5, average national caesarean section rates vary between 5 and 15%. 5. Maternal mortality The maternal mortality rate among the surveyed population was - roughly estimated through the indirect sisterhood method - 1756/100.000 women of reproductive age (95% confidence interval = [840 to 3496]). Even if imprecise and not representative for the total population, it is a very high rate and coherent with recent published figures by UNICEF (1600 per 100.000 live births, 95% CI [1100 – 2000]). 6. Family planning (FP) • On average the women reported a desired family size of 5.2 children. 75% of the women thought their husband would agree with that number. • The mean age of FP users was 32.7 years old, which was significantly higher than the mean age of non-users. The average number of previous live births was also significantly higher among the users (5.3 versus 3.9). • 40% of the women considered their family size met (most of them being more than 30 years old), but only 23% were currently using a FP method, indicating there is still an unmet FP need • Among the non – users of any FPmethod, 18% were pregnant. 52% did not know about any method to delay or avoid pregnancy. Lack of knowledge can therefore be considered as the most important obstacle to FP services. Among the remaining 30%, most women wanted another child, • 13% had fear of the side effects of contraceptives; 10% said they were culturally not allowed to use any FP method and 8% mentioned financial or geographic barriers. 7 • 16% of all married women were using modern contraception and 7% a natural family planning method. Among the modern methods, the IUD seemed most popular. Among the natural methods, withdrawal was most mentioned, followed by periodic abstinence. When asked which method the women would prefer to use, preference was given to modern family planning methods. The relative preference given to a particular modern contraception method was very similar to the distribution of currently used methods. Child wish , FP use and Pregnancy 0% 16% 28% 52% 61% 78% 88% 0% 7% 26% 29% 38% 18% 50% 67% 42% 31% 21% 19% 8% 5% 15 – 19 years 20 – 24 years 25 – 29 years 30 – 34 years 35 – 39 years 40 – 44 years 45 – 49 years 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% % women who do not want more children % users of any F.P. method % pregnant now 7. Reproductive Tract Infections (RTI) / Sexually Transmitted Infections (STI) • Only 24% of the interviewed women said to have knowledge of any STI. Among the STIs they knew, HIV / AIDS was the most mentioned (72%), followed by gonorrhoea. • The sources of information regarding STIs were - in order of importance- a person from a health facility (43%), followed by relatives (18%), radio (16%), reading (9%) and television (8%). • Even women who knew about STIs, were badly informed on prevention mechanisms: 29% of them wrongly supposed they could avoid STIs through good general hygiene and bathing. The use of a condom was very rarely mentioned as a prevention method for STIs. • 36% of the women had ever heard about HIV/AIDS and 80.5% of these women claimed to know the transmission ways of the virus. Nevertheless their real knowledge turned out to be quite low. Almost half of the women who claimed to know the ways of transmission, believed one could be infected with HIV/AIDS through kisses and hugs and 42% thought they could get infected through mosquito bites. Only 19% gave correct answers. 8 • 54% of the women said they knew what a condom was. (Note: prompt knowledge among the interviewed women on condoms as FP method was 33%). Less than 25% of them said they had used or would be using a condom as protection against sexually transmitted infections. 8. Health and Gender issues • Most of the women considered themselves to be in “normal” health (between “very bad” and “very good”). The perceived health condition one year earlier (just before American bombing started) was not significant better. • Only 25% of the women mentioned medical care as a priority to improve their health condition. Improved access to drugs was perceived as much more needed than access to health structures. The other priority needs concerned basic needs such as food, housing and money for daily survival. 12% of the women said a better security situation was the most needed for being healthier. • 79% of the women interviewed agreed with the statement that “a woman should be allowed to choose a husband.” 87% agreed that “a woman should have the right to decide on her number of children”. • 76% of the women did agree with the statement that “it is wife’s duty to have sex with her husband, even if she does not want”. 57% agreed even so with the idea that “a husband has the rights to beat his wife if she disobeys him.” • Almost all women (98%) seem to perceive the importance of education, since 98 % agreed that all girls should learn to read and to write. The mean age till which a girl should be attending school was 19.4 years according the interviewed women. • The best age for a girl to marry was considered 20.2 years, nearly 3 years older than the median age at which the interviewed women got married themselves. C. Factors determining some reproductive health indicators: • Multivariate analysis showed a strong positive and significant association between the educational level of the woman and most of the reproductive health parameters under study. Use of antenatal care services (OR 4.8), institutional delivery (OR 2.3), skilled assistance at delivery (OR 2.1), use of family planning (OR 4.6) were all associated with schooling of the woman. • Attending antenatal care during the last pregnancy was found to be independently associated with institutional delivery (OR 2.8), skilled assistance at birth (OR 3.4) and better knowledge of FP methods • Experience of some particular problems pre-, intra or post- partum, appeared not to be significantly related with skilled birth attendance and/or delivery in a health facility. Yet the questioned symptoms - like severe vaginal bleeding before or after delivery, high fever and weakness, general oedema and weakness, prolonged labour, convulsions / cramps - are considered as potentially dangerous, in which case institutional delivery were preferable. • Besides knowledge on any FP method, the use of FP methods was associated with educational level of the mother, older age and with the desired family size. • Overall, the use of reproductive health care services improved with the educational level of the mother. Yet, only small differences were found between primary and secondary or higher education. 9 • No association was found between the educational level of the women’s husband, husband’s literacy and profession, ethnical group, economical status… and the studied reproductive health parameters. D. Conclusion and recommendations This study shows that: • The desired family size expressed by the Afghan women as well as the high fertility at young age reflects the importance and emphasis put on the reproductive role of the women in the Afghan society. • Even within this privileged group of women, maternal mortality rate was found to be very high and the caesarean section rate far too low. • The knowledge on sexual and reproductive health in general and on more particular aspects like family planning and STIs is low. Yet, this survey was held within a privileged group of women: living in Kabul and having access to primary health care. We presume this knowledge to be even worse in rural areas. • Socio-cultural factors do play a very important role in the use and non-use of some reproductive health care services like emergency obstetrical care and family planning services • Reproductive health should be seen in a broader perspective than just from a medical point of view. Education and women’s social position are at least as important. This KAP survey did not assess potential barriers to reproductive health services like geographic accessibility, quality of services and staff training. And surely this survey does not want to undermine the importance and need for appropriate medical services in Afghanistan. The lack of health infrastructures, of trained health staff etc… do play a capital role in the utterly bad Afghan reproductive health indicators. But besides that, we want to emphasize the influence of the entire society on the reproductive health indicators and the importance of a multi-sectoral approach in order to improve reproductive health in a context like Afghanistan. Education of girls / women, empowerment of the social position of women, and community education are three key elements in this process. As such, one can expect that it will take many years of social investment and of commitment to peace before reproductive health can be achieved for the majority of Afghan women. 10 [...]... the promotion of women’s health and rights In this perspective, we need a far better understanding of what women’s position in society currently is and what women actually want We hope this KAP study can contribute to this broader over-all goal of better health for the Afghan population SURVEY OBJECTIVES General Objective To contribute to a better understanding of reproductive health as perceived by... the use of some reproductive health services among Afghan women To document the reasons and obstacles explaining the use / non use of these reproductive health care services To document the preferences of these women regarding place of delivery, birth attendance, family planning method … To document the knowledge on family planning methods, on STIs, … To document prevailing opinions regarding gender... capacity of the health care system Geographic accessibility of the health care facility A question was asked regarding the distance between the health structure the women were attending and their house The average walking distance was around 25 minutes Around 38 % of the interviewed women had to walk less than 15 minutes, but about 17% had to walk more than one hour to reach the health facility Health care... than half of the women seemed to prefer the public health sector for treatment in first instance Public primary health care services are usually inexpensive Nevertheless, the table also shows the importance of the private sector as health care provider in an urbanised area like Kabul city, despite the higher costs Health care permission Before going to a health centre, most of the women reported to have... From the ones who delivered in a health institution, almost 87% choose for a public health structure Last del place Home Institution TOTAL Frequency 229 158 Percent 59.2 % 40.8 % 387 Type health structure 100 % Public hospital Public health centre Private hospital Private clinic Percent 65.8% 20.9 % 9.5 % 3.8 % A high percentage (83.5%) of the women who delivered in a health institution, were (very)... personnel for the surveyed population is far higher than the national estimate of 8 to 11 % This can be explained by following factors: • More skilled health professionals are present in Kabul as well as 3 accessible public maternity hospitals in Kabul city • Selection bias: only women who have access to health facilities are included in the survey Main reason for not delivering in a health structure... per 1,000 live births The needs within the area of reproductive health care are enormous Yet, improving RH is not an easy goal in Afghanistan Because of the multiple problems, any initiative to improve the RH status of the population will have to be socially integrated and culturally well accepted Understanding how women perceive their reproductive health and rights is an absolute condition for the... lack of time Four hundred sixty eight accepted to participate Time Frame The survey was conducted between19 and 31 October 2002 in Kabul Survey implementation The survey questionnaire has been developed in English by ICRH in collaboration with IbnSina Hereafter the questionnaire was translated in Dari Four female medical surveyors have been selected (two medical doctors, one medical student and one...INTRODUCTION Many reproductive health indicators remain unknown in Afghanistan But partial as they are, the existing figures reflect a disastrous reproductive health situation E.g mortality and morbidity rates for women and children are amongst the highest in the world (source: UNICEF / WHO)... of 152 women) want to give birth in a health facility again Last delivery place TOTAL Home Health facility Desired delivery place Home Health facility 74 (20.7 %) 117 (32.8 %) 7 (2.0 %) 140 (39.2 %) 81 (22.7 %) 257 (72.0 %) TOTAL Do not know 14 (3.9 %) 5 (3.3 %) 19 (5.3 %) 205 (57.4 %) 152 (42.6 %) 357 (100 %) Most women would like to be delivered by a skilled health personnel (83.6%) More than half . for Reproductive Health, University Ghent IUD Intra Uterine Device KAP Knowledge, Attitudes and Practices MCH Mother and Child Health RH Reproductive. extremely bad reproductive health (RH) situation in Afghanistan. The needs for RH care are enormous. However improvement of reproductive health care is