GENERAL SUMMARY
BACKGROUND
The 2004 national Survey of Demography and Reproductive and Sexual
Health, ENDSSR-2004, was conducted by the Paraguayan Center of
Population Studies (CEPEP), with the cooperation of the United States
Agency of International Development (USAID), the United Nations
Population Fund (UNFPA), the International Planned Parenthood
Federation (IPPF), and with the technical assistance of the Division of
Reproductive Health of the Centers for Disease Control and Prevention
(CDC) in Atlanta, Georgia USA. It is the fifth of a series of surveys
on this topic carried out at the national level by CEPEP, with the
objective of maintaining periodic evaluation of maternal and child
health topics and updating principal programmatic indicators. The
results obtained allow the Ministry of Health, NGOs and donor agencies
to have the updated current status of the reproductive health situation
in the country and makes possible the comparison of results with other
national and international surveys.
For ENDSSR 2004 a Master sample maintained by CEPEP was utilized as a
sampling frame. This master sample was created in 2001 based on census
data and all primary sampling units were updated in the field between
August and September 2003. For the first time, field work was assisted
by geo-referenced maps produced by CEPEP with cooperation of USAID.
Each field supervisor and team supervisor had a Geographic Position
System (GPS) unit that contained the location of the households in the
352 clusters that made up the sample. The GPS units assisted in the
location of sample households in less time and with more reliability in
each sample cluster than in previous surveys.
As in past surveys in Paraguay, ENDSSR 2004 was implemented in the
Eastern region of the country, plus the Villa Hayes district as part of
Metropolitan Asuncion, but excluded the rest of the Chaco (Western
Region) due to the low density and dispersion of the population. About
98 percent of the population is concentrated in the Eastern Region. The
sampling design included a threestage probability sample selection
self-weighted at the level of four regions of Eastern Paraguay: (1)
Metropolitan Asuncion, (2) North, (3) South Central, excluding
districts that are part of Metropolitan Asuncion, and (4) East. This
design permits estimations at the national level, urban and rural
areas and the four regions.
A total of 12,236 households were selected in the sample of which
10,792 were occupied. In these households, 7,519 eligible women (15-44
years of age) were identified in the household questionnaire, and the
individual questionnaire was successfully completed for 7,321 of them
(97.4%). Less than one percent of eligible women refused to be
interviewed and 1.2% were not found for interview after up to three
visits to each household. In addition, information was obtained for
4,025 children less than five years of age.
HOUSEHOLD AND RESPONDENT
CHARACTERISTICS
The results show that 78% of families own their own households; 87% in
rural areas and 72% in urban areas. Two-thirds (67%) of households
receive drinking water through household connections, including 55%
inside the house and 12% in the patio. More than 90% of the households
have household connections in Metropolitan Asuncion compared with a
range of 49% in the Eastern region to 69% in the Central-South region.
Almost two-thirds (65%) of households have a bathroom connected to a
public network or septic tank. This percentage ranges from 92% in
Metropolitan Asuncion to 60% in the Eastern region, 58% in the
Central-South region and 30% in the North region. Almost all households
(96%) report having electricity and 58% report using gas for cooking
meals.
An improvement in educational attainment was found compared with
ENSMI-1998, the last survey. The percentage of women with 12 years or
more education increased from 21% to 33% and the percentage with less
than 3 years of education decreased by 50% from 8% to 4%.
Slightly more than one-half of women (54%) are married (33%) or in a
consensual union (21%) and 39% have never been married or in a
consensual union. Only 11 percent of adolescents 15-19 years of age
report that they are married or in a consensual union. As reported
below, 44% of 40-44 year olds married before 20 years of age compared
with 33% of 20-24 year olds.
Thirty percent of respondents report that the family normally speaks
guaraní in the household and 36% speak both guaraní and
spanish; 31% speak only spanish in the household and 3% speak other
languages, principally Portuguese (2%; 6% in the Eastern region).
FERTILITY
Paraguay has had an important decline in the Total Fertility Rate (TFR)
between 1998 and 2004. The survey data show that the TFR has declined
from 3.9 children per women in the period from 1995-1998 to 3.4 from
1998-2001 to 2.9 from 2001 - 2004. This decline is inversely related to
the significant increase in the education level of Paraguayan women and
increase in the prevalence of modern methods of contraception.
As in the past, there still exist important differences in fertility by
residence, educational attainment, socioeconomic status (SES) and
language usually spoken in the home: the TFR for women in urban areas
is 2.5 compared with 3.7 for women in rural areas; the TFR for women
with less six years of education is 4.2 compared with 2.1 for women
with 12 or more years of education; the TFR is 5.4 for women in the
very low category of SES compared with only 1.9 for women
classified as very high; If only guaraní is usually spoken in
the home, the TFR is 3.9 versus 2.3 in homes where only spanish is
spoken.
Also contributing to the decline in fertility is the later age of
marriage. The proportion of women who married before 20 years of age
has declined from 44% of 40-44 year old women in the sample to 33% of
20-24 year olds. At the same time, the proportion of women 40-44 years
of age having their first birth before 20 years of age is 38% compared
with 28% of 20-24 year old women.
FAMILY PLANNING
Contraceptive prevalence among married women 15-44 years of age is 72.8
percent. This finding represents over a 90% increase in prevalence
since 1987 when contraceptive prevalence was 37.6%. Contraceptive use
increased by 27%, from 57.4% to 72.8%, since the last survey in 1998.
The increase recorded in rural areas since 1998 was higher, increasing
by 48% from 49.3% to 67.4%.
In spite of the increase in contraceptive use since 1998, there still
exist important differences by residence and region. Even with the
greater increase in contraceptive use in rural areas, prevalence in
urban areas (77%) is still higher than in rural areas (67%). Prevalence
is lowest in the mostly rural Northen Region at 61% compared with 76%
in the CentralSouth region, 75% in metropolitan Asuncion and 73% in the
Eastern region.
Continued significant differences were also found by educational
attainment and socioeconomic status (SES). Only 61% of women with less
than three years of education use contraception compared with 80% of
women with at least 12 years of education. A similar difference is
found by SES with 63% of lower SES women using contraception compared
with 80% of high SES women.
As in past surveys, the pharmacy is the principal source of
contraception (50%). Almost one-third of couples (32%) obtain their
methods in the public sector, including 27% in Ministry of Health
facilities. Most condom, pill and injectable users went to pharmacies
and most IUD and sterilization users used public-sector facilities.
NON-USERS AND NEED FOR
SERVICES
Twenty-seven percent of married women were not using contraception at
the time of the survey. Of these women, 86% reported reasons related to
pregnancy, sub-fecundity or not being sexually active as the reason for
non-use. Also, 84% reported their intention to use contraception at
some time in the future and 97% of them know where to obtain
contraception.
Of all women, 15% are estimated to be at risk of an unintended
pregnancy and are estimated to be in need of a modern method. This
includes 6% of non-users and 9% of women using traditional methods. The
percentage in need of a modern method is higher in rural areas (17%)
and the Northern Region (18%). Restricting the denominator to married
women, 19% are in need of a modern method with higher proportions in
rural areas (23%) and in the Northern Region (24%).
ADOLESCENTS AND YOUNG
ADULTS
More than one-half (56%) of adolescents and young adult women (15-24
years of age) report that they have had sexual relations and 54% of
them had premarital sex at the time of their first sexual experience
(prior to first marriage or consensual union). The proportion of
sexually experienced young women 15-24 years of age have had a
significant increase in premarital sexual experience increasing from
35% in 1987 to 54% in 2004. Premarital sexual experience in urban areas
is higher in urban areas (58%) than in rural areas (45%). Young women
reporting premarital sexual experience have had their sexual debut at a
younger age than women reporting sexual debut at marriage: 33% before
16 years of age and 35% at 16-17 years of age.
The proportion of young women using contraception at their first
premarital sexual experience increased by almost 10 percentage points
in each of the surveys conducted in 1987, 1995 and 1998. In the last
six years, the proportion using contraception at first premarital sex
increased by more than 20 percentage points, from 33% to 58%. Young
adults and adolescents in urban areas (62%) report a much higher
percentage of contraceptive use at first premarital sex than those
living in rural areas (47%). Condoms are the principal method used.
About 80% of women 15-24 years of age reported receiving a course or
lecture on sex education in or out of the school environment
representing an important increase over previous surveys, increasing
from 52% in 1995 to 61% in 1998 to 80% in 2004.
MATERNAL HEALTH
Detailed information was obtained on all births reported between March
1999 and February 2004 and 94% of mothers reported that they had at
least one prenatal visit, 6 percentage points higher than 88% reporting
prenatal care in 1998. However, 10% of women 15-19 years of age, women
living in households where Guaraní is the principal language
spoken or women living in the Northen region reported no prenatal care.
The worst situation was found for women with less than three years of
education: 17% not receiving prenatal care.
Almost three-fourths (71%) of women reported five or more prenatal
visits, but only 69% began prenatal care in the first trimester.
In Paraguay, the percentage of births in medical institutions has
increased significantly from 56% in 1998 to 74% in 2004. The range by
region is from 60% in the Northern Region to 92% in Metropolitan
Asuncion. Almost one-half of the births (45%) were realized in Ministry
of Health institutions, 16% in private hospitals, and 7% in facilities
belonging to the Institute of Social Security. One-quarter (27%) of the
births were delivered by cesarean section, a significant increase since
1998 when 17% were reported to be cesarean deliveries.
Almost all women (99%) with sexual experience know about PAP smears of
which 70% have had a PAP test at sometime during their life. Of those
with a PAP test, 73% have had one in the last two years. Most PAP tests
were realized in public sector facilities (67%) and one-fourth (26%) in
private facilities. Six percent of women had their test in either CEPEP
facilities or in Brazil or Argentina.
INFANT AND CHILD HEALTH
Of all live births between March 1999 and February 2004, 93% of mothers
reported that their baby was weighed at the time of birth; 9% were
reported to be less than 2500 grams.
Breastfeeding is almost universal in Paraguay considering that 95% of
births were breast-fed; 16% began breastfeeding within 10 minutes of
birth and 23% within one hour. Another 42% initiated breastfeeding
before 24 hours after birth. The average duration of breastfeeding is
11.8 months similar to the average reported in the 1995 and 1998
surveys. Most breastfeeding was suspended between 4 to 11 months (39%)
or between 12 and 23 months (36%) of age. The main reason for
terminating breastfeeding for infants between 4 and 11 months was the
mother returning to either work or school (64%). For those between 12
and 23 months, the baby was most often considered to be "too big" (61%).
Of infants less than 6 months of age, 22% were exclusively breast-fed
and 28% predominantly breast-fed. The practice of exclusive
breastfeeding was highest among mothers in the Eastern Region and
Metropolitan Asuncion and those classified in the highest SES.
Two-thirds (65%) of children between 12 and 23 months of age were
reported to completely vaccinated, that is they have received a
complete series of BCG, polio, DPT and measles. In 1995, the last time
immunization data was collected, only 50% were reported to be
completely vaccinated.
The infant mortality rate for the period 1999-2004 is estimated to be
29 per 1000 live births, similar to the estimate of 27/1000 for the
period 1990-1995 in the 1995 survey. However, there is no significant
difference between these two estimates.
KNOWLEDGE, ATTITUDES AND
BEHAVIOR RELATED TO STIs AND HIV/AIDS
In Paraguay, with the exception of HIV/SIDA, women 15-44 years of age
have relatively low knowledge of sexually transmitted infections
(STIs). Without probing, only 41% of women could cite a STI. After
probing, 95% said that they have heard of at least one STI. The
infection most known after probing was syphilis (77%) followed by
gonorrhea (73%), vaginal drainage (67%) and fungal infection (58%).
Less than half of women knew of other infections associated with STIs.
When asked about HIV/AIDS, 99% of women had heard of AIDS, of which 88%
responded spontaneously that they knew about HIV/AIDS before probing.
Nevertheless, many women have a superficial knowledge about the
infection and disease. Six percent of women think that there is a cure
for AIDS and 21% think that someone has to be ill with symptoms when
they are infected with the virus.
Also, in spite of the high percentage of women who say they know about
AIDS, only 2% of women could spontaneously mention all three of the
principal modes of transmission. When probed, this percentage increases
to 79%. This substantial difference in knowledge of modes of
transmission between spontaneous and probed approaches brings up the
question of methodological differences in questionnaire design.
Almost one-fourth of women (22%) with knowledge of AIDS say that they
have some risk of contracting HIV/AIDS: 21% a moderate risk and 2% high
risk. Among those saying that they have no risk, the main reasons are:
confidence in their partner (33%), sexually inactive (32%), have only
one partner (12%), they know their partner well (9%) and they do not
have sex with unknown persons (9%).
At the national level, 73% of women have heard about the test for HIV
infection, but only 13% have had the test; over half of those who have
had the test have done so since January of 2002. Of those who have had
the test, 61% said that it was voluntary, 35% said that they had to
present the result for work, travel or military service, and 4% felt
obligated to take the test. Of those who have never had a test, 59%
said that they saw no reason to have the test.
Women who have had prenatal care since January 1999 were asked if they
took the test as part of prenatal care and were counseled about
vertical transmission of HIV. Only 37% said that they were counseled
about the HIV/AIDS test during prenatal care and 18%, one half of them,
were offered the test. Of these women, most (14%) took advantage of the
test.
VERBAL, PHYSICAL AND
SEXUAL VIOLENCE
As in 1995 and 1998 the 2004 survey asked about verbal and physical
abuse, and for the first time, included questions on sexual violence.
The results refer to physical violence suffered by the woman before 15
years of age by her parents, sexual violation against all respondents,
and for ever-married women, abuse by a partner during her lifetime and
in the past 12 months prior to interview.
Of all women interviewed, 21% reported that they had seen or heard
their parents abusing each other before they were 15 years of age and
14% reported they had received physical abuse from their parents;
49% reporting that they received abuse from their father and 40% their
mother.
Currently married women report that family decisions are usually taken
together by her and her partner. However, among women separated or
divorced, she usually made the decisions in the family. Among women who
were never abused, 79% reported that their partner consulted her about
most things and were affectionate (90%) and respected her rights (92%).
The corresponding proportions among abused women were 63%, 71% and 72%,
respectively.
Of all ever-married women, 33% reported verbal abuse, 19% physical
abuse and 8% sexual abuse from their current or a former partner at
sometime during her life. In the past 12 months, 15% reported verbal
abuse, 7% physical abuse and 2% sexual abuse against her will, by her
current or former partner.
Among all women, 7% reported that they had been raped at least one
time; 59% reported that the first (or only) rape occurred before 20
years of age, including 6% prior to 10 years of age. The great majority
of sexual violations were committed by persons known by the victim. Two
thirds of women (67%) reported that their aggresors were their partner
or ex partner; were reported to be their husband (34%), ex-husband
(12%) or a boy friend or ex-boy friend (22%). Only 12% reported that
the aggressor was an unknown person.
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