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PART 3
SUMMARY,
CONCLUSIONS AND RECOMMENDATIONS
3.1.
General Design and Methodology
This
report represents the findings from the first nation-wide population-based
study on Sexual and Reproductive Health of Armenian men and women, with
special reference to infertility and sexually transmitted diseases. The
purpose of this nation-wide epidemiological study was to provide
information on the sexual and reproductive health status of Armenian men
and women that will enable policy makers to make informed decisions during
development and implementation of Reproductive Health oriented projects.
The
survey was designed and implemented in 1997 by the Armenian Family Health
Association (AFHA) in collaboration with the Republican Center on
Perinatology, Obstetrics and Gynecology (RCPOG), in support to the
Armenian National Program on Reproductive Health. The United Methodist
Committee on Relief, Armenia Office (UMCOR) has kindly provided financial
and technical assistance for project implementation. The RCPAG was
responsible for the recruitment and training of interviewers, and data
collection. The AFHA conducted verification of the questionnaires, data
processing, analysis and evaluation.
The
assessment of the sexual and reproductive health status of Armenian men
and women has been carried out by means of a questionnaire-based
nation-wide survey of 1400 men and 1400 women, ever married or in
consensual union, between 15 and 44 years of age throughout Armenia. The
survey was carried out in all 11 regions ("marzes") of the
country, including the capital Yerevan.
Determination
of the sample size was based on official data concerning the size of the
target population, on the confidence, precision desired, and variables of
the study. The sample of eligible respondents was selected from the total
population of men of reproductive age, using the method of a random
cluster sampling with a multistage sampling design. Each of eligible
respondents had exactly the same chance to be selected for the
survey-interview.
Information
obtained was evaluated using standard statistical package Epi-Info. The
governmental authorities, non-governmental organizations and international
agencies were provided with representative data on sexual and reproductive
health status of Armenian men and women; in particular, about their sexual
behavior, knowledge, attitude and practice of contraception and abortion
use, and the prevalence of STDs and infertility. Based on the survey
results an appropriate action plan was developed towards improvement of
the Sexual and Reproductive Health in Armenia.
3.2.
Summary of Main Findings
Attitudes
towards sexuality and gender-related issues
According
to the survey results, the great majority of men and women involved in
this survey expressed an opinion that a woman should be a virgin when she
marries, but the man is allowed to have sex before marriage. Most of the
respondents of both genders disapprove of sexual relationships outside the
marriage by either partner. The great majority of male respondents and 41%
of females consider that a woman does not have a right to decide on
abortion, if her husband objects to it.
Although
the subject of adolescent sexuality remains "taboo" in the
traditional Armenian society and sexual health education of children until
now has largely been ignored, the common view was expressed by most of the
participants that there is a need for sex education of children in
schools.
First
sexual experience, number of sex partners and marriage pattern
More
than one half of the male respondents had their first sexual intercourse
in their adolescence. The average age of men at their first sexual
intercourse was about 19 years, while at their first marriage was about
24.0. The time-interval between the first sexual intercourse and the first
marriage of men was almost five years.
In
fact, according to the probably biased replies, almost all women had their
first sexual intercourse at their first marriage or union. The average age
at first sexual intercourse, as well as at first marriage was about 20
years. However, given that pre-marital intercourse is such a taboo in the
society, the reported age at first intercourse may be artificially low.
According to the survey results, about 44% of women had their first sexual
intercourse and were first time married in their adolescence.
On
the average, each man had about six sexual partners during his life span.
However, the great majority of women reported that they ever had only one
sexual partner.
Family
size preferences, the actual number of children and determinants of family
size
Almost
all participants of both genders considered an ideal family size as having
at least two children, and the great majority desired this number at the
time of their first marriage. Most of the respondents had no intention to
have more children. An average actual number of children, together with
additional wanted was less then an ideal and desired numbers.
By
the time of this survey-interview 13% of men and 8% of women were
childless. About 19% of men and the same proportion of women have had only
one child. The first and most important determinant of family size is
family income. The second most important determining reason for stopping
future childbearing is completed family formation, and the third reason is
inadequate housing conditions.
Knowledge
about Family Planning
The
majority of the female and male respondents was aware of condoms and IUDs,
and knew where to obtain them. However, knowledge about the hormonal
contraceptive pills and sterilization is very low. Friends from peer
groups are found to be the most important source of information about
condoms and the withdrawal method.
Information about the pills and IUDs is obtained mainly through
written press, health providers, and sexual partners.
There
is a lack of knowledge of both genders about the risk, benefits and
efficacy of specific family planning methods. Information about oral
contraceptive pills is inadequate and misleading. About 53% of women and
21% of men had an opinion that taking pills for too long can cause female
facial hair growth. Almost 32% of women and 11% of men believe that taking
pills might result in infertility. More than 22% of women and 13% of men
suspected that taking the pills increased the risk of a woman getting
cancer. Although the majority of women and men believe that the IUD
insertion is easier as compared to abortion, still about 14% of women and
15% of men consider that an abortion is easier.
A
number of factors, such as age, education, place of living and level of
urbanization determine the knowledge about issues related to sexual and
reproductive health. The level of Family Planning/Sexual and Reproductive
Health (FP/SRH) knowledge is lower in adolescents, as compared to adults.
It is better among women and men with a university level of education, as
compared to lesser educated, as well as in urban population, in comparison
to rural. The place of residence is also important determinant of
knowledge on FP/SRH.
The
awareness and knowledge about STDs/HIV/AIDS
The
majority of both female and male respondents were aware of AIDS and
Syphilis. However, most of the female respondents (61%) never heard of
Gonorrhea or Chlamydial infection (87%). In contrast, the great majority
of male respondents were aware of Gonorrhea (79%). But only 8% of men ever
heard about infection with Chlamydia.
The
majority of women (64%) and men (53%) had poor knowledge about the
transmission of STDs/HIV transmission. There were some prevalent false
ideas mentioned, such as the high probability of infection transmission
through shaking hands, using domestic objects of an infected person, using
public bathrooms, or by mosquito bite. Among the startling observations of
this study is the fear of a high probability of infection with STDs/HIV in
the health facilities that most of the respondents had. This finding
indicates an existing mistrust by Armenian people concerning the safety of
health facilities in Armenia.
Access
to Mass Media
Generally
speaking, young people in Armenia still do not have access to adequate
information on issues related to family planning, sexual and reproductive
health. The friends from the peer groups are found to be the most
important source of information of these survey respondents about condoms
(66%) and the withdrawal method (66%). Health providers, teachers and
parents rarely provide the first information about modern family planning
methods.
One
of the encouraging observations of this study is high availability of TV
at homes. Most of the respondents watch TV regularly (usually in the
evening or at night), but only occasionally hear radio programs. TV
programs are the first and most important sources of information about
sexuality and sexual health, among all existing means of the mass media.
However,
the target population currently has little access to newspapers, magazines
or other educational literature on public health related issues. Access is
correlated with the age of respondents, the highest levels of their
education and urbanization. It is lower in individuals below 24 years of
age, as compared with elder age cohorts. Those with a university education
had better access to mass media and printed materials, as compared to
lower educated respondents. We found also that access is lower in rural
respondents, as compared to urban.
According
to the opinion of more than one half of the survey respondents, TV, books,
brochures, magazines, newspapers and radio were the most expedient means
used for public education on sexual and reproductive health. Thus,
socio-economic and cultural realities of present life require special
attention to potential role of the mass media and printed formats, as very
important sources of information on sexuality, sexual and reproductive
health.
Family
Planning Practice
This
survey shows that among the sample of 1400 men and 1400 women of
reproductive age, the majority had ever used some method of contraception.
However, about 21% of men and 22% of women never used any contraception.
At the time of the survey-interview 68% of male respondents and 57% of
female respondents are current family planning users. About 11% of male
respondents and 21% of females stopped using contraception. The most
frequently mentioned reasons for stopping contraception are either desired
or current pregnancy, or postpartum. Significant proportion of both male
and female respondents stopped contraceptive use because of subsequent
sub-fertility.
The
great majority of married couples are using family planning methods for
child spacing, but not for postponing first birth. The most popular
methods previously and currently used are withdrawal, condom, and the IUD.
The hormonal contraceptive pills and not popular. Other modern methods,
such as voluntary sterilization, injectables, implants, etc. are not yet
widely available. Most couples are using unreliable methods, which are
free or have a little cost.
Unwanted
pregnancy and abortion use
Results
of this survey on reproductive health of Armenian men and women indicate
that induced abortion is widely used all over the country as a method of
birth control. According to the information obtained, most respondents of
this survey reported at least one induced abortion during their lifetime.
An average number of reported abortions for the total sample of women is
2.7, and for sample of men 2.1. Among those women who had an abortion, the
average number is 4.2. In the survey of men the rate is 4.0.
The
great majority of the respondents of both genders already had at least one
child before the first abortion. However, more than 15% of men and 4% of
women did not have children at that time. The most common reason for the
first abortion is a willingness to postpone the birth of the next child,
while the most common reason for the last abortion is completion of family
formation. Lack of income, inappropriate housing, and poor health are
other important reasons for abortion. It was found also that partners of
about 13% of respondents performed their first abortion because the
pregnancy was outside the marriage. Abortion practice in Armenia is based
mainly on the willingness of both partners.
The
assessment shows that unwanted pregnancy and induced abortion are either
results of unprotected intercourse or contraceptive failure. The failures
of the contraceptive method of choice, as well as incorrect use of the
methods are the main background factors of unwanted pregnancy and induced
abortion. In most of the cases, unreliable withdrawal method was used
prior to the both first and the last abortion.
Based
on the responses of women it was found that in about 13% of the cases of
the first abortion and in 12% of the last abortion, the gestational age of
pregnancy was more than 12 weeks. According to the results of the survey
among men, these figures are about 8% and 7%, respectively. In a
significant proportion of the abortion cases, the procedure was performed
in unsafe conditions, with high rates of immediate complications and late
consequences. Most abortions were carried out without anesthesia. In a
significant proportion of women abortion caused depression.
To
overcome financial difficulties and fear of abortion, many women in
Armenia try to induce spontaneous abortion themselves through unsafe,
unhygienic, and often-dangerous interventions, facing the high risk of
complications and even death. Most women, who have experienced
self-induced abortion are never referred to a health facility for medical
care, therefore these kinds of unsafe abortions are not officially
registered. Thus, about 12% of women ever tried to self-induce
miscarriage, using unsafe and often dangerous interventions. Almost 4% of
men were aware that their wives/partners ever made self-induce abortion
attempts. The rates of the immediate complications and the late
consequences of self-induced abortion are quite high. The most alarming is
the fact that some women try to induce miscarriage repeatedly, like a
method for birth control.
Those
women who had “successful” self-induced abortion never applied to a
health facility for medical care; therefore these kinds of abortions most
probably are not officially registered.
Respondents of this survey reported successful self-induced
abortion as a spontaneous abortion, which artificially increase the
prevalence rates of the spontaneous abortion. Thus, about 24% of women
mentioned the history of at least one spontaneous abortion during the life
span. The corresponding figure from the survey among men is about 19%.
Women
who have undergone abortion are at risk of another unwanted pregnancy and
unsafe abortion. However, a significant number of couples did not receive
adequate post-abortion family planning counseling or care.
Fertility
and reproductive outcome
The
great majority of the female respondents (89%) and spouses/partners of the
male respondents (92%) have been ever pregnant. By the time of this
survey-interview about 7% of the female respondents and 9% of the
spouses/partners of the male respondents were pregnant. But more than 4%
of the female respondents and about 8% of the spouses/partners of the male
respondents had never been pregnant.
The
majority of female and male respondents mentioned more than one conception
during their life span. Based on the replies of the female respondents,
there are 5.3 conceptions per respondent, while based on the men’s
replies an average number of conceptions are about 4.5.
The
most frequent pregnancy outcome mentioned by the respondents of both
genders is induced abortion. In both the last and previous
marriages/unions of the female respondents the most frequent pregnancy
outcome is induced abortion. However, based on the replies of the male
respondents, the most frequent pregnancy outcome in the current
marriage/union is the live birth (49%), while in other marriages/unions is
induced abortion (85%).
The
majority of female respondents and the spouses/partners of the male
respondents ever have had live births. On the average, there are about 2
live births per couple, for both surveys. About 8% of women and the
spouses/partners of more than 13% of men never had live births. Results of
both surveys among women and men show that the proportion of couples
having only one live birth is about 18%.
The
proportion of women, which had history of stillbirth, is about 2%. The
corresponding figure from the survey among men is about 3%. Based on the
replies of the female respondents, stillbirths constitute 0.9% of the
total births, while based on the replies of the male respondents this rate
is twice higher (1.8%). Twenty four percent of the female respondents and
about 20% spouses/partners of the male respondents had history of at least
one spontaneous abortion. The recurrent spontaneous abortion (more than 2)
to total spontaneous abortion ratio is about 10% in both survey samples.
Childhood
survival
About
8% of the female respondents and 7% of the males who had live born
child/children, have had at least one deceased child by the time of the
survey-interview. More than 4% out of total live born children of the
female respondents and 3.5% of the male respondents, died. Infant
mortality remains the largest percentage of overall childhood deaths. The
cumulative neonatal mortality is quite high (41% in the sample of women
and 46% in the sample of men).
The proportion of the childless women is about 8% and of the
childless men - almost 13%.
Incidence
of congenital birth defects
About
2% of the respondents of both genders had at least one child with
congenital birth defects. The proportion of children born with congenital
birth defect among total live born children was about 1% in both survey
samples. The most frequent types of congenital malformations were defects
of the cardiovascular and gastro-intestial systems, and Down’s syndrome.
Sexually
transmitted infections
According
to the information obtained from the survey respondents, the first most
frequent self-reported STD in Armenian men is Trichomoniasis (10%), and
the second is Gonorrhea (8%). The first most frequent self-reported STD in
women is fungal infection (15%), and the second is Trichomoniasis (6%).
About 2.5% of female respondents and 2% of male respondents
reported the history of Chlamydial infection.
The
admitted clinical signs, symptoms and diseases for which sexual
transmission is of epidemiological importance, indicate that the actual
rates of the specific STDs in both women and men might be higher than
reported.
In
many STD cases, however, respondents were not aware that infection might
exist in both partners. Only about 9% of the female respondents and 12% of
the male respondents admitted history of STDs in their spouses/partners,
which is much less than might be expected from their own medical history.
The
assessment shows that sexual partners of the male respondents that were
infected with STDs have been treated only in about 26% of Gonorrhea cases,
42% of cases of Chlamydial infection and 36% of cases of Trichomoniasis.
In about 50% of mentioned STDs cases, men had no idea about the
partner’s treatment, and 5% said that sex partners remained untreated.
According to the best of women’s knowledge, only 61% of men with history
of STDs received treatment. A significant proportion of both women and men
admitted clinical signs, symptoms and diseases suggestive of sexually
transmitted infections also did not receive adequate sexual health care.
Polycystic
ovaries syndrome and benign genito-urinal tumors
This
study shows that about 5% of the female respondents had history of
diagnosed Polycystic Ovaries Syndrome or Ovarian Cysts. In fact, 16% of
the respondents mentioned excessive hair growth in their face or on the
other unusual places of their bodies (hirsutism). The hirsutism might be
constitutional, or associated with the polycystic ovarian syndrome, tumors
or other endocrine disorders. The mean age at start of hirsutism is about
27 years. Most (84%) of women suffering from the hirsutism, however, did
not apply for medical care. More than 5% of those women applied, but did
not receive treatment, and 3% received ineffective treatment.
About
4% of women had a history of the Uterine Myomas or Fibromyomas. About 2%
of women had the history of the removal of endometrial or cervical polyps,
which were recurrent in 18% of cases. The above-mentioned syndrome and
diseases have often been associated with infertility or miscarriage.
Menstrual
dysfunction and other symptoms of the endocrine disorders
Almost
all women, except for one, have had menstrual periods. About 13% of the
respondents had irregular periods, and 2% had secondary amenorrhoea.
Before the start of sexual activity more than 39% of women had painful
menstrual periods, so called primary dysmenorrhoea. After the start of
sexual activity the frequency of dysmenorrhoea decreased considerably
to10%.
At
the time of this survey about 1.8% of the respondents had discharge from
the nipples and the same number of women (1.8%) mentioned that they had
discharge in the past. In most of the cases (68%) it was abnormally
copious milk secretion after cessation breast-feeding (galactorrhoea).
Many of the women with menstrual disorders and/or galactorrhea have been
classified as infertile.
Infertility
The
results of this first nation-wide survey on infertility in men and women
show that its prevalence rate is quite high. The prevalence rate of total
infertility in the sample of male respondents is 18.6%, while in the
sample of female respondents it is 31.9%. The rate of primary infertility
is 3.4% for both genders. In fact, the rate of secondary infertility is
much lower among male respondents, as compared with females (15.2% versus
28.5%). The great majority of primarily infertile women and men wanted to
have offspring. In fact, most secondarily infertile women did not want to
have (another) child in the near future, while the majority of secondarily
infertile men wanted to have (another) child.
Although
the majorities of women and men believed that they are able to produce
offspring, about 28% of women and 6% of men have had contrary or uncertain
beliefs. The current or past difficulties to achieve conception, sexual
health disorders, diseases or their consequences were most frequently
mentioned reasons of these negative beliefs.
In
most of the infertility cases the causes of infertility are identified in
female partners (84% - as reported by women and 58% - as reported by men).
The male causes are identified less frequently (35% - as reported by women
and 43% - as reported by men).
In a significant proportion of couples the causes of infertility
remain unknown (10% - as reported by women and 16% - as reported by men).
According
to the replies of the respondents, we assumed that the most frequent
causes of female infertility are acquired infection–related tubo-ovarian
and uterine abnormalities, and ovulatory disorders. The most frequently
diagnosed causes of male infertility are abnormal quality or quantity of
sperm, varicocele, male accessory gland infection, and sexual dysfunction.
There is a direct relationship between fertility and sexual function in
men: large majority of men with sexual and ejaculatory dysfunction (63%)
were either primarily or secondarily infertile.
This
study found that smoking decreases fertility potential of both women and
men. Thus, the proportion of smokers is significantly higher among both
women and men with primary infertility, as compared to fertile
respondents. It was found also that excessive use of alcoholic beverages
and the use of narcotic drugs decrease fertility in both sexes.
A
strong relationship was found between a history of certain STDs and
Infertility. The history of Gonorrhea, Syphilis, Chlamydial infection, and
Trichomoniazis was more common in women and men with impaired fertility,
as compared to fertile.
Management
of infertility includes investigation, diagnosis, treatment, if needed,
and follow-up counseling of both partners. However, in the large majority
of cases with impaired fertility neither partner applied for investigation
and reproductive health care. We found that some categories of infertile
patients, particularly men with sexual dysfunction, usually have a fear of
investigation or feel shy to speak about this issue. A significant
proportion of infertile couples don’t know where to apply for medical
care, and/or have no means to afford investigation and treatment, and/or
had difficulties in finding prescribed medicine, and/or were living far
away from a health facility.
Among the startling observations of this survey was the fact that
about 5% of men and 2% of women belive that health providers lack
counseling and clinical skills for infertility management.
The
evaluation of survey results shows that for many couples infertility is a
hard condition to cope with psychologically. Both partners are often
depressed and need not only physical but also emotional care. For many
couples inability to have children is disturbing their interpersonal
family relationships.
3.3.
Conclusions
The
main conclusions that have been drawn from this study are described below:
Attitudes
towards sexuality and sex education
Sexual
and reproductive behavior
Fertility
and determinants of family size
Public
awareness and knowledge about family planning and STDs/HIV
Access
to mass media
Family
Planning Practice
Incidence,
safety and determinants of induced abortion
Fecundity,
fertility and pregnancy wastage
Child
survival
Sexually
transmitted infections
History
of other diseases, disorders and factors with possible adverse effects on
fertility
Infertility
3.4.
Recommendations
Below
are recommendations that could be used to plan effective information,
education and service delivery campaigns and projects.
Public
information and education
Professional
education
Improvement
of access to the FP/SRH services
Improvement
of the quality of care
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