Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694824403871.pdf (Georgia)
https://www.caucasushealth.ge 1 Influence of Area of Residence on Contraception Use of Different Socio-Economic Characteristics Women in Georgia Tamar Japaridze1, Jenara Kristesashvili2, Paata Imnadze3 Iv.
Javakhishvili Tbilisi State University, Faculty of Medicine, Georgia 1PhD student; 2Supervisor, MD, PhD, Associate Professor; 3Supervisor, MD, PhD, Professor Summary Aim: The aim of our study was to determine area of residence (urban, rural) influence on overall contraception usage, including modern and traditional contraceptive methods in different groups of women distinctive by socio-economic characteristics: age, level of education, women material status, wealth tercile, number of living children and ethnicity.
Methodology: By secondary analysis of data of “Women Reproductive Health Survey 2010 in Georgia”, with alterna- tive statistical approaches and recoded variables association of predictor variables area of residence with dependent vari- ables: use of modern or traditional methods of contraception were examined in selected women (n=2234, who currently used contraceptive methods) split into groups by age, level of education, ethnicity, wealth tercile, women material status and number of living children.
Descriptive statistics methods and multivariate logistic regression analysis were done.

Results: Modern contraceptive methods were used by 1436 (64.3%) women in urban areas and by 798 (35.7%) women in rural areas.
Women living in urban areas (n=1053) of 20-44 years, with higher level of education (p<0.01), lower wealth terciles (p<0.05), with low material status (p<0.01), along with 1, 2, 3 living children (p<0.01), with Georgian and Armenian ethnicity (p<0.001) compared to women living in rural areas (n=1181) were more likely to use modern methods of contraception.
With no differences regarding the lowest level of education, the highest economic condition, 4 and more children, Azeri and others and 15-19 years age between women living in urban and rural areas.

Conclusions: It is very important, that healthcare providers take into the consideration identified in our study socio- economic factors, associated with low usage of modern contraception in rural areas and intensify informing and educated this target groups.
This will increase use of high effective contraception and reduce the number of unintended pregnan- cies and induced abortion.

Key words: Use of contraception, residence, Georgia Problems statement: Use of contraception, especially modern and effective methods of contraception is significant determinant of un- planned pregnancy rate, which is often terminated by in- duced abortion or unwanted birth.
This may affect sexual, reproductive and general health status of woman; result in serious mental and physical problems for her as well as her family (Barber, 1999).

According to Women Reproductive Health Survey 2010 in Georgia unintended pregnancies constituted 36% of all pregnancies.

Total induced abortion rate was 1.6 abortions per women.

Contraception was cur- rently used by 32% of all 15-44 years women and 53 % of married women, including 35% using modern methods in Georgia [Ross, 2010].
Since previous years use of contra- ception has been increased due to increased use of modern contraception from 20% in 1999 to 35% 2010, which re- duced the number of unplanned pregnancies and induced abortions [Serbanescu, 2005; Serbanescu, 2001).
Given trends can be explained by healthcare system reorganiza- tion and by the programs conducted by international organ- izations (United Nations Population Fund (UNFPA), Unit- ed States Agency for International Development (USAID), United Nations Children’s Fund (UNICEF)) since 2000, leading to improvement of sexual/reproductive health indi- cators, including usage of modern methods of contraception in Georgia (“UNFPA Georgia”, 2016, “USAID”, 2014, Ross,2012).
However, these indicators are unfavorable, as the rate of unintended pregnancies and induced abortion are still high.

Subsequent analysis of 1999 and 2005 Reproduc- tive Health Surveys findings showed that non-use of con- traception was the major determinant of the rate of induced abortions, and use of modern contraception significantly reduced the number of unplanned pregnancies (Serbanescu, 2010).
As surveys, conducted in other countries in the world, showed women socio-economic characteristics: area of res- idence, age, level of education, ethnicity, number of living children, women economic condition with other factors have influenced on contraception use, it is very interesting to examine these factors influence on use of methods of contraception, particularly of use of modern, effective con- traception in Georgia (Daniels, 2014, Mekonnen,2011, Pal- amuleni, 2013).
In Georgia there are compact settlements of population of different religion and ethnicity.

Population in urban and rural areas has different views and tradition, different ac- cessibility to education, including been informed about modern methods of contraception (Ethnoses in Georgia, 2008).
In order to identify high-risk women and provide imple- mentation of appropriate preventive measures through in- crease of informing and knowledge of population and in- crease of accessibility, it is essential for health care system E ISSN 2449-2450 Caucasus Journal of Health Sciences and Public Health, Volume 1, Issue 1, June 2016 https://www.caucasushealth.ge 2 providers and physicians to know the risk factors associat- ed with non use of modern contraceptive methods for in- stance, the area of residence.
Because of the changes in their effects could lead to an improvement in the contracep- tive use over time (Ulrich, 2001).
Based on all above mentioned objective of our study was to determine predictor variables- area of residence (urban, rural) influence on dependent variables - overall contra- ception usage, including modern and traditional contracep- tive methods use in different groups of women distinctive by socio-economic characteristics: age, level of education, women material status, wealth tercile, number of living children and ethnicity.
Methodology Secondary analysis of database of 2010 Reproductive Health Survey was performed.

Cross-sectional study, using stratified multistage sampling method was conducted from October 2010 through February 2011, with approval of the ethics committee of National Center for disease Control of Georgia.
After obtaining informed consent, 6292 women regardless of marital status, living in Georgia during the survey period (excluding separatist regions of Abkhazia and South Ossetia), were interviewed at their homes.

Inclu- sion criterion was age of 15 and 44 year.

For our study, inclusion criterion was, women who were currently used modern or traditional methods of contraception.
In addition of this for each statistical analysis inclusion criteria were different and were included women with the same charac- teristics, in which field were they examined.
Women were categorized into groups according to age: 15-19, 20-24, 25 -29, 30-34, 35-39, 40-44 years, Level of education: Incom- plete technicum, diploma/ postgraduate, ethnicity: Georgian, Azeri, Armenian and other, women material status: Can hardly satisfy their needs, can somehow satisfy their needs, can easily satisfy their needs, wealth tercile: low, middle, low and number of living children: 0,1,2,3,4 and more.

Anyone outside these groups was excluded from the analysis.
secondary, secondary, The survey helped to obtain the data about basic character- istics and health indicators of population.

Based on the re- sponses received through the survey dependent variable has been selected: Currently use of contraception.

Women were categorized into those using a modern method of contra- ception and those using a traditional method of contracep- tion.
Modern methods of contraception included use of the pill, intra-uterine device (IUD), condom plus IUD, condom plus traditional method of contraception, spermicides, or injectables, while traditional methods of contraception in- cluded use of calendar/rhythm method, withdrawal and calendar plus withdrawal.
In our study the factors potentially associated with use of contraception, identified as predictor variables was area of residence: which was categorized into those living in urban areas and those living in rural areas.

Data were analyzed using the statistical software SPSS ver- sion 17.

Descriptive statistics and multinomial logistic re- gression were used.
Multinomial logistic regression was done to calculate odds ratios (ORs) for use of each method of contraception for area of residence separately in selected groups of women splitting by age, level of education, eth- nicity, material status, wealth tercile, number of living chil- dren.

Results Average age of women involved in the survey was 29.5 (SD=8.1; range=15-44).

2234 respondents reported to cur- rently use modern or traditional methods of contraception with mean age 32.33 (SD=6.37).
Majority were ethnically Georgian women.

40.6% had university/post-graduate edu- cation; 1181 (52.9%) women lived in rural areas (Table 1).

Modern contraceptive methods were used by 1436 (64.3%) women in urban areas and by 798 (35.7%) women in rural areas.
After conducting Multinomial logistic regression in different groups of selected women, statistical analysis showed that women living in urban areas compared to women living in rural areas were more likely to use modern methods of contraception or regarding use of modern and traditional methods of contraception in urban and rural are- as significant difference was not found (Table 2).
Women of 20-24, 25-29, 30-34, 35-39, 40-44 age groups living in urban areas were more likely to use modern con- traceptive methods (p<0.05).

Exception was 15-19 years age group, which did not show statistically significant dif- ference regarding modern and traditional methods use in urban and rural areas (p<0.05).
Regarding education it was established, that in groups of women with the lower levels of education modern contra- ceptive methods use was associated with living in urban areas (p<0.01), while women with the highest level of edu- cation did not show statistically significant difference by usage of modern methods of contraception regarding resi- dence (p>0.05).
Statistical analysis, conducted in selected groups split by ethnicity showed that only women of Georgian and Arme- nian ethnicity living in urban areas were more likely to use modern methods of contraception compared to women with same ethnicity living in rural areas.

Azeri and women with other ethnicity were not differently used contraceptive methods regarding residence.
Women with the highest wealth tercile and women who can easily satisfy their needs were equally used modern contraception in urban and rural areas.

On the contrary, women in low and middle tercile and who can hardly or somehow satisfy their needs were more likely to use mod- ern contraception in urban areas (p<0.05).

Table 1.
Background characteristics of study sample (Total n=2234) E ISSN 2449-2450 Caucasus Journal of Health Sciences and Public Health, Volume 1, Issue 1, June 2016 https://www.caucasushealth.ge 3 Age Other 15-19 30-34 25-29 35-39 20-24 40-44 Ethnicity Armenian Secondary Education Technicum Total N (%) Diploma/ Postgraduate Incomplete sec- ondary Use of modern methods of contraception N (%) 6(30.0) 14 (70.0) 107 (55.7) 85 (44.3) 174 (51.9) 161(48.1) 196 (53.8) 168 (46.2) 177 (56.9) 134 (43.1) 110 (51.4) 104 (48.6) 51 (25.2) 151 (74.8) 114 (40.6) 167 (59.4) 148 (50.0) 148 (50.0) 457 (69.6) 200 (30.4) 23 (63.5) 20 (46.5) 28 (60.9) 18 (39.1) 8 (15.4) 44 (84.6) 711 (54.9) 584 (45.1) 111 (35.8) 199 (64.2) 587 (57.2) 440 (42.8) 721 (72.7) 27 (27.3) 528 (95.35) 25 (4.5) 200 (39.2) 310 (60.8) 42 (11.3) 331 (88.7) 20 (76.9) 6 (20.1) 228 (60.6) 148 (39.4) 436 (54.0) 371 (46.0) 77 (40.1) 115 (59.9) 9 (25.7) 26 (74.3) E ISSN 2449-2450 Caucasus Journal of Health Sciences and Public Health, Volume 1, Issue 1, June 2016 Use of traditional meth- ods of contraception N (%) 2 (28.6) 5 (71.4) 22 (27.2) 59 (72.8) 45(33.1) 91 (66.9) 80 (36.0) 142 (64.0) 71 (36.8) 122 (63.2) 63 (39.6) 96 (60.4) 30 (17.8) 139(82.2) 56 (26.2) 158 (73.8) 58 (34.9) 108 (65.1) 139 (55.8) 110 (44.2) 7 (46.7) 8 (53.3) 16 (18.6) 70 (81.4) 7 (15.2) 39 (84.8) 253 (38.9) 398 (61.1) 67 (24.0) 212 (76.0) 199 (40.0) 299 (60.0) 17 (81.0) 4 (19.0) 170 (97.1) 5 (2.9) 92 (29.8) 217 (70.2) 21 (6.7) 293 (93.3) 2 (40.0) 3 (60.0) 75 (46.6) 86 (59.4) 166 (35.1) 307 (64.9) 31 (23.5) 101 (76.5) 9 (33.3) 18(66.7) 8 (29.6) 19 (70.4) 129 (47.3) 144 (52.7) 219(46.5) 252 (53.5) 276 (47.1) 310(52.9) 248 (49.2) 256 (50.8) 173 (46.4) 200 (53.6) 81 (21.8) 290 (78.2) 170 (34.3) 325 (65.7) 206 (44.6) 256 (56.4) 596 (65.8) 310 (34.2) 30 (51.7) 28 (48.3) 44 (33.3) 88 (66.7) 15 (15.3) 83 (84.7) 964 (49.5) 982 (50.5) 170 (30.2) 411 (69.8) 796 (51.5) 739 (48.5) 89 (74.2) 31 (25.8) 698 (95.9) 30 (4.1) 292 (35.7) 527 (64.3) 63 (9.2) 924 (90.8) 22 (71.0) 9 (29.0) 303 (56.4) 234(43.6) 602 (47.0) 677
 (53.0) 108 (33.3) 216 (66.7) 18 (29.0) 44 (61.0) Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Urban Rural Number of living chil- dren Can easily satis- fy their needs Can hardly sat- isfy their needs Can somehow satisfy their needs Material status Wealth tercile Georgian Middle Azeri High Low 0 1 4 3 2 https://www.caucasushealth.ge 4 Table 2.
OR of use of modern and traditional contraceptive methods by urban and rural areas Age 15-19 20-24 25-29 30-34 35-39 40-44 OR95%CI ns 3.376 (1.916-5.948)*** 2.186 (1.441-3.315)*** 2.071 (1.470-2.918)*** 2.270 (1.570-3.282)*** 1.612 (1.063-2.443)* Education Incomplete secondary ns Ethnicity Secondary Technicum Diploma/Postgraduate Other Armenian Azeri Georgian Material status Can hardly satisfy their needs 1.926 (1.308-2.836)** 1.862 (1.258-2.756)** 1.808 (1.339-2.442)*** ns 6.806 (3.047-15.199)*** ns 1.915 (1.581-2.320)*** 1.765 (1.232-2.529)** Wealth tercile Number of living children Can somehow satisfy their needs 2.004 (1.612-2.492)*** Can easily satisfy their needs High Middle Low 0 1 2 3 4 ns ns 1,522 (1.125-2.058)** 1.770 (1.025-3.059)* ns 1.766 (1.217-2.564)** 2.173 (1.720-2.747)*** 2.181 (1.329-3.580)** ns The reference category is use of traditional methods of contraception.
*** (p<0.001), ** (p<0.01), * (p<0.05), ns p>0.05 not significant Modern contraception were more likely used in urban areas compared to women living in rural areas by women having 1,2,3 living children (p<0.01), while having 0 or more then 4 child did not show statistical significant difference.
Discussion Our Study shows, that like other countries, socio-economic and demographic characteristics of women have influence on contraceptives, particularly modern contraceptive meth- ods use (Achana, 2015, Khan, 2012, Oddens, 1997).

Partic- ularly, living area could have an impact on contraception use.
As the women living in urban areas have more oppor- tunity to be more informing and acquiring more knowledge about modern contraceptive methods, have more accessi- bility to healthcare facilities and pharmacies.

As it was es- tablished in our study women living in urban areas more frequently used modern methods of contraception, except several groups showed equally usage of modern and tradi- tional methods of contraception.
In lower age group (15-19 year) women living in urban areas and living in rural areas did not differently used mod- ern methods of contraception.

This finding could be ex- plained by the behavior regarding pregnancy intention in Georgia.

Due to tradition of each countries women attitude to pregnancy planning is different regarding age.
For ex- ample, in India newly married women may be willing to postpone their first pregnancy but they may be constrained to take specific action because of the family and social E ISSN 2449-2450 Caucasus Journal of Health Sciences and Public Health, Volume 1, Issue 1, June 2016 https://www.caucasushealth.ge 5 pressure to prove their fertility (Khaurasia, 2014).

Young Europeans may not feel the same social pressure to get married and have children as did their parents and grand- parents.
Europe's low fertility has also been linked to the so -called "contraceptive revolution" (Worku, 2014).

In Georgia young women begin sexual life mainly after marriage and want to become pregnant and have a child very soon.

Therefore most of pregnancies in younger age are intended and consequently there is a less demands of use of contraception (Daniels, 2014).
Like this, frequently woman with 0 living child, wanted to get pregnant, had no needs to prevent pregnancy and less used contraception, therefore statistical analysis did not show difference re- garding residence of modern and traditional contraception use in this group.

Contrary, women with 4 and more chil- dren are strongly motivated to prevent unintended pregnan- cies.

So, villagers used modern methods of contraception equally high to citizens.
In Georgia fertility rate is low 2.0 births per woman, in our data analysis women with 4or more living children included only a few cases, this might affect results of statistical analysis.

According to surveys, conducted in many other countries level of education has a significant influence on contracep- tion use [Bbaale, 2011, Font-Ribera, 2008, Nur, 2012, Saleem, 2005, Yago, 2014, Yousef, 2002).

In our study level of education has a clear impact on modern contracep- tion use by women.
Women with higher level of education (incomplete secondary, secondary and „technicum“) statis- tically significantly were more likely to use modern contra- ception in urban areas.

But examining women with the lowest level of education revealed that educated women living in rural areas equally to women living in urban areas used modern methods of contraception.

Thus, impact on modern contraception use in rural areas has only high level of education.
Intension to avoid unwilling pregnancy moti- vates her to search for and use safe and highly effective methods of contraception.

They have high probability to acquire knowledge about sexual health, providing them with more autonomy and ability to make a decision regard- less area of residence.

High accessibility to healthcare services and high mobility explains equally use of modern contraceptive methods in urban and rural areas by women in the highest wealth tercile and who can easy satisfy their need.
While women in low and middle tercile and who can hardly or somehow satisfy their needs frequently are without these opportuni- ties.

Armenian women living in rural places have a high risk of not using modern contraception, they traditionally use withdrawal (Armenian demographic and health survey, 2010).

This fact demands attention of healthcare providers to intensify work with this population.
Conclusions Thus, our study ascertained that women living in urban areas compared to women living in rural areas were more likely to use modern methods of contraception.

Women of almost all age groups, lower level of education, lower wealth terciles and low material status, with 1,2, 3 living children, Georgian and Armenian ethnicity were more like- ly to use modern methods of contraception in urban areas.

Thus, women living in rural areas are in high risk of low use of modern contraception.
It is important, that health care providers will take into consideration factors identi- fied in our study and intensify work with those target groups in rural areas: women of 15-19 years, lower level of education, lower economic condition, with 1,2, 3 living children, Georgian and Armenian ethnicity, by the im- provement of the knowledge about contraception, especial- ly its modern methods, increasing accessibility to these methods and their use, help women to make well informed decision about high effective contraceptive choice.
That, in turn, will reduce the number of unintended pregnancies and associated induced abortions with direct participation of health care providers.

Acknowledgments We thank Georgian National Center for disease Control and Public Health for providing us the data of Reproduc- tive health survey Georgia 2010.

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