REPRODUCTIVE, MATERNAL, AND 

CHILD HEALTH IN CENTRAL AMERICA

Trends and Challenges Facing Women and Children

El Salvador ∙ Guatemala ∙ Honduras ∙ Nicaragua

Division of Reproductive Health

Centers for Disease Control and Prevention (DRH/CDC)

ATLANTA, GEORGIA USA

United States Agency for International Development (USAID)

August, 2005
 
Acknowledgements I

Trends and Challenges Facing Women and Childern

Acknowledgements

This comparative report, which summarizes the major findings from a series of 15 surveys conducted in 

Central America in the period 1987 – 2003, has been prepared by the Division of Reproductive Health of 

the Centers for Disease Control and Prevention (DRH/CDC), Atlanta, GA. The funding for the report was 

provided by the Latin America and Caribbean Bureau, and the Office of Population and Reproductive Health 

of USAID and by the USAID country missions in El Salvador, Guatemala, Honduras and Nicaragua. 

While DRH/CDC provided technical assistance for the majority of the surveys included in this report, we 

would like to acknowledge the contributions of ORC Macro and Family Health International, which also 

provided technical assistance for some of the surveys included here. Their contributions have made this 

report possible and richer in content. 

Particular acknowledgement is made to the organizations that implemented the surveys in the participating 

countries of this study. The staffs of these organizations provided dedicated and expert guidance for the 

surveys and were instrumental in producing the individual survey reports on which this report relies. 

These organizations are recognized by name on the following page. 

We wish to thank the dedicated interviewers, field supervisors and data processing staff in each country for 

their commitment and dedication, as well as the thousands of respondents who willingly shared information 

about their lives to make the surveys possible. 

A special thanks goes to Rose Pecoraro, for the graphic design and layout of the report and to Danielle 

Jackson for detailed editorial assistance in the final stages of this project. 

We would also like to thank the following individuals at USAID who have been instrumental both in 

initiating this project and in reviewing earlier drafts of the document: 

Kelly Saldana, LAC Bureau; Mary Ann Anderson, USAID/ Guatemala; Connie Johnson, USAID/El 

Salvador; Herb Caudill, USAID/Honduras; Jay Anderson, USAID/Honduras and Alonzo Wind, USAID/

Nicaragua. 

Paul W. Stupp

 Project Coordinator

Report Prepared by:

Richard S. Monteith, Division of Reproductive Health, CDC

Paul W. Stupp, Division of Reproductive Health, CDC

Stephen D. McCracken, Division of Reproductive Health, CDC
II Acknowledgements

Reproductive, Maternal, and Child Health in Central America

Implementing Organizations for Surveys:

Country Year of Survey Organization

El Salvador: 1988 Asociación Demográfica Salvadoreña 

1993 Asociación Demográfica Salvadoreña 

1998 Asociación Demográfica Salvadoreña 

2002/03 Asociación Demográfica Salvadoreña 

Guatemala: 1987 Instituto de Nutrición de Centro América y 

Panamá

1995 Instituto Nacional de Estadística

1998 Instituto Nacional de Estadística

2002 Ministerio de Salud Pública y Asistencia Social y 

Universidad del Valle

Honduras: 1987 Ministerio de Salud Pública y Asociación 

Hondureña de Planificación de Familia

1991/91 Ministerio de Salud Pública 

1996 Secretaría de Salud y Asociación Hondureña de 

Planificación de Familia

2001 Asociación Hondureña de Planificación de Familia 

y Secretaría de Salud

Nicaragua: 1992/93 Asociación Pro-Bienestar de la Familia 

Nicaragüense

1997 Instituto Nacional de Estadísticas y Censos y 

Ministerio de Salud

2001 Instituto Nacional de Estadísticas y Censos y 

Ministerio de Salud
Preface III

Trends and Challenges Facing Women and Childern

Preface

It is our pleasure and privilege on behalf of the Latin America and Caribbean (LAC) Bureau and the Central 

American and Mexico (CAM) Social Sector Component of the United States Agency for International 

Development (USAID), to write the preface to the most comprehensive compilation of data regarding 

women’s and children’s health in the Central American Region. Recognizing the wealth of social sector 

data available from the Demographic and Health Survey (DHS) and Reproductive Health Survey (RHS) 

programs, health and education office directors in the CAM region consisting of El Salvador, Guatemala, 

Honduras and Nicaragua wanted to compare and contrast trends in key maternal and child health indicators 

in order to identify needs and potential synergies. The LAC Bureaus’ Health Program joined the effort 

to help ensure that such information would aid the design and refinement of health programs and identify 

areas where these countries might work together more closely. 

Great strides have been made in improving reproductive and child health in these countries during the 

last 10 years. In all of these countries, USAID has been the major donor in the health sector and can be 

proud of being a partner to these achievements. Still, disparities exist between rural and urban areas in all 

countries and between the income levels in each country. Often the reader will see similarities between 

achievements of El Salvador and Nicaragua compared to those of Guatemala and Honduras. Much is yet 

to be done in each country to achieve the health statistics of its neighboring country, Costa Rica, which has 

a similar culture and history, but overall better social and economic levels and health outcomes. 

The RHS and DHS population-based survey programs have become the gold standard for health sector 

planners and decision makers in USAID Missions, as well as for host country governmental and nongovernmental organizations and donor agencies such as UNFPA, PAHO, and UNICEF, the World Bank, 

and the Inter American Development Bank. This report provides insight on health behaviors, knowledge 

of HIV/AIDS, infant and child mortality and reproductive health. Regional trend data are easily available 

and usable for those seeking a regional approach to similar complex health problems, thus trying to 

maximize the impact of scarce health resources.

We wish to express our gratitude to the member countries and LAC that so generously helped with the 

resources and review of the report. Special thanks go to Dr. Mary Ann Anderson of USAID/Guatemala 

for her leadership in initiating this important work together with Kelly Saldaña of the USAID/LAC Health 

Team. Throughout the process, Dr. Paul Stupp, Dr. Steve McCracken and Mr. Richard Monteith of the 

Centers for Disease Control and Prevention as colleagues and professionals have been unwavering in 

their commitment to prepare a technically sound and helpful reference document for the development and 

improvement of women and children’s health programs. To all of you, we appreciate your contributions. 

Karen Welch

Health Team Leader

Office of Regional Sustainable Development

Latin America and Caribbean Bureau

USAID/W

Connie J. Johnson

Coordinator, CAM Social Sector Component

Health Office

USAID/El Salvador
IV Preface

Reproductive, Maternal, and Child Health in Central America
Table of Contents V

Trends and Challenges Facing Women and Childern

TABLE OF CONTENTS

ACKNOWLEDGEMENTS .................................................................................................. I

Implementing Organizations for Surveys .................................................................. II

PREFACE ............................................................................................................................. III

TABLE OF CONTENTS ..................................................................................................... V

LIST OF TABLES ................................................................................................................ VII

LIST OF GRAPHS ........................................................................................................... XIII

LIST OF MAPS ............................................................................................................. XVII

CHAPTER 1: INTRODUCTION .................................................................................... 1

Background ..................................................................................................................... 2

Surveys and Measurement Issues ............................................................................... 2

CHAPTER 2: CHARACTERISTICS OF HOUSEHOLDS AND WOMEN .............. 5

Characteristics of Households ..................................................................................... 5

Characteristics of Reproductive Age Women ........................................................ 12

Summary of Findings .................................................................................................. 16

CHAPTER 3: FERTILITY .............................................................................................. 17

Fertility Levels and Trends ........................................................................................ 18

Median Age at First Intercourse, First Union, and First Birth ......................... 26

Percent Married or in a Consensual Union ............................................................. 28

Birth Intervals ............................................................................................................... 28

Reproductive Preferences ............................................................................................. 31

Summary of Findings ................................................................................................... 35

CHAPTER 4: FAMILY PLANNING ............................................................................ 37

Knowledge of Contraceptives ..................................................................................... 37

Current Use of Contraceptives ................................................................................... 38

Source of Contraceptives ........................................................................................... 46

Intention to Use Contraception Among Non-users .......................................................... 48

Summary of Findings ................................................................................................... 50

CHAPTER 5: SEXUAL AND CONTRACEPTIVE BEHAVIOR OF YOUNG ADULTS ... 51

First Sexual Experience ............................................................................................. 52

Age at First Sexual Relation .................................................................................... 54

Use of Contraceptives at First Sexual Intercourse ................................................. 57

Reasons for not Using Contraception at First Intercourse ...................................... 58

Recent Sexual Activity ..................................................................................................... 60

First Pregnancy ............................................................................................................. 62

Sex Education ............................................................................................................... 68

Summary of Findings .................................................................................................. 69
VI Table of Contents

Reproductive, Maternal, and Child Health in Central America

CHAPTER 6: HIV/AIDS ................................................................................................. 71

Knowledge of Gonorrhea and Syphilis ..................................................................... 72

Knowledge of HIV/AIDS ............................................................................................ 74

Means of Preventing the Transmission of HIV/AIDS ............................................. 76

Knowledge and Use of the Test to Detect HIV .................................................... 80

Stigma and Discrimination .......................................................................................... 82

Knowledge and Use of Condoms ............................................................................... 84

Number of Sexual Partners in the Past 12 Months and the Use of Condoms ........ 86

Summary of Findings .................................................................................................... 90

CHAPTER 7: Maternal Health .................................................................................................. 91

Prenatal Care ........................................................................................................................... 91

Delivery Care .......................................................................................................................... 95

Cesarean Births ...................................................................................................................... 100

Postpartum Care ..................................................................................................................... 101

Changes in the Use of Maternal Health Services ............................................................ 102

Cervical Cancer Screening ................................................................................................... 102

Tetanus Toxoid Injections ..................................................................................................... 103

Summary of Findings ............................................................................................................ 104

CHAPTER 8: Infant and Child Mortality ............................................................................... 105

Mortality Differentials ........................................................................................................... 108

Perinatal Mortality ................................................................................................................. 115

Summary of Findings ............................................................................................................ 117

CHAPTER 9: Child Health ...................................................................................................... 119

Birth Weight ............................................................................................................................ 120

Well-Baby Care ....................................................................................................................... 120

Child Immunization ................................................................................................................ 121

Prevalence and Treatment of Diarrhea and Acute Respiratory Infections ....................... 126

Summary of Findings ........................................................................................................... 133

CHAPTER 10: Infant Feeding Practices and Nutrition Status of Children ......................... 135

Breastfeeding ........................................................................................................................... 135

Nutrition Status of Children ................................................................................................. 138

Anemia in Children ............................................................................................................... 144

Anemia in Mothers ................................................................................................................ 148

Summary of Findings .............................................................................................................. 149

CHAPTER 11: Educational Status of Children Aged 7–14 Years ......................................... 151

Summary of Findings ............................................................................................................ 158

REFERENCES ............................................................................................................................. 159

Reports Referenced in This Document: ............................................................................... 159
 List of Tables VII

Trends and Challenges Facing Women and Childern

LIST OF TABLES

Table 2.1 Trends in the Availability of Basic Services in the Household that are 

Related to Health .............................................................................................6

Table 2.2 Availability of Basic Services in the Household that are Related to Health

According to Area of Residence (Most Recent Survey) .................................7

Table 2.3 Trends in the Availability of Goods and Services in the Household ......................7

Table 2.4 Availability of Goods and Services in the Household According to Area of 

Residence ............................................................................................................8

Table 2.5 Trends in The Educational Level of Women Who Have Been

Interviewed Women Aged 15–49 ...................................................................12

Table 2.6 Educational Level of Women Who Have Been Interviewed According to 

Area of Residence Women Aged 15–49 .......................................................14

Table 2.7 Trends in the Religion Professed by Female Respondents: Women Aged 15–49 ....16

Table 3.1 Trends in Total Fertility Rates by Area of Residence: Women Aged 15-49 .......18

Table 3.2 Trends in Total Fertility Rates According to Education: Women Aged 15–49 .......19

Table 3.3 Trends in Age-Specific and Total Fertility Rates: Women Aged 15–49 .......20

Table 3.4 Age-Specific and Total Fertility Rates According to Area of Residence:

Women Aged 15–49 (Most Recent Survey) .......................................................22

Table 3.5 Median Age at First Intercourse First Union and First Birth According to 

Sex of Respondent: Women Aged 15–49 and Men Aged 15–59 

(Most Recent Survey) .......................................................................................26

Table 3.6 Percent Currently in a Union According to Age and Sex of Respondent:

Women Aged 15–49 and Men Aged 15–59 (Most Recent Survey) ...................28

Table 3.7 Percent of Births Occuring Within Select Periods of Time Since the 

Previous Birth: Births of Order 2 and Higher in the Five Years Before 

the Survey (Most Recent Survey) ...................................................................29

Table 3.8 Wanted and Unwanted Total Fertility Rates According to Area of Residence

Women Aged 15–49 (Most Recent Survey) .......................................................32

Table 3.9 Mean Ideal Number of Children According to Sex of Respondent and Area 

of Residence: Women Aged 15-49 and Men Aged 15-59 

(Most Recent Survey) ...............................................................................34

Table 4.1 Knowledge of Specific Contraceptive Methods: Married Women of Fertile

Age and Married Men Aged 15–59 (Most Recent Survey) ...............................38

Table 4.2 Trends in Contraceptive Use by Area of Residence: Married Women of 

Fertile Age (Most Recent Survey) ...................................................................39

Table 4.3 Trends in the Use of Contraceptive Methods by Method and Type of Method

Married Women of Fertile Age ...................................................................40
VIII List of Tables 

Reproductive, Maternal, and Child Health in Central America

Table 4.4 Current Use of Contraceptive Methods According to Area of Residence:

Married Women of Fertile Age (Most Recent Survey) ...............................41

Table 4.5 Trends in the Use of Contraceptive Methods by Age: Married 

Women of Fertile Age ...............................................................................42

Table 4.6 Trends in the Source of Modern Contraceptive Methods: Married 

Women of Fertile Age ...............................................................................46

Table 4.7 Desire to Use Contraceptive Methods Now or in the Future by Area of 

Residence: Married Women of Fertile Age Non-Users of 

Contraception (Most Recent Survey) .......................................................48

Table 4.8 Preferred Contraceptive Method Among Married Women of Fertile Age

Non-Users of Contraception Who Desire to Use Contraceptives Now 

or in the Future (Most Recent Survey) .......................................................49

Table 5.1 Reported Sexual Experience by Marital Status at Time of First 

Sexual Experience According to Current Age: Women and Men 

Aged 15–24 (Most Recent Survey) ...................................................................52

Table 5.2 Reported Sexual Experience by Marital Status at Time of First 

Sexual Experience According to Area of Residence: Women and Men

Aged 15–24 (Most Recent Survey) ...................................................................53

Table 5.3 Age at First Sexual Experience According to Area of Residence: 

Women Aged 15–24 (Most Recent Survey) .......................................................54

Table 5.4 Age at First Sexual Experience According to Area of Residence: 

Men Aged 15–24 (Most Recent Survey) .......................................................55

Table 5.5 Use of Contraceptives in First Sexual Relation by Marital Status at 

Time of First Sexual Experience According to Area of Residence: 

Women and Men Aged 15–24 (Most Recent Survey) .........................................57

Table 5.6 Primary Reasons For Not Using Contraceptives During First 

Sexual Experience: Women and Men Aged 15–24 Whose First 

Sexual Relation Was Marital Or Premarital (Most Recent Survey) ...................59

Table 5.7 Sexual Activity and Use of Contraceptives During the 30 Days Prior 

to Interview According to Current Marital Status: Women Aged 

15–24 With Sexual Experience (Most Recent Survey) ...............................60

Table 5.8 Sexual Activity and Use of Contraceptives During the 30 Days Prior to 

Interview According to Current Marital Status: Men Aged 15–24 With 

Sexual Experience (Most Recent Survey) .......................................................61

Table 5.9 Percent of Women Who Have Ever Been Pregnant According to

Marital Status at Time of First Pregnancy By Actual Age:

Women Aged 15–24 (Most Recent Survey) .......................................................62

Table 5.10 Percentage of Women Who Did Not Believe They Could Become Pregnant 

When They Became Pregnant the First Time According to Age at First 

Pregnancy: Ever-pregnant Women Aged 15–24 (Most Recent Survey) ..............64

Table 5.11 Primary Reasons for Believing That Could Not Become Pregnant the 

First Time: Ever-pregnant Women Aged 15–24 (Most Recent Survey) .......65
 List of Tables IX

Trends and Challenges Facing Women and Childern

Table 5.12 Percentage of Women Who Did Not Plan Their First Pregnancy According 

to Age at First Pregnancy: Women Aged 15–24 (Most Recent Survey) .......65

Table 5.13 Percentage of Women Who Were Students When They First Became 

Pregnant According to Age at First Pregnancy: Women Aged 15–24

(Most Recent Survey) ...............................................................................66

Table 5.14 Percentage of Women Who Resumed Their Studies After They Completed 

Their First Pregnancy According to Grade Level When Suspended Their 

Studies: Women Aged 15–24 (Most Recent Survey) ...........................................67

Table 5.15 Percentage of All Women and Men Who Have Received Information From 

Talks Or Courses on Various Topics Related to Sexuality and Reproductive 

Health: Women and Men Aged 15–24 (Most Recent Survey) ...................68

Table 6.1 Knowledge of Gonorrhea and Syphilis According to Area of Residence: 

Women of Fertile Age and Men Aged 15–59 (Most Recent Survey) ...................72

Table 6.2 Knowledge of HIV/AIDS and Percent Who Know That HIV Infections

Can be Asymptomatic and that no Cure Exists for AIDS According to 

Area of Residence: Women of Fertile Age and Men Aged 15–59 

(Most Recent Survey) ...............................................................................74

Table 6.3 Number of Means Mentioned Spontaneously to Prevent the Transmission 

of HIV/AIDS According to Area of Residence: Women of Fertile Age 

and Men Aged 15–59 (Most Recent Survey) ...........................................78

Table 6.4 Percentage of Women and Men Who Mentioned Spontaneously the 

Primary Means to Prevent the Sexual Transmission of HIV/AIDS

According to Area of Residence: Women of Fertile Age and Men 

Aged 15–59 (Most Recent Survey) ...................................................................79

Table 6.5 Knowledge of the Test to Detect HIV According to Area of Residence: 

Women of Fertile Age and Men Aged 15–59 (Most Recent Survey) ...................80

Table 6.6 Knowledge of the Test to Detect HIV and Ever Been Tested For HIV/AIDS

According to Education: Women of Fertile Age and Men Aged 15–59 

(Most Recent Survey) ...............................................................................81

Table 6.7 Acceptance of Persons Living With HIV/AIDS According to Area of 

Residence: Women Aged 15–49 and Men Aged 15–59

(Most Recent Survey) ...............................................................................83

Table 6.8 Knowledge and Use of Condoms According to Area of Residence: 

Women Aged 15–49 and Men Aged 15–59 (Most Recent Survey) ...................84

Table 6.9 Number of Sexual Partners in the 12 Months Prior to Interview

According to Marital Status: Men Aged 15–59 With Sexual 

Experience in the Previous 12 Months (Most Recent Survey) ...................86

Table 6.10 Number of Sexual Partners in the 12 Months Prior to Interview With Whom 

Condoms Were Used in the Last Sexual Relation According to Number of 

Sexual Partners: Men With Sexual Experience During the Previous 12 

Months (Most Recent Survey) ...................................................................87

Table 6.11 Use of Condoms in Last Sexual Relation According to Relation to Sexual 

Partner: Men Aged 15–59 (Most Recent Survey) ...........................................88
X List of Tables 

Reproductive, Maternal, and Child Health in Central America

Table 6.12 Percentage of Men Who Believe That Condoms are Effective in Preventing 

the Transmission of HIV According to Education: Men Aged 15–59

(Most Recent Survey) ...............................................................................89

Table 7.1 Trends in the Use of Prenatal Care: Live Births in the Five Years Prior 

to the Survey ...........................................................................................92

Table 7.2 Use of Prenatal Care According to Area of Residence By Trimester of 

First Visit and Number of Controls: Live Births in the 5 Years Prior to 

the Survey (Most Recent Survey) ...................................................................93

Table 7.3 Trends in the Percentage of Deliveries Attended in a Medical Facility

By Area of Residence: Live Births in the 5 Years Prior to the Survey ................96

Table 7.4 Trends in the Percentage of All Deliveries That Were By Cesarean Section: 

Live Births in the 5 Years Prior to the Survey .........................................100

Table 7.5 Trends in the Use of Postpartum Care: Live Births in the 5 Years

Prior to the Survey .........................................................................................101

Table 7.6 Percentage of Women Who Have Ever Been Screened For Cervical 

Cancer By Area of Residence: All Sexually Experienced Women 

Aged 15–49 (Most Recent Survey) ................................................,................103

Table 7.7 Percentage of Women Who Have Received Two Or More Doses of 

Tetanus Toxoid in Their Life By Area of Residence: Women Aged 

15–49 (Most Recent Survey) ...........................................................................103

Table 8.1 Trends in Infant and Child Mortalit .................................................................107

Table 8.2 Infant and Child Mortality Estimates According to Area of Residence

(Most Recent Survey) ....................................................................................108

Table 8.3 Infant and Child Mortality Estimates According to Education 

of Mother (Most Recent Survey) .................................................................109

Table 8.4 Infant and Child Mortality Estimates According to Age of Mother at 

Birth (Most Recent Survey) .............................................................................110

Table 8.5 Infant and Child Mortality Estimates According to Previous Birth Interval 

(Most Recent Survey) .............................................................................111

Table 8.6 Infant and Child Mortality Estimates According to Birth Order

(Most Recent Survey) .............................................................................113

Table 8.7 Infant Mortality Estimates According to Place of Birth (Most Recent Survey) ...114

Table 8.8 Perinatal Mortality Estimates According to Area of Residence 

(Most Recent Survey) .............................................................................116

Table 9.1 Percentage of Children Weighed at Birth Or During the 7 Days Following 

Birth By Area of Residence: Live Births During the 5 Years 

Prior to the Survey (Most Recent Survey) .....................................................120

Table 9.2 Trends in the Use of Well-baby Care: Live Births During The Five Years 

Prior To The Survey To Women Of Fertile Age .........................................121
 List of Tables XI

Trends and Challenges Facing Women and Childern

Table 9.3 Percentage of Children Aged 12–23 Months Who are Fully Immunized

According to Area of Residence By Vaccine (Most Recent Survey) .................122

Table 9.4 Trends in the Percentage of Children Aged 12–23 Months Who are 

Fully Immunized By Vaccine .................................................................124

Table 9.5 Percentage of Children With Diarrhea During the Two Weeks Prior to 

Interview By Area of Residence: Children Less Than 5 Years of Age 

(Most Recent Survey) .............................................................................126

Table 9.6 Percentage of Children With Diarrhea During the Two Weeks Prior 

to Interview By Age of Child (In Months): Children Less Than 

5 Years of Age (Most Recent Survey) .....................................................127

Table 9.7 Percentage of Children Less Than 5 Years of Age With Diarrhea During 

the Two Weeks Prior to Interview Whose Mothers Consulted With 

Someone About Their Recent Episode of Diarrhea By Area of Residence: 

Children Less Than 5 Years of Age (Most Recent Survey) .............................128

Table 9.8 Percentage of Children With Diarrhea During the Two Weeks Prior 

to Interview Whose Mothers Treated Them With Oral Rehydration 

Salts By Area of Residence: Children Less Than 5 Years Of Age

(Most Recent Survey) .............................................................................128

Table 9.9 Percentage of Children With Diarrhea During the Two Weeks Prior to 

Interview Whose Mothers Increased the Amount of Liquids Given to 

Them During Their Recent Episode of Diarrhea By Area of Residence: 

Children Less Than 5 Years of Age (Most Recent Survey) .............................129

Table 9.10 Percentage of Children With Respiratory Infections During the Two 

Weeks Prior to Interview By Area of Residence: Children Less Than 

5 Years of Age (Most Recent Survey) .....................................................130

Table 9.11 Percentage of Children With Respiratory Infections During the Two 

Weeks Prior to Interview By Age of Child (In Months): Children 

Less Than 5 Years of Age (Most Recent Survey) .........................................131

Table 9.12 Percentage of Children Less Than 5 Years of Age With Respiratory 

Infections During the Two Weeks Prior to Interview Whose Mothers 

Consulted With Someone About Their Illness By Area of Residence: 

Children Less Than 5 Years of Age (Most Recent Survey) .............................132

Table 9.13 Percentage of Children Less Than 5 Years of Age With Respiratory

Infections During the Two Weeks Prior to Interview Who Were 

Treated With Antibiotics By Area of Residence (Most Recent Survey) ...........132

Table 10.1 Trends in the Initiation of Breastfeeding: Live Births in the 

5 Years Prior to the Survey .............................................................................136

Table 10.2 Trends in the Mean Duration of Breastfeeding (in months): 

Live Births in the 5 Years Prior to the Survey .........................................137

Table 10.3 Percentage of Children Who are Currently Being Exclusively 

Breastfed According to Age of Child in Months (Most Recent Survey) .....138
XII List of Tables 

Reproductive, Maternal, and Child Health in Central America

Table 10.4 Type of Breastfeeding (Indicators of the World Health Organization)

According to Area of Residence by Age of Child (In Months): 

Children Aged 0–23 Months (Most Recent Survey) .........................................139

Table 10.5 Percent of Children Classified as Undernourished by Three Anthropometric 

Indices* According to Area of Residence: Children Aged 3–59 Months

(Most Recent Survey) .............................................................................140

Table 10.6 Trends in the Percentage of Children Classified as Undernourished by 

Three Anthropometric Indices*: Children Aged 3–59 Months .................141

Table 10.7 Percentage of Children With Anemia According to Selected 

Characteristics: Children Aged 12–59 Months (Most Recent Survey) ............146

Table 10.8 Percentage of Children With Anemia According to Education of Mother: 

Children Aged 12–59 Months (Most Recent Survey) .............................147

Table 10.9 Percentage of Women With Anemia According to Selected Characteristics

Non-Pregnant Women Aged 15–49 Years With Children Aged 

3–59 Months (Most Recent Survey) .................................................................148

Table 10.10 Percentage of Women With Anemia According to Education: 

Non-Pregnant Women Aged 15–49 Years With Children Aged 

3–59 Months (Most Recent Survey) .................................................................149

Table 11.1 Educational Status of Children Aged 7–14 Years According to Selected 

Characteristics: El Salvador 2002/03 .....................................................152

Table 11.2 Educational Status of Children Aged 7–14 Years According to Selected 

Characteristics: Guatemala 2002 .................................................................153

Table 11.3 Educational Status of Children Aged 7–14 Years According to Selected 

Characteristics: Honduras 2001 .................................................................154

Table 11.4 Percentage of Children Repeating a Grade During the Year of the Survey

According to Age at Beginning of School Year: Children Aged 7–14 

Who Were Attending School (Most Recent Survey) ........................................157

Table 11.5 Primary Reasons For Dropping Out of School Children Aged 7–14 Who Have 

Dropped Out of School .............................................................................158
List of Graphs XIII

Trends and Challenges Facing Women and Childern

LIST OF GRAPHS

Graph 2.1 Change Between Early 1990s and Early 2000s in Percent of Households With 

Piped Water, Electricity, Flush Toilet or Latrine and that Cook With Gas or 

Electricity (First and Third Surveys) .............................................................9

Graph 2.2 Percentage of Households With Television, Telephone, Refrigerator and 

Automobile (Most Recent Survey) ..........................................................................9

Graph 2.3 Percentage of Women, 15 to 49, by Highest Grade Level Completed 

(Most Recent Survey) ....................................................................................13

Graph 2.4 Percentage of Women, 15 to 49, by Highest Grade Level Completed 

and Area of Residence (Most Recent Survey) ..............................................14

Graph 2.5 Percent of the Reproductive Age Female Population that Is Urban and 

Percent of Births in the Last Five Years Occurring to Urban Women 

(Most Recent Survey) ...................................................................................15

Graph 3.1 Trends in the Total Fertility Rate (Four Most Recent Surveys) ....................18

Graph 3.2 Age-Specific Fertility Rates (Most Recent Survey) ..............................................21

Graph 3.3 Reductions in Age-Specific Fertility Rates (ASFRs) From the Early 

1990s to the Early 2000s (Third From Last and Last Surveys) ....................21

Graph 3.4 Total Fertility Rates, by Area of Residence (Most Recent Survey) ....................23

Graph 3.5 Percentage of Live Births that Were Wanted, Mistimed or Unwanted: 

Live Births in the Five Years Prior to Interview (Most Recent Survey) ........31

Graph 3.6 Total Fertility Rate, by Whether Births Were Wanted or not 

(Most Recent Survey) ....................................................................................33

Graph 3.7 Total Fertility Rate, by Area of Residence and Whether Births Were 

Wanted or not (Most Recent Survey) ...........................................................33

Graph 4.1 Trends in the Use of Contraceptives, According to Last Four Surveys: 

Married Women of Fertile Age (Four Most Recent Surveys) ....................39

Graph 4.2 Change Between Early 1990s and Early 2000s in Percent Using 

Contraception, by Method: Married Women of Fertile Age 

(Third From Last and Last Surveys) ...........................................................41

Graph 4.3 Use of Contraceptive Methods, by Age: Married Women 

of Fertile Age (Most Recent Survey) ..........................................................43

Graph 4.4 Change Between Early 1990s and Early 2000s in Percent Using 

Contraception, by Age: Married Women of Fertile Age 

(Third From Last and Last Surveys) ..........................................................43

Graph 4.5 Source of Modern Methods of Contraception: Users of Modern Methods

(Most Recent Survey) ....................................................................................47
XIV List of Graphs 

Reproductive, Maternal, and Child Health in Central America

Graph 4.6 Preferred Contraceptive Method: Married, Non-Users of 

Contraception (Most Recent Survey) ...........................................................49

Graph 5.1 Percentage of Persons With Sexual Experience, by Age and Sex: 

Men and Women Aged 15–24 (Most Recent Survey) .................................53

Graph 5.2 Age at First Sexual Experience: Women Ages 15–24 ..............................................55

Graph 5.3 Age at First Sexual Experience: Men Ages 12–24 ..............................................56

Graph 5.4 Use of Contraceptives at First Sexual Relation, by Area of Residence: 

Sexually Experienced Men and Women Aged 15–24 

(Most Recent Survey) ....................................................................................58

Graph 5.5 Percentage of Women Who Have Ever Been Pregnant, by Marital Status 

at Time of First Pregnancy, for Each Country: Women Aged 15–24 

(Most Recent Survey) ....................................................................................63

Graph 5.6 Percentage of Women Who did not Believe They Could Become Pregnant 

When They did: Ever Pregnant Women Aged 15–24 .................................64

Graph 5.7 Percentage of Women Who did not Plan Their First Pregnancy: 

Ever-Pregnant Women Aged 15–24 ..........................................................66

Graph 6.1 Knowledge of Gonorrhea and Syphilis: Women of Fertile Age 

and Men Aged 15–59 (Most Recent Survey) .............................................73

Graph 6.2 Knowledge that HIV Can Be Asymptomatic, by Area of Residence: 

Women of Fertile Age (Most Recent Survey) .............................................76

Graph 6.3 Knowledge that HIV Can Be Asymptomatic, by Area of Residence: 

Men Aged 15–59 (Most Recent Survey) ..........................................................77

Graph 6.4 Knowledge of the Exam to Detect HIV, by Area of Residence and Sex: 

Women of Fertile Age and Men Aged 15–59 (Most Recent Survey) .......80

Graph 6.5 Knowledge and Use of Condoms: Women of Fertile Age 

and Men Aged 15–59 (Most Recent Survey) ..............................................85

Graph 6.6 Percentage of Men With Two or More Sexual Partners in the 12 Months 

Prior to Interview, by Marital Status: Men Aged 15–59 Who Were 

Sexually Active in the Last 12 Months (Most Recent Survey) ....................87

Graph 6.7 Use of Condoms by Sexually Active Men in Last Sexual Relation: 

According to Relationship to Sexual Partner (Selected Relationships) 

(Most Recent Survey) ....................................................................................88

Graph 7.1 Use of Prenatal Care, by Area of Residence (Most Recent Survey) ....................92

Graph 7.2 Percentage of Births Attended in a Medical Facility, by Area of Residence 

(Most Recent Survey) ....................................................................................97

Graph 7.3 Percentage of All Deliveries that Were Cesarean, by Area of Residence 

(Most Recent Survey) ...................................................................................100

Graph 7.4 Use of Postpartum Care, by Area of Residence (Most Recent Survey) ......101
List of Graphs XV

Trends and Challenges Facing Women and Childern

Graph 7.5 Percent Change Since the Early 1990s in the Use of Key 

Maternal Health Services ...................................................................................102

Graph 8.1 Trends in Under-Five Mortality, Last Three Surveys ............................................107

Graph 8.2 Infant Mortality by Previous Birth Interval, Most Recent Survey ...................112

Graph 8.3 Infant Mortality by Place of Delivery ......................................................................115

Graph 9.1 Percentage of Children Weighed at Birth or During the Seven Days 

Following Birth, by Area of Residence: Live Births in the Five 

Years Prior to Survey (Most Recent Survey) ............................................120

Graph 9.2 Use of Well-Baby Care, by Area of Residence: Live Births in the 

Five Years Prior to Survey (Most Recent Survey) ............................................121

Graph 9.3 Percentage of Children Who Are Fully Immunized With BCG, Polio, 

DPT, and Measles Vaccines, by Area of Residence: 

Children Aged 12–23 Months (Most Recent Survey) ...............................123

Graph 9.4 Percentage of Children Age 12–23 Months Who Are 

Completely Immunized (Most Recent Survey) ............................................123

Graph 9.5 Percentage of Children With Diarrhea During the Two Weeks Prior 

to Interview, by Area of Residence: Children Less Than Five 

Years of Age (Most Recent Survey) .........................................................126

Graph 9.6 Percentage of Children With Diarrhea by Age of Child (in Months): 

Children Less Than 5 Years of Age (Most Recent Survey) ...................127

Graph 9.7 Percentage of Children With Diarrhea Who Were Treated With Oral 

Rehydration Salts, by Area of Residence: Children Less Than Five 

Years of Age (Most Recent Survey) .........................................................128

Graph 9.8 Percentage of Children With Diarrhea Who Were Given More Liquids 

by Their Mothers, by Area of Residence: Children Less Than Five 

Years of Age (Most Recent Survey) .........................................................129

Graph 9.9 Percentage of Children With Respiratory Infections During the Two Weeks 

Prior to Interview, by Area of Residence: Children Less Than Five 

Years of Age (Most Recent Survey) .........................................................130

Graph 9.10 Percentage of Children With Respiratory Infections, by Age of Child 

(in Months): Children Less Than 5 Years of Age (Most Recent Survey) ......131

Graph 10.1 Initiation of Breastfeeding: Live Births in the Five Year Period Prior 

to the Most Recent Survey ...................................................................................136

Graph 10.2 Mean Duration of Breastfeeding (in Months): Live Births in the Five Years 

Prior to the Most Recent Survey ......................................................................137

Graph 10.3 Percentage of Children Classified as Low Height-for-Age, Low 

Weight-for-Height and Low Weight-for-Age: Children Aged 3–59 

Months (Most Recent Survey) ......................................................................140
XVI List of Graphs 

Reproductive, Maternal, and Child Health in Central America

Graph 10.4 Trends in the Percentage of Children Classified as Low Height-for-Age, 

According to Last Four Surveys: Children Aged 3–59 Months 

(12–59 Months for Honduras) ......................................................................142

Graph 10.5 Trends in the Percentage of Children Classified as Low Weight-for-Age, 

According to Last Four Surveys: Children Aged 3–59 Months 

(12–59 Months for Honduras) ......................................................................142

Graph 10.6 Percentage of Children Classified as Low Height-for-Age, by Area of 

Residence: Children Aged 3–59 Months (Most Recent Survey) ...................143

Graph 10.7 Percentage of Children Classified as Low Weight-for-Age, by Area of 

Residence: Children Aged 3–59 Months (Most Recent Survey) ...................143

Graph 10.8 Percentage of Children With Anemia, by Age of Child (in Months): 

Children Aged 12–59 Months ......................................................................147

Graph 11.1 Percent Attending School by Age at Start of School Year 

(Most Recent Survey) ...................................................................................155

Graph 11.2 Percent Attending Expected Grade for Age or Higher, by Age at 

Start of School Year (Most Recent Survey) ............................................155
List of Maps XVII

Trends and Challenges Facing Women and Childern

LIST OF MAPS

Map 2.1 Percent of Households With Electricity by Region/Department 

(Last Survey) ..............................................................................................10

Map 2.2 Percent of Households With a Water Faucet in House or Property by Region/

Department (Last Survey) .................................................................................11

Map 2.3 Percent of Households With a Refrigerator by Region/Department 

(Last Survey) ..............................................................................................11

Map 3.1 Total Fertility Rate by Region/Department (Next-to-Last Survey) .................24

Map 3.2 Total Fertility Rate by Region/Department (Last Survey) ..............................25

Map 3.3 Median Age At First Sex by Region/Department (Last Survey) ..............................27

Map 3.4 Median Age At First Birth by Region/Department (Last Survey) ..............................27

Map 3.5 Percent of Non-First Births in the Last Five Years With a Birth Interval of 

Less Than 36 Months (Last Survey) ....................................................................30

Map 4.1 Current Contraceptive Use Among Married Women of Fertile Age by Region/

Department (Next-to-Last Survey) ....................................................................44

Map 4.2 Current Contraceptive Use Among Married Women of Fertile Age by Region/

Department (Last Survey) .................................................................................45

Map 6.1 Percent of Women Who Have Heard of HIV/AIDS by Region/Department 

(Last Survey) ..............................................................................................75

Map 6.2 Percent of Women Who Know HIV Can Be Asymptomatic by Region/

Department (Last Survey) .................................................................................77

Map 7.1 Use of Prenatal Care for Births in the Previous 5 Years by Region/

Department (Next-to-Last Survey) ....................................................................94

Map 7.2 Use of Prenatal Care for Births in the Previous 5 Years by Region/

Department (Last Survey) .................................................................................95

Map 7.3 Percent of Births in the Previous 5 Years Attended in a Medical Facility 

by Region/Department (Next-to-Last Survey) ..........................................98

Map 7.4 Percent of Births in the Previous 5 Years Attended in a Medical Facility 

by Region/Department (Last Survey) .......................................................99

Map 8.1 Infant Mortality Rate for 10 Year Period Prior to Survey 

by Region (Last Survey) ...............................................................................106

Map 9.1 Complete Immunization of BCG, DPT/Penta, Polio and Measles, 

Children 12 – 59 Months (18–29 in Nicaragua) (Last Survey) ...............125

Map 10.1 Percent of Children 3 – 59 Months of Age With Low Height for Age 

(Stunting) by Region/Department (Last Survey) .........................................144

Map 10.2 Percent of Children 3 – 59 Months of Age With Low Weight for Age 

(Underweight) by Region/Department (Last Survey) .........................................145

Map 11.1 Percent of Children Ages 7 to 14 Years Old Not in School by Region/

Department (Last Survey) ...............................................................................156

Map 11.2 Percent of Children Ages 7 to 14 Years Old Who are Behind Expected 

Grade of Schooling by Region/Department (Last Survey) ............................157
XVIII List of Maps

Reproductive, Maternal, and Child Health in Central America
Introduction 1

Trends and Challenges Facing Women and Children

 CHAPTER

Introduction

Since the 1970s, 22 surveys of women (some 

also including men) have been conducted 

in El Salvador, Guatemala, Honduras, 

and Nicaragua. The majority of these surveys 

have been conducted as part of the Reproductive 

Health Surveys (RHS) program which are 

implemented with technical assistance from the 

Division of Reproductive Health, Centers for 

Disease Control and Prevention (CDC) or as part 

of the Demographic and Health Surveys (DHS) 

program with technical assistance provided by 

ORC/Macro. These surveys primarily report on 

fertility, contraceptive use, infant mortality, use 

of maternal and child health services, and the 

nutritional status of children and their mothers. 

In recent years, the scope of the surveys has 

broadened by including modules on HIV/AIDS, 

violence, and educational status of children, just 

to mention a few. In general, the survey findings 

are used to evaluate maternal and child health 

and family planning programs, to aid in the 

design of new programs and the restructuring of 

ongoing programs, and to provide baseline data 

to guide and evaluate new initiatives.

This comparative study describes the similarities 

and differences between El Salvador, Guatemala, 

Honduras, and Nicaragua, and to a limited 

extent, highlights subgroups with specific 

needs, in order to provide information for policy 

formulation at the regional and country levels. 

1
2 Introduction

Reproductive, Maternal, and Child Health in Central America

The data presented in this study primarily come 

from the last three surveys conducted in each 

country since the early 1990s, although some 

tables contain data from surveys conducted in 

the late 1980s. While men were interviewed 

in some of the surveys, this report primarily 

focuses on the information provided by female 

respondents.

Until now, a comparison of key health 

indicators had never been compiled for the 

Central American region. It is intended that this 

comparative analysis, although limited to the 

aforementioned countries, serve as a reference 

document for readers interested in major health 

findings in these countries, while more detailed 

information may be found in the individual 

country reports (see references). 

Background

This report sets forth comparative health data 

collected in face-to-face interviews from 

representative household samples of women 

of reproductive age in El Salvador, Guatemala, 

Honduras, and Nicaragua. Demographically 

and socially, the countries included in this 

report have much in common. Women tend to 

marry early, have their first child shortly after 

they marry, and achieve the desired family size 

in their mid- to late 20s. For many women, the 

only “career path” that they have is to marry, 

have children, and raise them. Traditionally, the 

educational level of the women has been low in 

these countries, especially among rural women, 

but there are indications from the survey data 

that more and more women are achieving higher 

levels of education. The relationship between 

education and the use of health services and 

the adoption of appropriate health behaviors 

conforms to expectations. For example, the 

use of key maternal and child health services 

increases steadily with increasing levels 

of education in all of the countries. Other 

socioeconomic factors also influence whether 

a woman uses a particular health service. As 

expected, urban women are more likely than 

rural women to use a particular health service 

in every country surveyed. Similarly, women 

classified as coming from higher socioeconomic 

households tend to use the health services in 

their respective countries at a higher rate than 

women from lower socioeconomic households.

In all of the countries, the principal provider 

of health services is the Ministry of Health, 

followed by the Social Security Institute, except 

in Nicaragua where the Social Security Institute 

is essentially a health insurance agency and, 

thus, does not provide direct health services. 

The Social Security Institute in each country is 

primarily urban based, and provides the bulk of 

its services in the capital city. Private clinics and 

hospitals have a minor role in providing health 

services. During the 1980s and early in the 

1990s, the private family planning association in 

each country played a major role in the provision 

of family planning services, but since the mid1990s their relative participation has diminished 

as they work toward becoming self-sustaining.

Surveys and 

Measurement Issues

The analyses in this report are based primarily on 

data collected in the last three surveys conducted 

in each country, although some tables include 

survey data from the late 1980s. For the most 

part, the questions asked in the surveys in each 

country are similar and, thus, are comparable, 

but some are not, and this is highlighted in the 

footnotes of the tables. The denominator used to 

analyze a particular variable sometimes varies 

from country to country. These differences exist 

particularly with respect to the family planning 

data, and are also highlighted in the footnotes of 

the tables.

Another measurement issue is that questions 

asked in the RHS surveys are not necessarily 

asked in the DHS surveys, and vice versa, thus, 

data are lacking in some tables of this report for 

some countries, and this is denoted by the letters 

‘na’ (not available). 

It should be emphasized that all results presented 

in the tables of this report are weighted to 

adjust for sampling design and non-response 

differentials, if necessary. In order to facilitate 

the reading of the tables, the unweighted and the 

weighted number of observations is not shown. 

An asterisk (*) is used to denote that there are 

less than 25 cases for a given cell.
Introduction 3

Trends and Challenges Facing Women and Children

Table 1.1 lists the surveys analyzed in this 

report. For each survey, the table shows the year 

in which the fieldwork was conducted, which 

organization provided technical assistance to the 

survey, number of women actually interviewed, 

and the number of live births in the 5 year period 

prior to interview. 

All of the surveys shown for El Salvador were 

conducted with the technical assistance of the 

Division of Reproductive Health, Centers for 

Disease Control and Prevention (CDC). The 1987, 

1995, and the 1998/99 surveys in Guatemala 

were conducted with the technical assistance of 

Macro International, Inc., while the 2002 survey 

was conducted with the technical assistance of 

CDC. The 1987 and 1991/92 Honduran surveys 

were conducted with the technical assistance 

of Family Health International (FHI) and 

Management Sciences for Health (MSH), while 

the 1996 and 2001 surveys were conducted with 

the technical assistance of CDC and MSH. The 

1992/93 survey in Nicaragua was conducted with 

the technical assistance of CDC, and the 1998 

and 2001 surveys were done with the assistance 

of Macro International, Inc. 

1.1 Characteristics of the Surveys

Country

Year

of Survey

Technical

Assistance

Number

of Women

Aged 15–49

Number of

Married Women

Aged 15–49

Number of

Live Births

El Salvador 1988 CDC 3,579* 2,276* 1,486†

El Salvador 1993 CDC 6,207 3,956 4,286

El Salvador 1998 CDC 12,634 8,085 8,488

El Salvador 2002/03 CDC 10,689 6,777 5,868

Guatemala 1987 Macro 5,160* 3,377* 4,581

Guatemala 1995 Macro 12,403 7,984 9,150

Guatemala 1998/99 Macro 6,021 3,964 4,545

Guatemala 2002 CDC 9,155 6,636 7,915

Honduras 1987 FHI, MSH 10,143* 6,093* 5,624

Honduras 1991/92 FHI, MSH 7,521* 4,323* 3,946

Honduras 1996 CDC, MSH 7,505 4,693 6,328

Honduras 2001 CDC, MSH 8,362 5,742 6,624

Nicaragua 1992/93 CDC 7,150 4,875 5,469

Nicaragua 1998 Macro 13,634 8,045 7,992

Nicaragua 2001 Macro 13,060 7,424 6,526

* Women aged 15–44.

†

 Last births only
4 Introduction

Reproductive, Maternal, and Child Health in Central America
Characteristics of Households and Women 5

Trends and Challenges Facing Women and Children

 CHAPTER

Characteristics of 

Households and 

Women

The availability of basic services such as 

piped water, electricity, and sanitation 

are indicators of the standard of living 

of a family and their risk of contracting disease. 

This section of the report discusses some of the 

services available to households, according to 

the last survey conducted in each country, and 

trends in the percentage of households that 

possess them. 

2

Characteristics of 

Households
6 Characteristics of Households and Women

 Reproductive, Maternal, and Child Health in Central America

Tables 2.1 and 2.3 show trends in the percentage 

of households in each country that possess 

selected services and goods related to the health 

of the population, while Tables 2.2 and 2.4 show 

rural/urban differentials for these same services 

and goods, according to the most recent survey 

in each country. Focusing on the last survey 

conducted in each country, almost 3 out of every 

4 households in Honduras have piped water 

inside the house or on the property compared 

to 6 out of every 10 households in El Salvador 

and Nicaragua, and almost 5 out of every 10 

households in Guatemala. In El Salvador and 

Guatemala, approximately 90 percent of the 

households have a flush toilet or latrine, while 

in Honduras and Nicaragua approximately 80 

percent of the household have these services. 

The percentage of households which adequately 

dispose their garbage ranges from a low of 64.9 

percent in Guatemala to a high of 84.2 percent 

in El Salvador. With respect to the energy used 

to cook food, 2 out of every 3 households in 

El Salvador use propane gas or electricity 

for cooking, while less than 40 percent of 

the households in Guatemala, Honduras, and 

Nicaragua use these energy sources. 

Table 2.1

Trends in the Availability of Basic Services in the Household that 

are Related to Health 

Country Year of Survey

Faucet in 

House or on 

Property

Flush Toilet or 

Latrine

Adequate 

Disposal of 

Garbage*

Cooks with 

Gas or 

Electricity Dirt Floor

El Salvador 1993 49.0 85.8 na 48.1 35.6

El Salvador 1998 59.9 88.4 74.6 59.4 31.5

El Salvador 2002/03 63.4 90.5 84.2 66.6 26.8

Guatemala 1995 49.4 82.9 na na 49.5

Guatemala 1998/99 54.7 79.9 na na 38.3

Guatemala 2002 46.6 87.6 64.9 32.5 35.9

Honduras 1991/92 65.7 63.0 68.6 na 46.9

Honduras 1996 69.2 73.8 68.0 20.4 40.6

Honduras 2001 74.3 78.0 74.8 31.1 32.1

Nicaragua 1992/93 58.8 79.6 na 26.8 na

Nicaragua 1998 64.1 83.2 na na 44.3

Nicaragua 2001 63.1 79.1 80.0 39.9 43.4

* Consists of municipal and private garbage collection, and the burning and burying of garbage.

na: Not available.

Still focusing on the last survey conducted in 

each country, it can be seen at a glance that in all 

four countries the rural population is less likely 

than the urban population to have access to the 

services presented in Table 2.2. For example, 

in Nicaragua, while 87.1 percent of urban 

households have piped water, only 27.6 percent 

of rural households do, for a 60 percentage point 

difference. The urban/rural differentials vary by 

service: the largest urban/rural differential with 

regards to piped water is found in Nicaragua; the 

largest differential with regards to flush toilets 

and latrines and the adequate disposal of garbage 

is found in Honduras; and the largest differential 

with regards to cooking with propane gas or 

electricity is found in Nicaragua. Comparing 

rural areas across countries, Honduras stands 

out as having the highest percentage of rural 

households with piped water (60.5 percent) and 

El Salvador as having the highest percentage of 

rural households with adequate garbage disposal 

(73.8 percent). 
Characteristics of Households and Women 7

Trends and Challenges Facing Women and Children

Table 2.2

Availability of Basic Services in the Household that are Related to Health, According 

to Area of Residence (Most Recent Survey)

Country/Area

Year of 

Survey

Faucet in House 

or on Property

Flush Toilet or 

Latrine

Adequate 

Disposal of 

Garbage*

Cooks with Gas 

or Electricity Dirt Floor

El Salvador 2002/03

Total 63.4 90.5 84.2 66.6 26.8

Urban 83.0 97.6 92.1 89.4 10.7

Rural 37.8 81.2 73.8 36.8 47.9

Guatemala 2002

Total 46.6 87.6 64.9 32.5 35.9

Urban 49.8 95.7 81.6 55.4 17.0

Rural 44.2 81.3 52.0 14.7 50.5

Honduras 2001

Total 74.3 78.0 74.8 31.1 32.1

Urban 89.0 94.7 90.8 53.5 11.2

Rural 60.5 62.1 59.6 9.9 51.8

Nicaragua 2001

Total 63.1 79.1 80.0 39.9 43.4

Urban 87.1 87.5 88.7 61.8 27.8

Rural 27.6 66.8 67.1 7.7 66.5

* Consists of municipal and private garbage collection, and the burning and burying of garbage.

Table 2.3

Trends in the Availability of Goods and Services in the Household 

Country 

Year of 

Survey Electricity Radio Television Refrigerator Telephone

Car or

Truck Computer

El Salvador 1993 75.8 na 64.5 39.8 11.5 12.4 na

El Salvador 1998 80.3 na 74.5 50.7 23.4 18.2 na

El Salvador 2002/03 86.9 na 80.9 54.9 46.0 17.4 na

Guatemala 1995 60.8 78.6 50.4 26.8 11.2 14.6 na

Guatemala 1998/99 70.9 79.5 55.6 30.6 15.6 16.7 na

Guatemala 2002 81.6 85.7 63.9 37.5 34.0 21.1 8.1

Honduras 1991/92 47.0 65.2 36.3 23.5 na na na

Honduras 1996 53.4 73.9 44.0 27.7 10.3 10.6 na

Honduras 2001 60.6 85.2 53.4 35.4 16.6 14.5 3.1

Nicaragua 1992/93 66.4 76.6 52.4 22.6 6.1 9.2 na

Nicaragua 1998 70.3 78.4 55.5 23.3 10.6 9.2 na

Nicaragua 2001 72.6 81.0 59.4 25.7 12.4 10.0 3.1

na: Not available.
8 Characteristics of Households and Women

 Reproductive, Maternal, and Child Health in Central America

Table 2.4

Availability of Goods and Services in the Household,

According to Area of Residence 

Country/

Area 

Year of 

Survey Electricity Radio Television Refrigerator Telephone

Car or

Truck Computer

El Salvador 2002/03

Total 86.9 na 80.9 54.9 46.0 17.4 na

Urban 96.3 na 91.8 70.8 61.2 23.8 na

Rural 74.6 na 66.6 34.1 26.0 9.0 na

Guatemala 2002

Total 81.6 85.7 63.9 37.5 34.0 21.1 8.1

Urban 94.6 91.6 83.6 57.8 53.8 32.1 14.6

Rural 71.5 81.2 48.6 21.8 18.6 12.6 3.1

Honduras 2001

Total 60.6 85.2 53.4 35.4 16.6 14.5 3.1

Urban 91.2 88.6 79.7 56.1 32.4 22.5 6.0

Rural 31.8 81.9 28.6 15.9 1.8 6.8 0.3

Nicaragua 2001

Total 72.6 81.0 59.4 25.7 12.4 10.0 3.1

Urban 94.5 85.4 80.2 37.8 20.2 14.4 5.0

Rural 40.1 74.4 28.6 7.6 1.0 3.5 0.3

na: Not available.

With regard to other household amenities 

related to health and communication, the data 

in Table 2.3 indicate that over 80 percent of 

households in El Salvador and Guatemala have 

electricity, compared to 72.6 and 60.6 percent 

of households in Nicaragua and Honduras. In 

Guatemala, Honduras, and Nicaragua, over 80 

percent of the households have a radio, while the 

percentage of households in all four countries 

that have television ranges from a low of 53.4 

percent in Honduras to a high of 80.9 percent 

in El Salvador. The likelihood of possessing 

a refrigerator is greatest in El Salvador (54.9 

percent) and lowest in Nicaragua (25.7 percent). 

In all of the countries, the probability of having 

a telephone in the household or of owning a 

vehicle is relatively low. Similarly, very few 

households have a computer.

Graphs 2.1 and 2.2 highlight trends in the 

possession of selected goods and services 

between the early 1990s and the most recent 

survey conducted since 2000. With few 

exceptions, there has been a general increase in 

the availability of these services in each country. 

The most notable increase is of the telephone, 

likely due to increased availability of cell phone 

services. El Salvador witnessed a 35 percentage 

point increase between 1993 and 2003. 

Nicaragua has the lowest percentage of 

households with TVs (televisions), telephones, 

refrigerators and automobiles. It also had the 

smallest percentage point increase in possession 

of these three goods between the first survey and 

the most recent survey.
Characteristics of Households and Women 9

Trends and Challenges Facing Women and Children

-10

0

10

20

30

40

50

Nicaragua

Honduras

Guatemala

El Salvador

Cooks

w/gas or

electricity

Toilet or

latrine

Piped Electricity

water

Graph 2.1

Change Between Early 1990s and Early 2000s in Percent of

Households With Piped Water, Electricity, Flush Toilet or Latrine 

and That Cook With Gas or Electricity (First and Third Surveys) Percentage Point Change

Service

0

10

20

30

40

50

Nicaragua

Honduras

Guatemala

El Salvador

Television Telephone Refrigerator Vehicle

Percentage Point Change

Graph 2.2

Change Between Early 1990s and Early 2000s in Percent of

Households With Television, Telephone, Refrigerator and Automobile

(First and Third Surveys)

Goods
10 Characteristics of Households and Women

 Reproductive, Maternal, and Child Health in Central America

Maps 2.1, 2.2 and 2.3 illustrate subnational 

variations in the percentage of households 

with electricity, piped water and a refrigerator, 

according to the most recent survey in each 

country. It is notable that electrification is most 

advanced (70 percent or more of households) 

along the Pacific coasts of Guatemala and 

Nicaragua and in all departments of El Salvador. 

Honduras stands out as having the broadest 

coverage of households with piped water (more 

than 60 percent of households in all but one of 

its health regions). Possession of a refrigerator 

is fairly widespread throughout El Salvador, 

but in Guatemala, Honduras and Nicaragua it 

is common only in the regions (or departments) 

containing Guatemala City, San Pedro Sula, 

Tegucigalpa and Managua. 

Map 2.1

Percent of Households with Electricity

by Region / Department

(Last Survey)

<40

40–54

55–69

70–84

85+

%Electricity
Characteristics of Households and Women 11

Trends and Challenges Facing Women and Children

Map 2.2

Percent of Households with a Water Faucet in 

House or Property by Region/Department

(Last Survey)

<35

35–49

50–59

60–69

70+

%Water

Map 2.3

Percent of Households with a Refrigerator

by Region / Department

(Last Survey)

<15

15–24

25–34

35–44

45+

% Refrigerator
12 Characteristics of Households and Women

 Reproductive, Maternal, and Child Health in Central America

Characteristics of 

Reproductive Age Women

As a result of numerous education reforms 

in these countries, levels of education have 

different meanings at different ages in each 

country. To simplify the presentation, years of 

schooling have been calculated and regrouped 

into the following three categories: none or less 

than 1 year; primary including 1 through 6 years 

of schooling, and secondary having 7 years or 

more of schooling. Table 2.5 presents trends 

in the percent distribution of reproductive age 

women by education level in the last three 

surveys conducted in each country. Table 2.6 

shows differentials by area of residence for the 

most recent survey in each country. By focusing 

on the lowest and highest educational level 

presented in Table 2.5, one can generalize that 

the proportion of respondents with no schooling 

has decreased since the early 1990s, while the 

Table 2.5

Trends in The Educational Level of Women Who Have Been 

Interviewed, Women Aged 15–49

Country Year of Survey None 1–6 7 or more

El Salvador 1993 18.5 43.0 38.6

El Salvador 1998 15.5 40.3 44.2

El Salvador 2002/03 12.5 35.8 51.7

Guatemala 1995 28.3 47.2 24.5

Guatemala 1998/99 25.3 49.3 25.4

Guatemala 2002 25.5 44.4 30.1

Honduras 1991/92 15.2 59.9 24.9

Honduras 1996 12.4 61.0 26.7

Honduras 2001 9.9 59.0 31.0

Nicaragua 1992/93 16.1 45.6 38.3

Nicaragua 1998 15.5 40.4 44.0

Nicaragua 2001 14.4 39.5 46.0
Characteristics of Households and Women 13

Trends and Challenges Facing Women and Children

proportion of respondents with at least some 

secondary education (grades 7 or higher) has 

gradually increased. Comparing the countries 

(Graph 2.3), in both El Salvador and Nicaragua 

almost half of women have at least 7 years of 

education. In both Honduras and Guatemala 

only about 30 percent of women had any 

secondary education and in Guatemala 25.5 

percent of women report no formal education at 

all. Given the importance of education for many 

reproductive health indicators it will be helpful 

to keep the education differential in mind when 

comparing these four countries. 

Country

0

20

40

60

80

100 7 or more

1-6

None

El Salvador Guatemala Honduras Nicaragua

Graph 2.3

Percentage of Women, 15 to 49, by Highest Grade Level Completed

(Most Recent Survey)

Percentage
14 Characteristics of Households and Women

 Reproductive, Maternal, and Child Health in Central America

Table 2.6 and Graph 2.4 show rural/urban 

differentials in education for the four countries. 

Focusing on the percent with at least some 

secondary education, it can be seen that the 

urban areas have a considerable advantage over 

rural areas in all four countries. The urban/

rural differentials range between 30 percentage 

points in Guatemala and 45 percentage points 

in Nicaragua. Within urban areas there are also 

notable differences between the four countries. 

While in El Salvador and Nicaragua, 67.3 and 

62.3 percent of urban women have at least some 

secondary education, in Guatemala and Honduras 

only 47.5 and 49.1 percent of urban women 

have some secondary education. The overall 

differential between countries in education 

level is therefore not explained by inter-country 

differences in the level of urbanization. 

Table 2.6

Educational Level of Women Who Have Been 

Interviewed, According to Area of Residence, Women Aged 15–49

Country/Area Year of Survey None 1–6 7 or more

El Salvador 2002/03

Total 12.5 35.8 51.7

Urban 6.6 26.1 67.3

Rural 20.3 48.5 31.2

Guatemala 2002

Total 25.5 44.4 30.1

Urban 15.7 36.9 47.5

Rural 32.8 50.1 17.2

Honduras 2001

Total 9.9 59.0 31.0

Urban 4.8 46.1 49.1

Rural 15.2 72.5 12.2

Nicaragua 2001

Total 14.4 39.5 46.0

Urban 6.6 31.1 62.3

Rural 27.8 54.2 18.0

Area of Residence / Country

Percentag

e

0

20

40

60

80

100

7 or more 1–6 None

El Salvador Guatemala Honduras Nicaragua

Graph 2.4

Percentage of Women, 15 To 49, By Highest Grade Level Completed and

Area of Residence (Most Recent Survey)

Urban Rural

El Salvador Guatemala Honduras Nicaragua
Characteristics of Households and Women 15

Trends and Challenges Facing Women and Children

Graph 2.5 depicts, for the most recent survey, 

the percent of reproductive age women living 

in urban areas and the percent of live births in 

the five years before the survey occurring to 

urban women. There is a considerable range of 

more than 20 percentage points in the “percent 

urban” among the four countries. Nicaragua 

has the highest percent urban of the countries 

with 63.1 percent of women living in in urban 

areas, followed by El Salvador (56.7 percent), 

Honduras (51.1 percent) and Guatemala (42.5 

percent). For all four countries the percentage of 

births occurring to urban women is considerably 

less than the percentage of women who are 

urban. This reflects the differences in fertility 

between urban and rural areas, which will be 

discussed in Chapter 3. Some of the indicators 

for maternal and child health presented in the 

report are based on births in the five years before 

the survey, so it is important to keep in mind that 

these indicators may be more strongly affected 

by area of residence than are indicators based 

on women.

Percentage Urban

0

10

20

30

40

50

60

70

Women, 15-49 Births last 5 years

El Salvador Guatemala Honduras Nicaragua

Graph 2.5

Percent of the Reproductive Age Female Population That is

Urban and Percent of Births in the Last Five Years Occurring to

Urban Women (Most Recent Survey)

Country
16 Characteristics of Households and Women

 Reproductive, Maternal, and Child Health in Central America

Table 2.7 shows trends in the religion professed 

by reproductive age women for El Salvador, 

Guatemala and Honduras. For each country there 

is notable growth in the proportion of women 

claiming to be Protestants. The latest survey in 

each country shows more than a third of women 

to be Protestants in these traditionally Catholic 

societies. 

Summary of Findings

• Since the early 1990s and in each country, 

there have been improvements in the 

proportion of households with goods and 

services that could affect health conditions. 

However, in all four countries the rural 

population is considerably less likely than 

the urban population to have access to these 

services and goods. 

• While there have been improvements in 

women’s educational attainment for all four 

countries, there are also sizeable differentials 

between countries. In both El Salvador and 

Nicaragua about half of reproductive age 

women have at least some secondary level 

education, while in Honduras and Guatemala 

less than a third of women do. 

Table 2.7

Trends in the Religion Professed by Female Respondents: 

Women Aged 15–49

Country Year of Survey Catholic Protestant Other None

El Salvador 1993 na na na na

El Salvador 1998 56.3 23.8 0.1 19.9

El Salvador 2002/03 50.2 31.1 0.3 18.4

Guatemala 1995* 60.7 25.9 2.2 11.2

Guatemala 1998/99 52.6 29.4 2.4 15.6

Guatemala 2002 51.2 35.8 1.5 11.5

Honduras 1991/92 65.3 21.3 0.4 13.0

Honduras 1996 56.8 26.0 0.1 17.1

Honduras 2001 53.0 34.1 0.4 12.5

Nicaragua 1992/93 na na na na

Nicaragua 1998 na na na na

Nicaragua 2001 na na na na

* Women aged 15–44.

na: Not available.
Fertility 17

Trends and Challenges Facing Women and Children

 CHAPTER

Fertility

This chapter presents findings concerning 

fertility levels, differentials, and time 

trends for the four countries being 

examined in this report. Information is also 

presented on indicators of exposure to the risk 

of pregnancy (i.e., age at first sexual relation), 

planned and unplanned fertility, and ideal 

number of living children.

Much of the following analysis is in terms of agespecific and total fertility rates (TFR). The TFR 

is interpreted as the number of births a woman 

would have during her childbearing years if she 

passed through those years experiencing the 

observed age-specific rates. 

3
18 Fertility

Reproductive, Maternal, and Child Health in Central America

Fertility Levels and Trends

Table 3.1 and Graph 3.1 show TFRs based on 

data collected in surveys conducted since the 

late 1980s (except Nicaragua). Focusing first 

on the most recent survey conducted in each 

country, El Salvador and Nicaragua have the 

lowest TFRs (3.0 and 3.2 live births per woman, 

respectively). Somewhat higher fertility was 

found for Guatemala and Honduras (4.4 live 

births per woman). To put these levels in 

perspective, the TFR estimated for Costa Rica in 

2000 was 2.4 live births per woman, the lowest 

TFR in the Central American region.

Table 3.1

Trends in Total Fertility Rates, by Area of Residence:

Women Aged 15-49

Country Year of Survey Time Period Total Urban Rural

El Salvador 1988* 1983–1988 4.2 nc nc

El Salvador 1993 1988–1993 3.9 3.1 4.7

El Salvador 1998 1993–1998 3.6 2.8 4.6

El Salvador 2002/03 1997–2002 3.0 2.4 3.8

Guatemala 1987* 1983–1987 5.6 4.1 6.5

Guatemala 1995 1992–1995 5.1 3.8 6.2

Guatemala 1998/99 1995–1998 5.0 4.1 5.8

Guatemala 2002 1999–2002 4.4 3.4 5.2

Honduras 1987* 1986/87 5.6 3.9 6.9

Honduras 1991/92 1989–1991 5.2 3.9 6.5

Honduras 1996 1993–1995 4.9 3.5 6.3

Honduras 2001 1998–2000 4.4 3.3 5.6

Nicaragua 1992/93 1987–1992 4.6 3.4 6.4

Nicaragua 1998 1993–1998 3.9 3.1 5.4

Nicaragua 2001 1999–2001 3.2 2.6 4.4

* Women aged 15–44.

nc - not comparable (sample in 1988 excluded some rural areas due to conflict)

Graph 3.1

Trends in the Total Fertility Rate 

(Four Most Recent Surveys)

0

1

2

3

4

6

Nicaragua

Honduras

Guatemala

El Salvador

First Second Third Fourth

Survey

TF

R
Fertility 19

Trends and Challenges Facing Women and Children

In all of the countries, fertility has been declining 

since the late 1980s or early 1990s. The pace 

of fertility decline from the first to last survey 

shown for each country in the table ranges from 

30.4 percent in Nicaragua, to 28.5 percent in El 

Salvador, and to 21.4 percent each in Guatemala 

and Honduras. 

Many studies have shown fertility levels to 

be lower among women with higher levels 

of education. This is true for the populations 

examined in this report, as shown in Table 3.2. 

The differential, at the time of the most recent 

survey, between women with the highest and 

lowest level of education in the table, ranges 

from 2.8 births in El Salvador, to 3.5 births in 

Nicaragua, 3.8 births in Honduras and 4.3 births 

in Guatemala. Generally, those with at least 

some secondary education have TFRs below 3.0, 

both in the most recent and earlier surveys. The 

recent fertility declines have been concentrated 

among women with just primary education. 

Table 3.2

Trends in Total Fertility Rates, 

According to Education: Women Aged 15–49

Country/Education Year of Survey

El Salvador 1993 1998 2002/03

Total 3.9 3.6 3.0

None 5.4 5.0 4.5

1–3 4.8 4.7 3.6

4–6 3.8 3.6 2.7

7–9 3.1 3.2 2.2

10+ 2.3 2.4 1.7

Guatemala 1995 1998/99 2002

Total 5.1 5.0 4.4

None 7.1 6.8 6.4

Primary 5.1 5.2 4.7

Secondary+ 2.6 2.9 2.1

Honduras 1991/92 1996 2001

Total 5.2 4.9 4.4

None 7.0 7.1 6.5

1–3 6.4 6.1 5.9

4–6 4.9 4.8 4.4

7+ 3.1 2.9 2.7

Nicaragua 1992/93 1998 2001

Total 4.6 3.9 3.2

None 6.9 6.1 5.2

1–3 5.8 5.2 4.2

4–6 4.3 4.1 3.3

Secondary 3.1 2.7 2.5

Superior 2.0 1.5 1.7
20 Fertility

Reproductive, Maternal, and Child Health in Central America

Age-specific fertility rates for each country are 

shown in Table 3.3 and Graph 3.2. The agespecific fertility rate is defined as the annual 

number of births per 1,000 women in the age 

group. Focusing first on the most recent survey, 

the countries exhibit a common age pattern of 

fertility, which is characterized by an early 

onset of childbearing and the completion of 

childbearing at a relatively late age. Childbearing 

begins in the late teenage years and peak fertility 

occurs in the age interval 20–24. The decline 

in the fertility rates after age 20–24 is gradual 

until age 30–34 is reached, when a steep decline 

begins. The age-specific rates for Guatemala 

and Honduras are similar and the age-specific 

rates for El Salvador and Nicaragua are similar. 

Honduras is notable for having the highest rate 

Table 3.3

Trends in Age-Specific and Total Fertility Rates:

Women Aged 15–49

Country Year of 

Survey

Age

15–19 20–24 25–29 30–34 35–39 40–44 45–49 TFR

El Salvador 1993 124 221 168 126 86 39 3 3.9

El Salvador 1998 116 211 167 118 68 29 8 3.6

El Salvador 2002/03 104 165 144 86 66 29 1 3.0

Guatemala 1995 126 262 235 200 136 54 13 5.1

Guatemala 1998/99 117 276 236 182 131 60 7 5.0

Guatemala 2002 114 233 218 150 119 38 4 4.4

Honduras 1991/92 132 264 232 191 134 74 16 5.2

Honduras 1996 136 243 210 169 142 78 12 4.9

Honduras 2001 137 229 202 161 94 56 9 4.4

Nicaragua 1992/93 158 251 198 148 103 41 13 4.6

Nicaragua 1998 139 203 173 132 82 35 9 3.9

Nicaragua 2001 119 178 145 108 64 26 6 3.2

 

for women 15–19 (136 annual births per 1,000 

women).

Graph 3.3 shows the changes in age-specific 

fertility rates (ASFR’s) between the third from 

last survey conducted in the early 1990s and 

the most recent survey since 2000. Nicaragua 

is notable for having the most pronounced 

declines for virtually every age group, followed 

by El Salvador. In Honduras the ASFR declines 

are concentrated among women over 24, and 

Guatemala has an irregular pattern with a 

particularly large decline in the 30–34 age group. 

With one exception, there has been a decline in 

fertility for each age group in each country since 

the early 1990s. The exception is Honduras 

where the age-specific fertility rate for women 

aged 15–19 has remained virtually unchanged.
Fertility 21

Trends and Challenges Facing Women and Children

0

50

100

150

200

250

Nicaragua

Honduras

Guatemala

El Salvador 

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Graph 3.2

Age-Specific Fertility Rates

(Most Recent Survey)

Age

Births Per 1,000 Women -80

-70

-60

-50

-40

-30

-20

-10

0

10

Nicaragua

Honduras

Guatemala

El Salvador

15-19 20-24 25-29 30-34 35-39 40-44 45-49

Age

Change in ASFR 

Graph 3.3

Reductions in Age-Specific Fertility Rates (ASFR’s)

From the Early 1990s to the Early 2000s 

(Third From Last and Last Surveys)
22 Fertility

Reproductive, Maternal, and Child Health in Central America

Table 3.4

Age-Specific and Total Fertility Rates, According to Area of Residence:

Women Aged 15–49 (Most Recent Survey)

Country/Area

Year of 

Survey

Age

15–19 20–24 25–29 30–34 35–39 40–44 45–49 TFR

El Salvador 2002/03

 Total 104 165 144 86 66 29 1 3.0

 Urban 88 138 118 62 52 15 0 2.4

 Rural 124 202 176 118 86 47 2 3.8

Guatemala 2002

 Total 114 233 218 150 119 38 4 4.4

 Urban 85 184 191 101 87 20 2 3.4

 Rural 133 267 240 190 145 50 7 5.2

Honduras 2001

 Total 137 229 202 161 94 56 9 4.4

 Urban 114 183 160 120 55 28 1 3.3

 Rural 162 277 249 202 131 84 20 5.6

Nicaragua 2001

 Total 119 178 145 108 64 26 6 3.2

 Urban 99 149 119 89 39 14 2 2.6

 Rural 153 226 186 141 107 49 13 4.4

Table 3.4 shows urban/rural differentials for 

age-specific and total fertility rates, according 

to the most recent survey in each country. In all 

of the countries, very little childbearing occurs 

among women older than 44 years, although rural women in Honduras aged 45–49 continue to 

bear children at a rate of 20 per 1,000 women. 

In all four countries fertility remains relatively 
Fertility 23

Trends and Challenges Facing Women and Children

high in the rural area compared to the urban 

area (see Graph 3.4). For example, the rural 

TFR for Honduras was 5.6 births compared 

to 3.3 births estimated for urban areas, for a 

difference of 2.3 live births per woman. In 

Guatemala and Nicaragua the difference 

is 1.8 births, while in El Salvador it is 1.4 

births. 

0

1

2

3

4

5

6

Nicaragua

Honduras

Guatemala

El Salvador

Total Urban Rural

Area of Residence

TFR

Graph 3.4

Total Fertility Rates, By Area Of Residence

(Most Recent Survey)
24 Fertility

Reproductive, Maternal, and Child Health in Central America

Maps 3.1 and 3.2 show the total fertility rates 

for subnational regions, according to the next to 

last and last surveys in each of the four countries. 

It is notable that for both periods of time there 

are large areas within Guatemala and Honduras 

with TFRs above 5 children per woman. Within 

these two countries the only regions with TFRs 

below 4 are those containing Guatemala City, 

Map 3.1

Total Fertility Rate by Region / Department

(Next-to-Last Survey)

<3.0

3.0–3.4

3.5–3.9

4.0–4.4

4.5–4.9

5.0–5.4

5.5 +

Total

Fertility Rate
Fertility 25

Trends and Challenges Facing Women and Children

Tegucigalpa and San Pedro Sula. El Salvador 

and Nicaragua, on the other hand, exhibit a 

more generalized fertility decline with most 

departments having TFRs below 4. In the most 

recent surveys, El Salvador has three departments 

with TFRs below 3 and Nicaragua has 6, mostly 

on the Pacific coast of the country. 

Map 3.2

Total Fertility Rate by Region / Department

(Last Survey)

<3.0

3.0–3.4

3.5–3.9

4.0–4.4

4.5–4.9

5.0–5.4

5.5 +

Total

Fertility Rate
26 Fertility

Reproductive, Maternal, and Child Health in Central America

Median Age at First 

Intercourse, First Union, 

and First Birth 

Fertility at younger ages is strongly affected by 

the ages at which women (and men) become 

sexually active, get married and become parents 

for the first time. Table 3.5 shows the median 

age at first intercourse, first union (either married 

or consensual), and first birth for women aged 

15–49 and men aged 15–59. The median age 

is the age by which 50 percent of women (or 

men) have experienced the event in question. 

El Salvador, Guatemala and Honduras all have 

similar median ages for all three events, for both 

women and men. Nicaraguan women stand 

out as having somewhat younger ages for all 

three events than their counterparts in the other 

three countries. There are no comparable data 

available on Nicaraguan men. Women’s age 

at first union exhibits the largest differential, 

varying between 19.8 in El Salvador and 18.3 

in Nicaragua. 

The male/female differentials are large and 

are similar for all three countries. Men 

report younger ages at first intercourse, but 

considerably older ages at first union and first 

birth. As a consequence the gap between first 

intercourse and first union is fairly large for 

men (between 6.1 and 6.8 years) and is fairly 

narrow for women (between 0.7 and 1.4 years). 

The delay between first union and first birth is 

similar for men and women. 

Maps 3.3 and 3.4 show that there are regional 

variations within countries in the age at first 

sex and age at first birth for women aged 15–

49. These variations are similar to those for the 

total fertility rate. Considering age at first sex, 

only isolated areas around Guatemala City, San 

Miguel and Tegucigalpa register a median age 

older than 18. For age at first birth, however, 

there are larger regions on the Pacific coasts of 

Guatemala and Nicaragua, western Honduras 

and most of El Salvador, where the median age 

is 20 or older.

Table 3.5

Median Age at First Intercourse, First Union, and First Birth,

According to Sex of Respondent: Women Aged 15–49 and

Men Aged 15–59 (Most Recent Survey)

Country/Sex First Intercourse First Union First Birth

El Salvador 

 Women 18.4 19.8 20.5

 Men 16.0 22.5 24.2

Guatemala

 Women 18.4 19.3 20.4

 Men 16.9 23.0 24.3

Honduras

 Women 18.3 19.0 20.2

 Men 16.0 22.8 24.3

Nicaragua

 Women 17.9 18.3 19.6*

 Men na na na

na: Not available.

* Women aged 25–49.
Fertility 27

Trends and Challenges Facing Women and Children

Map 3.3

Median Age at First Sex by Region / Department

(Last Survey)

16

17

18

19

20

Median Age

Map 3.4

Median Age at First Birth by Region / Department

(Last Survey)

18

19.0–19.4

19.5–19.9

20.0–20.4

20.5+

Median Age
28 Fertility

Reproductive, Maternal, and Child Health in Central America

Percent Married or in 

a Consensual Union

As can be seen in Table 3.6, while women enter 

unions (marriage or consensual) younger than 

men, they are less likely to be in a union at older 

ages. In El Salvador and Guatemala at ages 

under 35 and in Honduras under 30, women are 

more likely to be in a union than men, but beyond 

that age men are more likely to be in a union. 

This reflects that women are more likely to be 

separated, widowed or divorced at these ages. 

It appears that men are more likely than women 

to have subsequent unions after separating. 

The sex differential is particularly pronounced 

for women 40 and older in El Salvador and 

Honduras. 

Birth Intervals

An important aspect of fertility behavior beyond 

the absolute number of births a woman has is the 

spacing between births. It has been demonstrated 

that shorter birth intervals are associated with a 

heightened risk of infant mortality. Generally, 

a birth at an interval less than 36 months is at 

higher risk and intervals less than 24 months 

are at considerably greater risk. As use of 

family planning for birth spacing increases, 

the proportion of births occurring after short 

intervals declines. 

Table 3.6

Percent Currently in a Union, According to Age and Sex of Respondent: 

Women Aged 15–49 and Men Aged 15–59 (Most Recent Survey)

Sex Age

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Nicaragua

2001

Women 15–19 19.2 18.2 26.0 22.3

20–24 51.5 56.9 57.7 55.5

25–29 67.8 77.3 71.2 69.7

30–34 78.2 81.3 78.1 76.1

35–34 74.7 80.4 77.1 74.7

40–44 71.5 84.4 73.9 71.0

45–49 66.0 73.9 70.2 64.8

15–49 56.4 60.4 59.7 56.8

Men 15–19 1.7 5.7 5.0 na

20–24 36.3 42.0 33.5 na

25–29 65.3 74.2 67.0 na

30–34 82.0 77.9 80.6 na

35–34 85.2 90.5 84.2 na

40–44 76.1 86.3 86.8 na

45–49 85.3 89.0 83.8 na

50–54 84.6 91.8 93.3 na

55–59 90.0 90.7 88.7 na

15–59 56.9 57.9 54.1 na
Fertility 29

Trends and Challenges Facing Women and Children

Table 3.7 shows the proportion of births (in the 

five years before the survey) that occurred within 

various windows of time after the preceding 

birth. Data are shown for the most recent survey 

in each country, and first births are excluded 

from the calculations. Taking El Salvador as an 

example, it can be seen that just 9.5 percent of 

births occur within 18 months after the previous 

birth, but that 22.5 percent occur within two years 

and 51.5 percent within three years. Focusing 

on the column presenting the percent of births 

within 3 years, in El Salvador and Nicaragua 

slightly more than half of births occur within 3 

years while in Guatemala and Honduras almost 

two thirds occur within 3 years.

Table 3.7

Percent of Births Occuring Within Select Periods of Time Since the 

Previous Birth: Births of Order 2 and Higher in the Five Years Before the 

Survey (Most Recent Survey)

Country/Area

Year of 

Survey

Months since the previous birth

<18 <24 <30 <36 <48 <60

El Salvador 2002/03

 Total 9.5 22.5 39.3 51.5 66.8 78.1

 Urban 7.3 19.4 33.0 43.2 57.7 71.2

 Rural 11.1 24.7 43.8 57.4 73.3 83.0

Guatemala 2002

 Total 11.0 29.9 52.4 66.3 82.5 89.5

 Urban 9.7 25.6 44.5 58.7 75.2 83.6

 Rural 11.5 31.8 56.0 69.7 85.8 92.1

Honduras 2001

 Total 11.4 29.0 49.7 63.0 77.7 85.6

 Urban 12.4 28.2 44.7 56.1 69.8 78.1

 Rural 10.9 29.6 52.5 66.8 82.1 89.8

Nicaragua 2001

 Total 11.6 26.3 41.5 52.8 68.2 78.6

 Urban 10.3 22.1 33.3 42.0 56.2 68.0

 Rural 12.7 29.9 48.2 61.8 78.1 87.3
30 Fertility

Reproductive, Maternal, and Child Health in Central America

Map 3.5 shows the percent of births with a 

previous interval less than three years for 

sub-national regions. Almost all regions of 

Honduras and the northeast of Guatemala 

exhibit the highest percentages (70 percent or 

higher). Only isolated areas of El Salvador 

and Nicaragua have percentages below 50 

percent and only the Department of Managua 

in Nicaragua has less than 40 percent of births 

with a short interval. 

Map 3.5

Percent of Non-First Births in the Last Five Years 

with a Birth Interval of Less than 36 Months

(Last Survey)

20–39

40–49

50–59

60–69

70–85

% Birth Interval

<36 Months
Fertility 31

Trends and Challenges Facing Women and Children

Reproductive Preferences

Graph 3.5 shows the percent distribution of 

births in the 5 years before the most recent 

survey, according to planning status of the 

birth. A birth is classified as “wanted” if the 

respondent planned it at the time it occurred. A 

birth is classified as “mistimed” if the respondent 

wanted the birth, but not at the time it occurred. 

And, a birth is classified as “unwanted” if the 

respondent did not want any more children. 

Despite having high fertility, Guatemala is the 

country with the highest percentage of births 

classified as “wanted” (68.3 percent) and the 

country with the lowest percentages classified as 

“mistimed” (16.5 percent) and “unwanted” (15.1 

percent). Nicaragua has the highest percentage 

“unwanted” (27.4 percent), followed closely by 

Honduras (25.5 percent) and El Salvador (24.2 

percent). 

0

20

40

60

80

100

Unwanted

Mistimed

Wanted

El Salvador Guatemala Honduras Nicaragua

Country

Percentag

e

Graph 3.5

Percentage of Live Births That Were Wanted, Mistimed Or

Unwanted: Live Births in the Five Years Prior to Interview

(Most Recent Survey)
32 Fertility

Reproductive, Maternal, and Child Health in Central America

Table 3.8 and Graph 3.6 show the total fertility 

rates for the most recent survey in each country 

disaggregated into wanted/mistimed unwanted 

components. The unwanted TFR is computed 

the same as the overall observed TFR except that 

only births classified as “unwanted” are included 

in the numerators of the rates. The wanted TFR 

can be interpreted as the hypothetical TFR that 

would occur if all unwanted births had been 

avoided. The unwanted TFR is simply the 

difference between the observed TFR and the 

wanted TFR. El Salvador has both the lowest 

wanted TFR (2.2 births per woman) and the 

lowest unwanted TFR (0.8 births per woman) 

among these four countries. Guatemala has the 

highest wanted TFR (3.7 births per woman) and 

Honduras has the highest unwanted TFR (1.3 

births per woman). 

Table 3.8

Wanted and Unwanted Total Fertility Rates, According to Area of Residence:

Women Aged 15–49 (Most Recent Survey)

Country/Area Year of Survey

Total Fertility Rate

Wanted Unwanted Observed

El Salvador 2002/03

 Total 2.2 0.8 3.0

 Urban 1.8 0.6 2.4

 Rural 2.8 1.0 3.8

Guatemala 2002

 Total 3.7 0.7 4.4

 Urban 2.8 0.6 3.4

 Rural 4.3 0.9 5.2

Honduras 2001

 Total 3.1 1.3 4.4

 Urban 2.5 0.8 3.3

 Rural 3.8 1.8 5.6

Nicaragua 2001

 Total 2.3 0.9 3.2

 Urban 1.8 0.8 2.6

 Rural 3.0 1.4 4.4

Graph 3.7 shows the same information as Graph 

3.6, but is disaggregated by area of residence. 

The results are similar to the national TFRs. 

Honduras has the highest unwanted TFR in 

both urban and rural areas (0.8 and 1.8 births 

per woman, respectively), and Guatemala has 

the highest wanted fertility in both areas (2.8 

and 4.3 births per woman, respectively). While 

the wanted TFRs are higher in rural areas than 

in urban areas, the wanted TFRs for rural El 

Salvador and Nicaragua are remarkably low 

(2.8 and 3.0). It should be noted that the wanted 

TFR for urban areas in both El Salvador and 

Nicaragua of 1.8 children per woman is below 

the replacement level. 
Fertility 33

Trends and Challenges Facing Women and Children

0

1

2

3

4

5

6

Unwanted

Wanted/Mistimed

El Salvador Guatemala Honduras Nicaragua

Country

TF

R

Graph 3.6

Total Fertility Rate, by Whether Births Were Wanted or Not

(Most Recent Survey)

0

1

2

3

4

5

6

Wanted/Mistimed Unwanted

Urban Rural

Area of Residence/Country

TF

R

Graph 3.7

Total Fertility Rate, by Area of Residence and

Whether Births Were Wanted or not

(Most Recent Survey)

El Salvador Guatemala Honduras Nicaragua El Salvador Guatemala Honduras Nicaragua
34 Fertility

Reproductive, Maternal, and Child Health in Central America

Table 3.9 shows the mean ideal family size for 

women and men, using data from the last survey. 

Focusing first on the women, the mean ideal 

family size is about 3 children in El Salvador, 

Honduras, and Nicaragua, while in Guatemala 

it is 3.4 children. In general, ideal family size 

reported by rural women exceeds that of urban 

women by about half a child. It should be noted 

that ideal family size at the national level has 

not changed in any of the countries between the 

earlier and the later survey (data not shown). 

The mean ideal family size reported by men 

does not substantially exceed women’s ideal 

family size. The largest difference is found in 

El Salvador where men report 3.8 children as 

their ideal compared to 3.1 children reported by 

women.

Table 3.9

Mean Ideal Number of Children, According to Sex of Respondent

 and Area of Residence: Women Aged 15-49 and Men Aged 15-59 

(Most Recent Survey)

Country/Area Year of Survey

Ideal Number of Children

Women Men

El Salvador 2002/03

 Total 3.1 3.8

 Urban 2.7 3.1

 Rural 3.6 4.5

Guatemala 2002

 Total 3.4 3.5

 Urban 3.0 3.1

 Rural 3.7 3.8

Honduras 2001

 Total 3.0 3.4

 Urban 2.7 3.1

 Rural 3.3 3.6

Nicaragua 2001

 Total 2.9 na

 Urban 2.5 na

 Rural 3.4 na
Fertility 35

Trends and Challenges Facing Women and Children

Summary of Findings

• Fertility levels have declined in all of the 

surveyed countries since the late 1980s or 

the early 1990s. The decline has been more 

accelerated in Nicaragua and El Salvador 

than in Guatemala and Honduras. According 

to the last survey conducted in each country, 

El Salvador has the lowest TFR (3.0 births 

per woman), followed closely by Nicaragua 

(3.2), while Guatemala and Honduras have 

the highest TFRs (4.4 births each).

• The age pattern of fertility is similar in each 

country, which is characterized by significant 

childbearing among women aged 15–19, 

peak fertility among women aged 20–24, and 

a gradual decline thereafter. However, the 

decline is more accelerated in Nicaragua and 

El Salvador than in the other two countries. 

In all countries, a high proportion of women 

who are 40 or more years old continue to 

have children, especially in Honduras and 

Guatemala.

• Substantial fertility differentials exist 

according to area of residence and 

educational level. As expected, the TFR of 

rural women and women with less formal 

education exceeds that of urban and more 

educated women. The differentials are more 

pronounced according to educational level. 

For example, the difference is more than 

four children between the lowest and highest 

levels of education in Guatemala. 

• Ages at initiation of sexual activity and 

childbearing have not changed substantially 

over time in each of the countries. For 

women age at first intercourse ranges from 

17.9 years to 18.4 years, age at first union 

ranges from 18.3 to 19.8 years, and age at 

first birth ranges from 19.6 years to 20.5 

years. In sum, family formation begins early 

in these countries.

• Short birth intervals are a critical health 

problem in all four countries. Excluding first 

births, slightly more than half of all births in 

Nicaragua and El Salvador, and two thirds of 

births in Guatemala and Honduras are within 

3 years of a previous birth.

• The data presented on the discrepancy 

between observed and wanted total fertility 

rates, and the planning status of births 

in the last 5 years, all suggest that many 

women are nowhere close to achieving 

their reproductive goals, and that there is 

still considerable unmet demand for family 

planning services. 
36 Fertility

Reproductive, Maternal, and Child Health in Central America
Family Planning 37

Trends and Challenges Facing Women and Childern

 CHAPTER

Family Planning

This chapter presents information 

on knowledge, use, and source of 

contraceptive methods in the four 

surveyed countries. Desire to use contraceptive 

methods among non-users and preferred method 

is also examined.

Knowledge of 

Contraceptives

According to the most recent survey, nearly all 

women surveyed in El Salvador, Honduras, and 

Nicaragua have heard of at least some method 

of contraception (Table 4.1). Knowledge of at 

least one method is lower among Guatemalan 

women in union (93.3 percent). A relatively high 

percentage of men in union aged 15–59 also 

have knowledge of at least one contraceptive 

method. Knowledge ranges from 95.3 percent in 

Guatemala to 99.9 percent in Honduras. Men’s 

knowledge of condoms was not investigated in 

El Salvador. No data are available for men in 

Nicaragua.

4
38 Family Planning

Reproductive, Maternal, and Child Health in Central America

In each country, condoms, oral contraceptives, 

injections, and female sterilization are the most 

widely recognized methods among both women 

and men (Table 4.1). With the exception of 

Guatemala and Honduras, knowledge of these 

methods is above 90 percent. Among women, 

knowledge of the IUD ranges from a low of 57.7 

percent in Guatemala to a high of 95.7 percent 

in Honduras. Knowledge of rhythm ranges from 

a low of 46.8 percent in Guatemala to a high 

of 58.5 percent in Honduras, while knowledge 

of withdrawal ranges from 26.7 percent in 

Guatemala to 53.9 percent in Nicaragua. 

Among men, knowledge of male sterilization or 

vasectomy ranges from a low of 57.0 percent 

in Honduras to a high of 85.1 percent in El 

Salvador. 

Current Use of 

Contraceptives

This section focuses on women in legal or 

consensual marriages, because they represent 

the majority of sexually active women, 

have greater frequency of intercourse, and 

have higher fertility and risk of unintended 

pregnancies. Data are not presented for married 

men since their use is very similar to that of 

married women.

According to the most recent survey, El 

Salvador, Honduras, and Nicaragua each exhibit 

a relatively high prevalence of contraceptive use 

(over 60 percent of currently married women), 

while use in Guatemala is relatively low (43.3 

percent) (Table 4.2). Contraceptive use is 

highest in Nicaragua (68.6 percent), followed 

closely by El Salvador (67.3 percent), while 

use in Honduras is 61.8 percent. As expected, 

urban women are more likely than their rural 

counterparts to be current users of contraceptives 

in all of the countries. The difference between 

urban and rural use is highest in Guatemala (22 

Table 4.1

Knowledge of Specific Contraceptive Methods: Married Women 

of Fertile Age and Married Men Aged 15–59 (Most Recent Survey)

Contraceptive

El Salvador 2002/03 Guatemala 2002 Honduras 2001 Nicaragua 2001

Women* Men Women† Men Women* Men Women† Men

At least one 98.9 99.3 93.3 95.3 99.9 99.9 99.2

Condoms 97.9 na 68.4 85.1 98.8 99.3 94.7 na

Orals 96.2 93.0 87.9 86.6 99.0 93.1 98.2 na

 Injection 97.4 92.4 86.9 83.2 98.3 87.3 96.9 na

Fem. Sterilization 94.6 96.7 82.9 83.8 98.5 94.2 90.5 na

IUD 78.7 58.9 57.7 47.9 95.7 79.1 89.7 na

Male Sterilization 58.1 85.1 62.7 73.9 58.8 57.0 64.7 na

Rhythm 56.8 63.0 46.8 55.2 58.5 59.5 55.4 na

Vaginals 41.0 51.2 37.8 39.9 45.7 43.3 38.1 na

Withdrawal 29.0 48.5 26.7 28.9 53.3 69.8 53.9 na

Norplant 21.7 13.6 16.8 11.7 5.7 6.0 7.5 na

MELA 18.6 11.6 31.5 29.5 na na 69.6 na

Billings 14.4 10.4 inc inc 17.9 10.2 inc na

EOC 11.8 22.7 na na 3.3 13.5 19.4 na

*

 Married women aged 15–44.

†

 Married women aged 15–49.

EOC: Emergency oral contraceptives.

na: Not available.

inc: Included with rhythm.
Family Planning 39

Trends and Challenges Facing Women and Childern

percentage points) and lowest in Nicaragua (11 

percentage points), indicating that rural women 

in Nicaragua may have greater access to family 

planning counseling and services than rural 

women living in Guatemala.

Use of contraceptive methods has been 

increasing steadily over the past decade in each 

of the countries (Graph 4.1 and Table 4.2). Since 

the early 1990s, use has increased by almost 20 

Table 4.2

Trends in Contraceptive Use, by Area of Residence: Married 

Women of Fertile Age (Most Recent Survey)

Country Year of Survey Total Urban Rural

El Salvador 1988* 47.1 59.9 34.2

El Salvador 1993* 53.3 61.3 45.6

El Salvador 1998* 59.7 67.8 51.2

El Salvador 2002/03* 67.3 73.4 60.1

Guatemala 1987† 23.2 43.0 13.8

Guatemala 1995† 31.4 48.9 19.8

Guatemala 1998/99† 38.2 52.3 27.7

Guatemala 2002† 43.3 56.7 34.7

Honduras 1987* 40.6 59.3 29.9

Honduras 1991/92* 46.7 60.7 36.1

Honduras 1996* 50.0 61.7 40.4

Honduras 2001* 61.8 70.4 54.6

Nicaragua 1992/93† 48.7 61.2 33.2

Nicaragua 1998† 60.3 66.3 51.4

Nicaragua 2001† 68.6 73.3 62.3

* Married women aged 15–44.

†

 Married women aged 15–49.

0

20

40

60

80

100

Nicaragua

Honduras

Guatemala

El Salvador

First Second Third Fourth

Survey

Percentag

e

Graph 4.1

Trends in the Use of Contraceptives, According to Last Four Surveys:

Married Women of Fertile age

(Four Most Recent Surveys)
40 Family Planning

Reproductive, Maternal, and Child Health in Central America

percentage points in Nicaragua, 15 percentage 

points in Honduras, 14 percentage points in El 

Salvador, and by almost 12 percentage points in 

Guatemala. In all of the countries, the increase 

in contraceptive use has been greater in the rural 

area, primarily because use back in the early 

1990s in the rural areas of each country was 

relatively low. Rural Nicaragua stands out in that 

use has increased by a spectacular 29 percentage 

points since 1992/93. In rural Honduras, use 

increased by almost 19 percentage points, 

while in rural El Salvador and rural Guatemala 

use increased by almost 15 percentage points. 

It should be pointed out that urban use in El 

Salvador, Honduras, and Nicaragua is over 70 

percent, according to the last survey conducted 

in these countries. Only 56.7 percent of urban 

women in Guatemala were using a contraceptive 

method at the time of the last survey. 

All of the countries profiled in this report exhibit 

a high reliance on contraceptive methods of high 

efficacy, such as female sterilization, injections, 

oral contraceptives, and the IUD (Table 4.3). 

In Nicaragua and El Salvador these methods 

account for 88.3 percent and 86.3 percent of total 

use, respectively. In Honduras and Guatemala 

these methods account for 77.0 percent and 

71.8 percent of total use, respectively, as use 

of rhythm/Billings and withdrawal is higher 

in these countries than in Nicaragua and El 

Salvador.

In all of the countries, female sterilization is 

the most used method of contraception, ranging 

from 16.8 percent in Guatemala to 32.7 percent 

in El Salvador. Since sterilization facilities 

are generally found in urban areas, use of this 

method is higher in urban areas than in rural 

areas (Table 4.4). In El Salvador and Guatemala, 

the injection is the second most used method, 

while in Honduras and Nicaragua it is the pill. It 

should be noted that in El Salvador, Honduras, 

and Nicaragua, the injection is used more in 

the rural area than in the urban area. With the 

exception of Honduras, the use of the IUD is 

relatively low, and in all of the countries, the 

use of the IUD is higher in urban areas than in 

Table 4.3

Trends in the Use of Contraceptive Methods, by Method and Type of Method:

Married Women of Fertile Age

Country

Year of 

Survey Total

Female 

Steril. Injection Orales IUD

CondomsRhythm/

Billings

Withdrawal Other

Type of Method

Modern‡ Traditional§

El 

Salvador*

1993 53.3 31.5 3.6 8.7 2.1 2.1 3.0 2.0 0.4 48.0 5.4

1998 59.7 32.4 8.9 8.1 1.5 2.5 3.1 2.6 0.7 53.4 6.4

2002/03 67.3 32.7 18.3 5.8 1.3 2.9 2.9 2.6 0.9 61.0 6.4

Guatemala† 1995 31.4 14.3 2.5 3.8 2.6 2.2 3.6 0.9 1.5 26.9 4.5

1998/99 38.2 16.7 3.9 5.0 2.2 2.3 5.7 1.5 0.8 30.9 7.3

2002 43.3 16.8 9.0 3.4 1.9 2.3 6.3 2.3 1.4 34.6 8.7

Honduras* 1991/92 46.7 15.6 0.5 10.1 5.1 2.9 6.7 5.0 0.3 34.7 12.0

1996 50.0 18.1 1.1 9.9 8.5 3.2 3.7 5.3 1.3 40.8 10.3

2001 61.8 18.0 9.6 10.4 9.6 3.2 4.4 6.4 0.2 51.0 10.8

Nicaragua† 1992/93 48.7 18.5 1.2 12.9 9.3 2.6 2.6 1.1 0.4 44.9 3.8

1998 60.3 26.1 5.2 13.9 9.1 2.6 1.6 1.0 0.5 57.4 2.9

2001 68.6 25.3 14.3 14.6 6.4 3.3 1.5 1.0 2.3 64.4 4.2

* Married women aged 15–44.

†

 Married women aged 15–49.

‡

 Includes female sterilization, vasectomy, injectables, orals, IUDs, condoms, vaginal methods, and Norplant.

§

 Includes rhythm, Billings, withdrawal, MELA, and folkloric methods.
Family Planning 41

Trends and Challenges Facing Women and Childern

rural areas. As the table shows, use of condoms 

as a family planning method is relatively low in 

each of the countries.

As mentioned earlier, the use of contraceptive 

methods has been increasing steadily over 

the past decade in each of the countries. The 

increase in use is principally due to an increase 

in the use of temporary methods, notably the 

injection (see Graph 4.2 and Table 4.3). Since 

the early 1990s, the use of female sterilization 

has not changed substantially in any of the 

countries. 

Contraceptive Method

Percentage Point Change

-5

0

5

10

15

Nicaragua

Honduras

Guatemala

El Salvador

Female Injection Orals IUD Condoms Traditional

Steril.

Graph 4.2

Change Between Early 1990s and Early 2000s in Percent Using 

Contraception, by Method: Married Women of Fertile Age

(Third From Last and Last Surveys)

Table 4.4

Current Use of Contraceptive Methods, According to Area of Residence:

Married Women of Fertile Age (Most Recent Survey)

Country/

Area

Year of

Survey Total Orals IUD Condoms Injection

Female

Steril.

Rhythm/

Billings

Withdrawal Other

El Salvador 2002/03*

 Total 67.3 5.8 1.3 2.9 18.3 32.7 2.9 2.6 0.9

 Urban 73.4 5.3 2.0 3.5 17.2 37.5 3.1 3.4 1.4

 Rural 60.1 6.2 0.5 2.3 19.5 27.1 2.6 1.5 0.4

Guatemala 2002†

 Total 43.3 3.4 1.9 2.3 9.0 16.8 6.3 2.3 1.3

 Urban 56.7 4.3 3.4 3.6 10.7 23.1 6.6 2.6 2.4

 Rural 34.7 2.8 0.9 1.5 7.9 12.8 6.2 2.1 0.4

Honduras 2001*

 Total 61.8 10.4 9.6 3.2 9.6 18.0 4.4 6.4 0.2

 Urban 70.4 11.5 14.7 4.1 8.8 20.3 5.3 5.6 0.1

 Rural 54.6 9.4 5.3 2.5 10.3 16.0 3.7 7.1 0.2

Nicaragua 2001†

 Total 68.6 14.6 6.4 3.3 14.3 25.3 1.5 1.0 2.3

 Urban 73.3 15.6 8.8 4.3 11.4 28.7 1.5 1.1 1.9

 Rural 62.3 13.3 3.1 2.0 18.1 20.7 1.4 0.8 2.7

* Married women aged 15–44.

†

 Married women aged 15–49.
42 Family Planning

Reproductive, Maternal, and Child Health in Central America

Table 4.5 and Graph 4.3 show contraceptive 

use by age of the woman, illustrating that in all 

four countries use rises steadily with age until 

the late 30’s or early 40’s at which age it levels 

off. Graph 4.4 shows the increase in use by age 

between the early 1990’s and the early 2000’s. 

El Salvador exhibits a distinctive pattern with 

the increase in use being especially pronounced 

for married women ages 15–24 and 40–44. In 

Nicaragua, the increase in use was high among 

married women aged 15–24, moderately high 

among married women aged 25–44, and uniform, 

at a moderate level, for remaining age groups. 

In both Honduras and Guatemala the increase 

in use was fairly uniform across all age groups, 

but in Honduras it hovers around a 20 to 25 

percentage point increase, while in Guatemala 

it is in the range of 10 to 15 percentage points. 

The information on use by age is encouraging 

in that it demonstrates that women are initiating 

the use of contraception at younger ages, rather 

than waiting until they have reached or exceeded 

their desired family in their mid- to late-20s.

Table 4.5

Trends in the Use of Contraceptive Methods, by Age:

Married Women of Fertile Age 

Country 

Year of 

Survey 15–19 20–24 25–29 30–34 35–39 40–44 45–49

El Salvador* 1993 22.5 40.0 57.8 66.4 66.6 55.5 na

1998 33.4 48.4 58.7 68.5 70.5 69.6 na

2002/03 48.0 62.6 64.9 71.5 75.3 72.6 na

Guatemala† 1995 12.1 22.6 30.9 38.8 41.0 37.7 25.8

1998/99 14.6 25.7 39.2 50.5 51.0 44.1 31.2

2002 22.5 34.9 41.8 50.6 53.2 49.7 40.0

Honduras* 1987 20.2 34.6 42.8 45.9 47.7 43.4 na

1996 27.6 39.4 54.2 57.8 58.0 55.5 na

2001 41.1 57.6 62.5 68.2 68.2 67.8 na

Nicaragua† 1992/93 23.2 41.6 53.2 58.2 60.5 55.5 38.9

1998 39.8 53.8 64.6 69.4 70.0 63.7 48.1

2001 55.2 66.3 69.8 75.3 75.2 70.5 58.6

* Married women aged 15–44.

†

 Married women aged 15–49.

na: Not available.
Family Planning 43

Trends and Challenges Facing Women and Childern

Age

Percentag

e

0

20

40

60

80

100

Nicaragua

Honduras

Guatemala

El Salvador

15-19 20-24 25-29 30-34 35-39 40-44

Graph 4.3

Use of Contraceptive Methods, by Age:

Married Women of Fertile Age

(Most Recent Survey)

Age

Percentage Point Change

0

10

20

30

40

Nicaragua

Honduras

Guatemala

El Salvador

15-19 20-24 25-29 30-34 35-39 40-44

Graph 4.4

Change Between Early 1990s and Early 2000s in Percent Using

Contraception, by Age: Married Women of Fertile Age

(Third From Last and Last Surveys) 
44 Family Planning

Reproductive, Maternal, and Child Health in Central America

Maps 4.1 and 4.2 show contraceptive prevalence 

for subnational regions according to the next to 

last and last surveys in each of the four countries. 

As expected from information on fertility 

levels, the areas of lowest contraceptive use 

are in Guatemala and Honduras. The increase 

in prevalence between the two surveys is very 

widespread for both El Salvador and Nicaragua. 

All but three departments in El Salvador and 

two departments in Nicaragua had sixty percent 

or more of women in union using a method at 

the time of the most recent survey. Only one 

region in Guatemala and three in Honduras had 

prevalence above 60 percent at the last survey.

Map 4.1

Current Contraceptive Use Among Married Women 

of Fertile Age by Region / Department

(Next-to-Last Survey)

<40

40-49

50-59

60-69

70+

%Contraceptive Use
Family Planning 45

Trends and Challenges Facing Women and Childern

Map 4.2

Current Contraceptive Use Among Married Women 

of Fertile Age by Region / Department

(Last Survey)

<40

40-49

50-59

60-69

70+

%Contraceptive Use
46 Family Planning

Reproductive, Maternal, and Child Health in Central America

Source of Contraceptives

Table 4.6 and Graph 4.5 present the percentage of 

currently married users of modern contraception 

who obtained their method from each type of 

source shown in the table (data for El Salvador 

include source of modern as well as traditional 

methods). Focusing on the last survey conducted 

in each country, source of contraceptives 

varies from one country to another. However, 

all countries have one thing in common: the 

Ministry of Health is the principal source of 

contraceptive methods in each country, ranging 

from 32.2 percent in Guatemala to 63.6 percent 

in Nicaragua. As shown in the table, the relative 

participation of the Ministry of Health has 

been increasing in each country over the past 

decade.

Table 4.6

Trends in the Source of Modern Contraceptive Methods:

Married Women of Fertile Age 

Country 

Year of 

Survey

Ministry of 

Health

Social 

Security FPA‡ Pharmacy

Private 

Clinic Other

El Salvador* 1993 48.9 14.5 15.3 9.3 4.2 7.5

1998 47.1 18.2 15.6 5.8 4.4 8.5

2002/03 55.9 19.3 10.1 4.3 2.3 7.2

Guatemala† 1995 18.9 8.2 41.5 11.6 17.0 2.1

1998/99 20.6 4.6 37.5 11.8 14.8 9.4

2002 32.2 11.9 29.4 11.5 13.6 1.2

Honduras* 1991/92 30.8 7.9 24.2 14.2 20.7 2.2

1996 27.0 7.8 37.0 13.0 11.8 2.6

2001 41.0 4.5 29.2 11.5 11.3 2.3

Nicaragua† 1992/93 58.6 na 6.0 18.0 11.8 3.6

1998 62.0 na 11.9 11.4 11.2 2.1

2001 63.6 na 9.8 12.1 10.9 0.7

* Married women aged 15–44. For El Salvador, modern as well as traditional methods are included.

†

 Married women aged 15–49.

‡

 Family planning association.

NA: Not available.
Family Planning 47

Trends and Challenges Facing Women and Childern

The second most important source of 

contraception in El Salvador is the Social 

Security Institute, while the private family 

planning association is the second most 

important source in Guatemala and Honduras. 

In Nicaragua, pharmacies are in second place.

While the family planning association is the 

third most important source of contraception in 

El Salvador, it is private clinics or physicians in 

Guatemala, and private pharmacies in Honduras 

and Nicaragua.

In general, the relative participation of the 

family planning association and private clinics 

in each country has been declining over the past 

decade. This is probably due to the fact that users 

of family planning services can obtain services 

and supplies at a lower price (or at no cost) 

from the public sector than they can from the 

private sector. Cost is particularly important for 

women who have traditionally been non-users 

of contraception, such as the rural, poor, and 

less educated women. However, the question is 

how much longer can the public sector afford 

to provide highly subsidized family planning 

services?

Country

Percentag

e

0

20

40

60

80

100 Other

Private Clinic

Pharmacy

FPA

Social Security

Ministry of Health

El Salvador Guatemala Honduras Nicaragua

Graph 4.5

Source of Modern Methods of Contraception:

Users of Modern Methods

(Most Recent Survey)
48 Family Planning

Reproductive, Maternal, and Child Health in Central America

Intention to Use 

Contraception Among 

Non-Users

Married, fecund women who were not using 

any contraceptive method at the time of the 

last survey conducted in each country were 

asked if they planned to use any method now 

or in the future. Intention to use in the future 

among non-users has to be taken into account 

when forecasting contraceptive needs of the 

family planning providers. Overall, between 

43.0 percent (Guatemala) and 72.5 percent 

(Honduras) intended to use a contraceptive 

method now or in the future (Table 4.7). It 

should be noted that the percentage of women 

who desire to use a contraceptive method does 

not vary substantially according to area of 

residence. 

Of the married women who desire to use a 

method now or in the future, the most preferred 

method in all of the countries is the injection, 

ranging from 31.9 percent in Honduras to 

43.4 percent in El Salvador (Table 4.8 and 

Graph 4.6). In El Salvador, Guatemala, and 

Honduras the second most preferred method 

is female sterilization, while it is the pill in 

Nicaragua. Oral contraceptives are in third 

place in El Salvador, Guatemala, and Honduras, 

while female sterilization is in third place in 

Nicaragua. The percentage of women who 

desire to use rhythm/Billings or withdrawal 

is relatively small in each country. These 

preferences contrast with actual current use 

in which female sterilization is most common 

in all four countries and oral contraceptives is 

second in Honduras and Nicaragua. It should be 

noted that a significant percentage of non-users 

in El Salvador, Guatemala, and Honduras are 

undecided about the method they would prefer 

to use.

Table 4.7

Desire to Use Contraceptive Methods Now or 

in the Future, by Area of Residence: Married Women of

Fertile Age, Non-Users of Contraception

(Most Recent Survey)

Country Year of Survey Total Urban Rural

El Salvador 2002/03* 52.1 55.5 49.4

Guatemala 2002† 43.0 46.1 40.9

Honduras 2001* 72.5 75.3 71.0

Nicaragua 2001† 61.7 62.7 60.8

* Married women aged 15–44.

†

 Married women aged 15–49.
Family Planning 49

Trends and Challenges Facing Women and Childern

Table 4.8

Preferred Contraceptive Method Among Married Women of 

Fertile Age, Non-Users of Contraception, Who Desire to Use 

Contraceptives Now or in the Future (Most Recent Survey)

Contraceptive 

Method

El Salvador 

2002/03*

Guatemala 

2002†

Honduras 

2001*

Nicaragua 

2001†

Injection 43.4 40.9 31.9 38.5

Fem. Sterilization 23.5 15.3 20.4 20.0

Orals 11.2 15.2 17.6 23.9

IUD 1.6 2.6 10.3 8.0

Condom 1.7 2.4 1.3 2.6

Rhythm/Billings 2.9 6.6 4.8 0.9

Withdrawal 0.3 0.9 2.0 0.6

Other 2.7 0.6 0.1 1.0

Don’t Know 12.6 15.0 11.7 4.5

* Married women aged 15–44.

†

 Married women aged 15–49.

Country

Percentag

e

0

10

20

30

40

50

Nicaragua

Honduras

Guatelmala

El Salvador

Don't

Know

Fem. Orals Injection IUD Condoms Natural

Steril.

Graph 4.6

Preferred Contraceptive Method:

Married, Non-Users of Contraception

(Most Recent Survey)
50 Family Planning

Reproductive, Maternal, and Child Health in Central America

Summary of Findings

• Awareness of contraceptive methods is 

high; at least 91 percent of women and 95 

percent of men of reproductive age in each 

country indicated that they have heard of 

at least one method. The four most known 

methods among women in each country 

include condoms, oral contraceptives, the 

injection, and female sterilization.

• Current use of contraceptives is also 

relatively high in El Salvador, Honduras, 

and Nicaragua as more than 61 percent of 

married women of reproductive age were 

using a method at the time that the last 

survey was conducted in each country. Only 

43 percent of married women were found 

to be using contraceptives in Guatemala. 

Important differentials in the use of 

contraceptives exist according to area of 

residence and education, with higher use 

found among urban and more educated 

women. In all of the countries there is a 

high reliance on contraceptive methods of 

high efficacy, such as female sterilization, 

injections, oral contraceptives, and the 

IUD. 

• Use of contraceptive methods has been 

increasing steadily over the past decade in 

each of the countries. In all of the countries, 

the increase in contraceptive use has been 

greater in the rural area than in the urban 

area. The increase in use is principally 

due to an increase in the use of temporary 

methods, notably the injection. 

• In all of the countries, the principal source 

of contraception is the Ministry of Health, 

whose relative participation has been 

increasing over the past decade. The role of 

the private family planning associations as a 

source of contraception has been declining 

since the early 1990s. Pharmacies and other 

private sources are important suppliers in 

Guatemala, Honduras, and Nicaragua.

• A substantial proportion (43 to 72 percent) 

of fecund, married women not currently 

using a contraceptive method want to use 

contraceptives sometime in the future. 

The three methods most preferred by 

these women are the injection, female 

sterilization, and the pill.
Sexual and Contraceptive Behavior of Young Adults 51

Trends and Challenges Facing Women and Childern

CHAPTER

Sexual and 

Contraceptive 

Behavior of Young 

Adults

The reproductive health knowledge 

of young adults and their sexual and 

contraceptive behavior have important 

implications for the future of a population’s 

health and well being. Worldwide, it has been 

estimated that almost half of new HIV infections 

and one-third of all new sexually transmitted 

infections occur to people younger than 25 years 

of age. In addition, an unintended pregnancy 

can disrupt a young girl’s life by interrupting 

further schooling and training. Parents, 

teachers, and health professionals are often 

unable to communicate effectively with young 

adults about their sexual and reproductive lives. 

In many countries, young people are seldom 

prepared with the information, skills, and 

resources needed to make a healthy transition 

to adulthood. Inadequate programs and lack of 

sex education can leave youth at the mercy of 

mass media and misinformation from peers.

A young adult module for women and men aged 

15–24 was included in the last survey conducted 

in El Salvador, Guatemala, and Honduras. The 

young adult modules included questions related 

to first sexual experience and current sexual 

behavior, including contraceptive use. The 

female questionnaires also included questions 

on the educational status of women at the 

time of their first pregnancy, and whether their 

pregnancy disrupted their studies.

In each of the surveys, first sexual experience 

is classified as premarital or marital. If the 

respondent’s first sexual partner was their 

husband, the first sexual experience was 

classified as marital. Sexual experience was 

5
52 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

classified as premarital if the first sexual 

experience occurred with someone other than 

their husband or if it occurred at least one month 

prior to the date of marriage.

First Sexual Experience

The reported sexual experience of young adult 

women and men is shown in Table 5.1. Focusing 

first on the women, at least half of the women 

aged 15–24 in El Salvador and Honduras 

reported sexual experience, compared to 43.0 

percent in Guatemala. Of those with sexual 

experience in Guatemala and Honduras, 27.2 

and 28.6 percent reported marital experience, 

respectively, while 15.8 and 27.2 percent 

reported premarital experience. The situation in 

El Salvador is different in that the majority of 

the women reported premarital experience (39.3 

percent premarital vs. 12.4 percent marital). As 

may be expected, sexual experience increases as 

age increases, with marked differences between 

adolescents (15–19 years) and 20–24-year-olds 

(Graph 5.1). 

Among the men, from 58.0 percent (Guatemala) 

to 66.4 percent (El Salvador) reported sexual 

experience. In all three of the countries, almost 

all of the men who reported sexual experience 

have had premarital sex. Like the women, sexual 

experience increases as age increases, with 

marked differences between adolescents (15–19 

years) and 20–24-year-olds (Graph 5.1). 

In Guatemala and Honduras, rural women were 

more likely to be sexually experienced than 

their urban counterparts, while the opposite 

was the case in El Salvador, although the 

urban/rural differential is small (Table 5.2). 

Also, in Guatemala and Honduras, rural women 

were more likely to be married at first sexual 

experience, while in El Salvador they were 

more likely to be single. In El Salvador and 

Honduras, urban women tended to report that 

their first sexual experience was premarital, 

while in Guatemala near equal percentages of 

urban women reported marital and premarital 

experiences (circa 19 percent).

With respect to the men, in all three countries 

urban men were more likely to be sexually 

experienced than men living in the rural area. 

Regardless of area of residence, the vast majority 

of the men with sexual experience reported that 

their first sexual experience was premarital.

Table 5.1

Reported Sexual Experience, by Marital Status at Time of First Sexual 

Experience, According to Current Age: Women and Men Aged 15–24 

(Most Recent Survey)

Country/

Age

Year of 

Survey

Females Males

No Sexual

Experience Marital Premarital Total

No Sexual

Experience Marital Premarital Total

El 

Salvador 

2002/03

Total 48.3 12.4 39.3 100.0 33.6 1.4 65.0 100.0

15–19 67.5 7.5 25.1 100.0 49.7 0.0 50.3 100.0

20–24 25.6 18.2 56.2 100.0 13.5 3.2 83.3 100.0

Guatemala 2002

Total 57.0 27.2 15.8 100.0 42.0 5.4 52.6 100.0

15–19 77.0 14.2 8.8 100.0 59.8 2.4 37.8 100.0

20–24 32.6 43.1 24.4 100.0 11.3 10.6 78.2 100.0

Honduras 2001

Total 44.2 28.6 27.2 100.0 35.3 2.2 62.5 100.0

15–19 61.9 19.9 18.2 100.0 51.3 0.6 48.1 100.0

20–24 22.9 39.0 38.1 100.0 15.6 4.1 80.3 100.0
Sexual and Contraceptive Behavior of Young Adults 53

Trends and Challenges Facing Women and Childern

Country / Sex

Percentag

e

Graph 5.1

Percentage of Persons With Sexual Experience, by Age and Sex:

Men and Women Aged 15–24

(Most Recent Survey)

0

20

40

60

80

100

20-24

Total

15-19

El Salvador Guatemala Honduras El Salvador Guatemala Honduras

Women Men

Table 5.2

Reported Sexual Experience, by Marital Status at Time of First Sexual 

Experience, According to Area of Residence: Women and Men Aged 15–24 

(Most Recent Survey)

Country/

Area

Year of 

Survey

Females Males

No Sexual 

Experience Marital Premarital Total

No Sexual 

Experience Marital Premarital Total

El 

Salvador 

2002/03

Total 48.3 12.4 39.3 100.0 33.5 1.1 65.4 100.0

Urban 47.8 8.3 43.9 100.0 24.9 0.7 74.4 100.0

Rural 49.0 17.6 33.4 100.0 43.1 1.5 55.4 100.0

Guatemala 2002

Total 57.0 27.2 15.8 100.0 42.0 5.4 52.6 100.0

Urban 61.9 19.2 18.9 100.0 39.2 3.8 56.9 100.0

Rural 53.6 32.7 13.7 100.0 43.9 6.5 49.6 100.0

Honduras 2001

Total 44.2 28.6 27.2 100.0 35.3 2.2 62.5 100.0

Urban 49.0 19.6 31.5 100.0 29.5 1.3 69.2 100.0

Rural 39.3 37.9 22.9 100.0 40.3 3.0 56.7 100.0
54 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

Age at First Sexual 

Relation

In Tables 5.3 and 5.4, age at first sexual experience 

is shown for women and men, respectively. In 

the last column of each table average age at first 

sexual relation is also shown.

As shown in Table 5.3 and Graph 5.2, the modal 

age at first sexual experience for women is 15–16 

years, as approximately a third of the women have 

their first relation in this age interval. However, 

it should be noted that 22 to 24 percent of the 

women are sexually experienced before their 

fifteenth birthday. Thus, by age 16, 54.6 percent 

(El Salvador) to 58.4 percent (Honduras) of the 

women have had their first sexual experience. 

Age at first sexual experience varies according 

to area of residence. For example, in Honduras, 

three-fourths of rural women are sexually 

experienced before their eighteenth birthday 

compared to 68.0 percent of urban women. The 

differential is even greater in Guatemala—73.6 

percent vs. 63.9 percent. In sum, in all of the 

countries, rural women initiate sex earlier than 

urban women, as indicated by average age at 

first sexual relation.

Table 5.3

Age at First Sexual Experience, According

to Area of Residence: Women Aged 15–24 

(Most Recent Survey)

Country/

Area

Year of 

Survey

Age Doesn’t

Remember

Average

<13 13 14 15 16 17 18 19 20–24 Age

El Salvador 2002/03

Total 4.0 5.6 12.2 18.3 14.5 12.3 12.5 7.8 12.0 0.8 16.4

Urban 2.8 4.7 10.6 18.6 13.6 12.9 13.8 8.7 13.8 0.5 16.7

Rural 5.5 6.7 14.2 18.0 15.7 11.6 10.7 6.7 9.8 1.3 16.1

Guatemala 2002

Total 3.0 6.0 13.2 16.6 16.2 15.1 11.5 7.7 10.2 0.5 16.4

Urban 2.3 6.6 11.5 16.0 13.8 13.8 13.0 9.2 13.7 0.2 16.6

Rural 3.4 5.6 14.1 17.0 17.5 15.9 10.7 6.9 8.2 0.6 16.2

Honduras 2001

Total 3.9 6.0 14.2 17.1 17.2 13.7 12.3 7.0 8.4 0.3 16.2

Urban 3.4 5.9 13.2 14.5 17.8 13.2 13.1 7.7 10.7 0.6 16.4

Rural 4.3 6.0 15.1 19.4 16.6 14.1 11.5 6.4 6.4 0.1 16.0
Sexual and Contraceptive Behavior of Young Adults 55

Trends and Challenges Facing Women and Childern

Table 5.4

Age at First Sexual Experience, According 

to Area of Residence: Men Aged 15–24 

(Most Recent Survey)

Country/

Area

Year of 

Survey

Age Doesn’t

Remember

Average

<13 13 14 15 16 17 18 19 20–24 Age

El Salvador 2002/03

Total 13.0 9.4 17.7 19.6 15.5 10.8 6.4 2.7 3.8 1.0 15.0

Urban 14.4 8.9 21.7 16.5 16.5 8.9 7.4 2.9 2.4 0.4 14.8

Rural 11.0 10.2 12.0 24.2 14.0 13.6 5.0 2.3 6.0 1.7 15.2

Guatemala 2002

Total 7.5 10.3 16.1 22.0 14.8 10.2 9.0 6.1 3.8 0.2 15.5

Urban 6.3 8.9 20.2 22.8 10.8 11.7 11.5 6.4 1.5 0.0 15.4

Rural 8.4 11.3 13.0 21.4 17.8 9.1 7.2 5.8 5.6 0.3 15.5

Honduras 2001

Total 9.4 8.9 16.5 20.5 18.2 13.1 6.2 3.6 2.2 1.4 15.1

Urban 11.3 10.5 15.8 19.9 18.2 12.8 6.5 2.2 1.2 1.5 15.0

Rural 7.5 7.2 17.2 21.1 18.2 13.4 5.8 5.0 3.2 1.3 15.3

Age

Percentag

e

0

4

8

12

16

20

Honduras

Guatemala

El Salvador

<13 13 14 15 16 17 18 19 20-24

Graph 5.2

Age at First Sexual Experience: Women Aged 15–24
56 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

The modal age at first sexual experience among 

men is 15 (Table 5.4 and Graph 5.3), but 

when disaggregated by area of residence some 

interesting variations emerge. In El Salvador the 

modal age in urban areas is 14, and initial age 

at first sex is highly concentrated at ages 14–15 

in urban areas of Guatemala. While 21.8 to 24.0 

percent of the women are sexually experienced 

before their fifteenth birthday, approximately a 

third of the men are. Of sexually experienced 

young men, three-quarters in El Salvador, 

73.5 percent in Honduras, and 70.7 percent 

in Guatemala have had intercourse by age 16. 

Average age at first sexual experience does not 

vary substantially according to area of residence. 

In all of the countries, first sexual intercourse 

occurs soon after the fifteenth birthday, one year 

less than among the women.

It is worthwhile mentioning, although the 

supporting data are not shown in this report, 

that the age of the first sexual partner of both 

adolescent women and men is considerably 

higher than their own age at first sexual 

experience. For example, among Honduran 

women who were less than 15 years of age at 

first intercourse, 47.3 percent of their first male 

partners men were 20 or more years old. The 

corresponding percentages for El Salvador 

and Guatemala are 34.6 and 38.8 percent 

respectively. And, among Honduran men who 

were 13–14 years of age at first intercourse, 23.0 

percent of their first female partners were 18 or 

more years old. These age differences suggest 

that the reproductive health of some women 

and men may have been in danger at their first 

sexual encounter, and that they may have had 

little to say on whether or not sexual activity 

should be initiated. In addition, it is reasonable 

to assume that their first sexual partners were 

sexually experienced.

Age

Percentag

e

0

4

8

12

16

20

24

Honduras

Guatemala

El Salvador

<13 13 14 15 16 17 18 19 20–24

Graph 5.3

Age at First Sexual Experience: Men Aged 15–24
Sexual and Contraceptive Behavior of Young Adults 57

Trends and Challenges Facing Women and Childern

Use of Contraceptives at 

First Sexual Intercourse

Sexually experienced respondents were asked 

if they or their partner used any contraceptive 

method during their first sexual encounter. Table 

5.5 shows that the highest rate of contraceptive 

use at the time of first intercourse among 

women was in El Salvador (17.8 percent). 

Lower rates were found in Honduras (8.8 

percent) and Guatemala (7.3 percent). In all 

three countries, a higher proportion of women 

reporting premarital sex used a contraceptive 

method than women reporting marital sex, 

ranging from 10.4 percent in Honduras to 19.6 

percent in El Salvador. The probability of using 

a contraceptive method at the time of first 

intercourse is much higher in urban areas than 

in rural areas in all of the countries, regardless 

of marital status at first sexual encounter. As 

noted in the table, contraceptive use is very 

low in the rural area, particularly in Guatemala 

and Honduras (see Graph 5.4). In El Salvador 

and Guatemala the most used method at first 

intercourse was the condom, while in Honduras 

it was withdrawal (data not shown).

Since the vast majority of men reported that their 

first sexual encounter was premarital, only total 

contraceptive use is shown in Table 5.5. Use 

at first intercourse varied from a high of 42.7 

percent in El Salvador to a low of 24.3 percent 

in Honduras. In Guatemala and Honduras, use 

at first intercourse is substantially higher among 

men living in the urban area than among men 

living in the rural area, especially in Guatemala. 

Use in El Salvador does not vary significantly 

according to area of residence (see Graph 5.4). 

As expected, the method of contraception most 

widely used by the men at first intercourse was 

the condom (data not shown).

Table 5.5

Use of Contraceptives in First Sexual Relation, by

Marital Status at Time of First Sexual Experience, According to 

Area of Residence: Women and Men Aged 15–24

(Most Recent Survey)

Country/Area

Year of 

Survey

Women

Total Marital Premarital

Men

Total

El Salvador 2002/03

Total 17.8 12.1 19.6 42.7

Urban 23.4 15.1 25.0 43.4

Rural 10.3 10.3 10.3 41.7

Guatemala 2002

Total 7.3 3.8 13.2 34.8

Urban 15.0 7.8 22.2 44.1

Rural 2.9 2.2 4.6 27.7

Honduras 2001

Total 8.8 7.4 10.4 24.3

Urban 12.4 12.2 12.6 28.7

Rural 5.7 4.8 7.2 19.8
58 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

Reasons for not Using 

Contraception at 

First Intercourse

Table 5.6 shows the primary reasons for not 

using contraception among sexually experienced 

respondents who did not use contraception at 

first sexual intercourse.

A large share of married, female respondents 

did not use contraception because they “wanted 

to become pregnant.” This response ranked 

highest in Guatemala (with 41.5 percent of 

respondents) and in El Salvador (with 37.7 

percent), and in second place in Honduras (22.3 

percent). In Honduras, the principal reason was 

they “didn’t know any contraceptive method” 

at the time of first intercourse (27.5 percent), 

and was the second ranked reason in Guatemala 

(with 35.9 percent) and El Salvador (20.0 

percent).

Common reasons unmarried women gave for not 

using contraception at first sexual intercourse 

was that they “did not expect to have sexual 

relations at that moment” and “they didn’t 

know any contraceptive method.” The former 

was the principal reason given in El Salvador 

and Honduras with 45.5 and 31.4 percent of the 

respondents giving this reason respectively, and 

ranked second in Guatemala with 22.7 percent. 

“Not knowing any contraceptive methods” 

was the principal reason given in Guatemala 

among a third of respondents and ranked 

second in Honduras and El Salvador. It should 

be noted that 15.8 percent of unmarried women 

in Guatemala responded that they “wanted to 

become pregnant” as the reason for not using 

a contraceptive method. This reason was also 

cited by 7.2 and 6.6 percent of the women living 

in Honduras and El Salvador, respectively.

Among El Salvadoran and Honduran men whose 

first sexual relation was premarital, the most 

common reason for not using contraception was 

“they did not expect to have sexual relations at 

that moment.” This reason ranked second in 

Guatemala. Like young unmarried women the 

most common reason given by Guatemalan 

men was they “didn’t know any contraceptive 

method.” (46.9 percent). This reason ranked 

second in El Salvador and third in Honduras (29.8 

and 25.6 percent respectively). In Honduras, the 

second most mentioned reason was that it “was 

the first time had sexual relations,” implying 

that the respondent and/or his partner believed 

that it is not possible for a woman to become 

pregnant the first time she has sex.

Country / Sex

Percentag

e

Graph 5.4

Use of Contraceptives at First Sexual Relation, by Area of Residence:

Sexually Experienced Men and Women Aged 15–24

(Most Recent Survey)

0

5

10

15

20

25

30

35

40

45

Urban

Total

Rural

El Salvador Guatemala Honduras El Salvador Guatemala Honduras

Women Men
Sexual and Contraceptive Behavior of Young Adults 59

Trends and Challenges Facing Women and Childern

Table 5.6

Primary Reasons For Not Using Contraceptives During First Sexual 

Experience: Women and Men Aged 15–24 Whose First Sexual Relation 

Was Marital Or Premarital (Most Recent Survey)

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Women

Reason—Marital

Wanted to become pregnant 37.7 41.5 22.3

Didn’t know any contraceptive method 20.0 35.9 27.5

Partner opposed the use of contraceptives 10.3 4.2 6.1

Did not like to use contraceptives 6.0 7.4 11.9

Contraceptives are dangerous to your health 5.8 0.6 na

Didn’t expect to have sexual relations at that moment 5.3 0.3 4.1

Was the first time had sexual relations na na 11.1

Reason—Premarital

Didn’t expect to have sexual relations at that moment 45.5 22.7 31.4

Didn’t know any contraceptive method 18.7 33.7 23.5

Wanted to become pregnant 6.6 15.8 7.2

Partner opposed the use of contraceptives 6.3 2.7 4.5

Did not like to use contraceptives 2.9 7.7 8.7

Was the first time had sexual relations na na 8.0

Men

Reason—Premarital

Didn’t expect to have sexual relations in that moment 37.7 23.1 32.4

Didn’t know any contraceptive method 29.8 46.9 25.6

Had confidence in my partner 5.3 na 1.1

Didn’t have contraceptives in that moment 4.8 3.9 na

Did not like to use contraceptives 4.0 10.3 na

Was the first time had sexual relations na 7.1 27.1

na: Not available.
60 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

Recent Sexual Activity

Tables 5.7 and 5.8 show the percentage of 

sexually experienced respondents aged 15–24 

who had sexual relations during the 30 days 

prior to interview, and the percentage that used 

a contraceptive method. Focusing first on the 

women, from 61.6 percent (El Salvador) to 69.0 

percent (Guatemala) had sexual intercourse 

during the 30 days prior to interview (Table 5.7). 

As expected, the majority of married women 

in each country reported sexual activity (over 

80 percent). Of the previously married women 

(separated, divorced or widowed women), 

from 12.2 percent (Guatemala) to 20.2 percent 

(Honduras) reported current sexual activity. Of 

those single women with sexual experience, 

from 20.1 percent (Guatemala) to 27.8 percent 

(El Salvador) reported having sex at least once 

in the 30 days prior to interview. 

Use of contraceptives among women with 

sexual relations in the past month varied from 

country to country, ranging from a low of 36.0 

percent in Guatemala to a high of 60.8 percent 

in El Salvador. Honduras was not far behind 

Table 5.7

Sexual Activity and Use of Contraceptives During the 30 

Days Prior to Interview, According to Current Marital Status: 

Women Aged 15–24 With Sexual Experience 

(Most Recent Survey)

Country/Marital Status Year of Survey

Had

Relations

Used

Contraceptives

El Salvador 2002/03

Total 61.6 60.8

Married 80.9 63.9

Previously Married 16.7 47.3

Single 27.8 50.4

Guatemala 2002

Total 69.0 36.0

Married 80.2 35.4

Previously Married 12.2 *

Single 20.1 *

Honduras 2001

Total 66.5 58.4

Married 83.4 58.4

Previously Married 20.2 62.4

Single 24.6 53.7

na: Not available.

* Less than 25 cases.
Sexual and Contraceptive Behavior of Young Adults 61

Trends and Challenges Facing Women and Childern

El Salvador with 58.4 percent of the women 

reporting contraceptive use. It should be noted 

that at least 50 percent of single women living in 

El Salvador and Honduras used a contraceptive 

method, while about 50 percent in each country 

did not. Comparing Table 5.7 with Table 5.5 

it is obvious that a much higher percentage 

of sexually active young adult women were 

currently using a contraceptive method than at 

time of their first sexual experience.

Among the men, from 42.3 percent (Honduras) 

to 54.8 percent (Guatemala) reported sexual 

activity during the 30 days prior to interview 

(Table 5.8). In all three populations, there was 

greater reported sexual activity among evermarried men compared to single men, which 

ranged from 25.3 percent in Honduras to 

36.0 percent in Guatemala. Almost an equal 

percentage of men (62 percent) living in El 

Salvador and Honduras used a contraceptive 

method during the 30 days prior to interview, 

while only 42.7 percent of Guatemalan men 

reported use. Among single men, contraceptive 

use ranged from 53.5 percent in Guatemala to 

72.1 percent in Honduras. 

Table 5.8

Sexual Activity and Use of Contraceptives During the 

30 Days Prior to Interview, According to Current Marital 

Status: Men Aged 15–24 With Sexual Experience 

(Most Recent Survey)

Country/Marital Status Year of Survey

Had

Relations

Used

Contraceptives

El Salvador 2002/03

Total 45.3 62.1

Ever-Married 73.9 62.6

Single 33.8 61.7

Guatemala 2002

Total 54.8 42.7

Ever-Married 90.2 37.1

Single 36.0 53.5

Honduras 2001

Total 42.3 61.9

Ever-Married 76.9 54.5

Single 25.3 72.1
62 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

First Pregnancy 

Table 5.9 and Graph 5.5 show the percentage 

of all women aged 15–24 who have ever been 

pregnant in their life, by current age. In general, 

48.3 percent of women living in Honduras 

reported having ever been pregnant compared 

to 40.9 percent in El Salvador and 38.5 percent 

in Guatemala. As expected, a higher proportion 

of pregnancies were conceived after marriage 

than before marriage. In Honduras, by the time 

women are 17 years of age, 28.7 percent have 

been pregnant, and by the time they are 20 

years of age, 57.8 percent. The corresponding 

percentages for El Salvador and Guatemala are 

17.0 and 46.7 percent, and 19.8 and 45.3 percent, 

respectively. At all ages, the percentage of 

pregnancies conceived after marriage is higher 

than those conceived before marriage. However, 

it should be noted that from 11.3 percent 

(Guatemala) to 19.6 percent (El Salvador) of 

the women aged 20 years reported that their 

first pregnancy was conceived before marriage. 

In general, the percentage of first pregnancies 

that were conceived before marriage increases 

as the age of the respondent increases. 

Table 5.9

Percent of Women Who Have Ever Been Pregnant, According to

Marital Status at Time of First Pregnancy, By Actual Age:

Women Aged 15–24 (Most Recent Survey) 

Country/

Marital 

Status

Year of 

Survey Total

Current Age

15 16 17 18 19 20 21 22 23 24

El Salvador 2002/03

Total 40.9 6.9 14.9 17.0 32.7 40.8 46.7 61.1 56.8 75.3 76.1

Marital 22.8 4.7 8.2 9.9 20.4 24.6 27.0 33.9 36.9 39.7 32.3

Premarital 18.1 2.2 6.8 7.1 12.4 16.2 19.6 27.1 19.9 35.5 43.8

Guatemala 2002

Total 38.5 6.2 11.9 19.8 28.5 32.9 45.3 58.9 63.7 76.6 75.3

Marital 28.7 4.3 8.2 15.7 17.2 23.2 34.0 46.8 49.5 60.7 52.7

Premarital 9.8 1.9 3.7 4.1 11.3 9.7 11.3 12.1 14.2 15.9 22.6

Honduras 2001

Total 48.3 10.7 16.0 28.7 39.0 55.6 57.8 66.1 74.1 77.9 83.1

Marital 35.8 9.2 11.8 21.9 29.9 41.3 43.0 48.8 55.1 55.0 59.4

Premarital 12.6 1.4 4.2 6.8 9.1 14.3 14.9 17.3 19.0 22.9 23.7
Sexual and Contraceptive Behavior of Young Adults 63

Trends and Challenges Facing Women and Childern

El Salvador

Percentag

e

0

20

40

60

80

100

Marital

Premarital

15 16 17 18 19 20 21 22 23 24

0

20

40

60

80

100

Marital

Premarital

15 16 17 18 19 20 21 22 23 24

Guatemala

0

20

40

60

80

100

Marital

Premarital

15 16 17 18 19 20 21 22 23 24

Honduras

Current Age

Percentag

e Percentag

e

Current Age

Current Age

Graph 5.5

Percentage of Women Who Have Ever Been Pregnant, by Marital Status 

at Time of First Pregnancy, for Each Country: Women Aged 15–24 

(Most Recent Survey)
64 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

Of the women who have ever been pregnant, a 

substantial proportion did not believe that they 

could become pregnant at the time they first 

became pregnant, ranging from 28.2 percent in 

Honduras to 32.6 percent in Guatemala (Table 

5.10). In all three countries, the percentage who 

believed that they could not become pregnant 

decreases as age at first pregnancy increases 

(Graph 5.6). Nonetheless, it is interesting that 

from 18.7 to 27.3 percent of the women aged 

20–24 at first pregnancy did not believe that 

they could become pregnant when they did. 

Table 5.10

Percentage of Women Who Did Not Believe They Could 

Become Pregnant When They Became Pregnant the First Time, According to

Age at First Pregnancy: Ever-pregnant Women Aged 15–24 

(Most Recent Survey)

Age at First

Pregnancy

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Total 28.5 32.6 28.2

< 15 38.8 43.8 41.5

15–17 30.5 33.7 30.4

18–19 28.0 29.5 20.7

20–24 18.7 27.3 24.3

Age at First Pregnancy

Percentag

e

0

5

10

15

20

25

30

35

40

45 El Salvador

Guatelmala

Honduras

<15 15-17 18-19 20-24

Graph 5.6

Percentage of Women Who did Not Believe They Could Become

Pregnant When They Did: Ever-pregnant Women Aged 15–24
Sexual and Contraceptive Behavior of Young Adults 65

Trends and Challenges Facing Women and Childern

The reason most frequently mentioned by 

Salvadoran women for believing that they 

could not become pregnant the first time was 

that “I had sexual relations infrequently,” 

while the principal reasons in Guatemala and 

Honduras were “it was the first time to have 

sexual relations” and “I didn’t believe that I was 

old enough to become pregnant,” respectively 

(Table 5.11). From 7.4 percent (Honduras) 

to 19.3 percent (El Salvador) of the women 

reported that their “partner said that I would 

not become pregnant.” Also, 13.8 and 15.5 

percent of women in El Salvador and Honduras, 

respectively, reported that “I believed I was 

not in my fertile period,” while 13.3 percent 

of Guatemalan women reported that “I didn’t 

know when my fertile period was.”

From 27.3 percent (Guatemala) to 40.8 percent 

(El Salvador) of first pregnancies were not 

planned (Table 5.12). In general, the proportion 

of first pregnancies that were not planned 

decreases as age at first pregnancy increases. 

Table 5.11

Primary Reasons for Believing That Could Not Become Pregnant the First 

Time: Ever-pregnant Women Aged 15–24 (Most Recent Survey)

Reasons

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Had sexual relations infrequently 25.3 9.7 5.5

Partner said that I would not become pregnant 19.3 11.8 7.4

Was the first time to have sexual relations 18.2 30.8 16.1

Believed I was not in my fertile period 13.8 na 15.5

Didn’t believe I was old enough to become pregnant 10.3 16.4 32.2

Previously had relations without becoming pregnant na na 7.8

Didn’t know when my fertile period was na 13.3 na

na: Not available.

Table 5.12

Percentage of Women Who Did Not Plan Their First 

Pregnancy, According to Age at First Pregnancy: Women 

Aged 15–24 (Most Recent Survey)

Age at First

Pregnancy

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Total 40.8 27.3 35.7

< 15 55.0 32.3 45.4

15–17 44.8 26.4 35.6

18–19 40.9 25.9 35.3

20–24 23.6 27.5 27.9
66 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

This relationship is strongest in El Salvador, 

followed by Honduras, and is relatively small 

in Guatemala (Graph 5.7). It is interesting to 

note that a surprising 45.0 to 67.7 percent of 

women, who were less than 15 years of age 

at first pregnancy, actually planned their first 

pregnancy. In other words, these pregnancies 

were wanted by these adolescent women.

In El Salvador, 25.2 percent of the women were 

students at the time they first became pregnant, 

while only 11.9 and 12.8 percent of women 

living in Guatemala and Honduras, respectively, 

were students (Table 5.13). Only 9.8 percent 

of Guatemalan women who were less than 

15 years of age at time of first pregnancy 

were students, proportion that increases to 

Age at First Pregnancy

Percentag

e

0

10

20

30

40

50

60 El Salvador

Guatelmala

Honduras

<15 15-17 18-19 20-24

Graph 5.7

Percentage of Women Who Did Not Plan Their First Pregnancy: 

Ever-Pregnant Women Aged 15–24

Table 5.13

Percentage of Women Who Were

Students When They First Became Pregnant, According 

to Age at First Pregnancy: Women Aged 15–24

(Most Recent Survey)

Age at First 

Pregnancy

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Total 25.2 11.9 12.8

< 15 32.6 9.8 17.3

15–17 30.2 12.0 12.7

18–19 22.4 13.3 11.4

20–24 12.4 11.6 12.0
Sexual and Contraceptive Behavior of Young Adults 67

Trends and Challenges Facing Women and Childern

17.3 percent in Honduras and to 32.6 percent 

in El Salvador. Similarly, from 12.0 percent 

(Guatemala) to 30.2 percent (El Salvador) of 

women aged 15–17 were in school at the time 

of their first pregnancy. These findings suggest 

that the only career alternative available to these 

women at the time of their first pregnancy was 

“motherhood.” 

Approximately 37 to 39 percent of women who 

were students at the time of their first pregnancy 

resumed their studies after their pregnancy 

ended (Table 5.14). In Guatemala, 39.2 percent 

resumed their studies, while 38.5 and 37.3 

percent of the women in Honduras and El 

Salvador returned to the classroom, respectively. 

As shown in the table, the probability of 

returning to the classroom after completing the 

first pregnancy increases substantially as grade 

level at time of first pregnancy increases. The 

percent returning to school among women in 

primary education is below 20 percent.

Table 5.14

Percentage of Women Who Resumed Their

Studies After They Completed Their First Pregnancy, 

According to Grade Level When Suspended Their 

Studies: Women Aged 15–24 

(Most Recent Survey)

Country/ Education Year of Survey Percentage

El Salvador 2002/03

Total 37.3

1–6 15.4

7+ 41.0

Guatemala 2002

Total 39.2

Primary 9.5

Secondary+ 43.4

Honduras 2001

Total 38.5

0–6 15.0

7+ 44.9
68 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

Sex Education

The threat of increasing rates of HIV/AIDS 

infections, increased rates of premarital 

intercourse and other related changes in sexual 

and reproductive health behaviors, and increased 

media sexual imagery have raised questions 

about the coverage and quality of sexuality 

education in the region. In general, efforts to 

educate young adults on sexuality, pregnancy, 

and sexual health have not been standardized, 

lacked national coverage, and often were limited 

in scope and time frame.

Table 5.15 shows the percentage of all women 

and men aged 15–24 who have been exposed 

to information from talks or courses on various 

topics related to sexuality and reproductive 

health. For example, only 28.5 percent of 

women in Guatemala have received information 

about menstruation, compared to 42.4 percent 

of Honduran woman and 84.7 percent of El 

Salvadoran women. Similarly, the percentage 

of women who have received information about 

contraceptive methods ranges from a low of 

25.8 percent in Guatemala to a high of 76.9 

percent in El Salvador. In El Salvador the 

Table 5.15

Percentage of All Women and Men Who Have Received Information

From Talks Or Courses on Various Topics Related to Sexuality and 

Reproductive Health: Women and Men Aged 15–24

(Most Recent Survey)

Women

Topic

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Menstruation 84.7 28.5 42.4

HIV/AIDS 76.4 28.0 42.1

Sexual relations 75.3 28.0 38.2

Pregnancy and birth 77.5 25.9 37.9

Reproductive organs 68.4 26.8 37.8

Physical changes in the body 68.5 25.6 36.9

Contraceptive methods 76.9 25.8 34.2

Men

Topic

Menstruation 68.9 28.7 19.0

HIV/AIDS 62.0 36.1 28.9

Sexual relations 68.9 34.4 25.6

Pregnancy and birth 67.9 27.3 20.4

Reproductive organs 75.1 32.0 21.7

Physical changes in the body 66.5 31.5 19.3

Contraceptive methods 57.9 30.7 18.2
Sexual and Contraceptive Behavior of Young Adults 69

Trends and Challenges Facing Women and Childern

majority of respondents interviewed indicate 

that information about reproductive health and 

contraception was learned at school (data not 

shown). In general, the probability of having 

been exposed to the various topics shown in the 

table is lowest in Guatemala and highest in El 

Salvador.

With the exception of Guatemalan men, men 

have had less exposure to the individual topics 

shown in the table than the women have. Using 

menstruation again as an example, only 19.0 

percent of Honduran men reported having ever 

received information on this topic, compared 

to 42.4 percent of Honduran women. Perhaps 

this is why some men told their sexual partners 

that they could not become pregnant (see Table 

5.11). In Honduras, more women have been 

exposed to information on HIV/AIDS than the 

men, which is an interesting finding given the 

number of talks that have been presented to 

both sexes on this subject in that country. 

In all three countries, there are indications that a 

greater proportion of women and men aged 15–

19 have been exposed to sexual and reproductive 

health information than women and men aged 

20–24 (data not shown), indicating that health 

promotion in schools has been increasing in 

recent years.

Summary of Findings

• At least one-half of young adult women in 

El Salvador and Honduras reported sexual 

experience compared with 43.0 percent of 

women in Guatemala. The percentage of men 

aged 15–24 who were sexually experienced 

increases from 58.0 percent in Guatemala, to 

64.7 percent in Honduras, and to 66.4 percent 

in El Salvador.

• More young adult women living in Guatemala 

and Honduras who reported sexual experience 

have had marital sexual intercourse than 

premarital intercourse, while in El Salvador 

the opposite is the case. The vast majority 

of young adult men in all three countries 

reported premarital sexual intercourse.

• The modal age at first sexual experience for 

both women and men in all three countries 

is about 15–16 years. Among young adult 

women who are sexually experienced, the 

average age at first intercourse ranges from 

16.2 to 16.4 years, while among men it 

ranges from 15.0 to 15.5 years.

• In all of the countries, a higher proportion 

of women with premarital sexual experience 

reported that they or their partner used 

contraception at sexual debut than did 

women whose first sexual experience was at 

the time of marriage. For both women and 

men, use of a contraceptive method at time 

of first intercourse was substantially higher 

in the urban area.

• The two principal reasons for not using a 

contraceptive method among women whose 

first sexual relation was premarital were 

“didn’t expect to have sexual relations at that 

moment” and “didn’t know any contraceptive 

method.” These are the same reasons given 

by men in El Salvador and Guatemala, while 

in Honduras the second most frequently 

mentioned reason was “it was the first time 

had sex.”

• Of the women and men who were sexually 

active during the 30 days prior to interview, 

a much higher proportion used contraception 

than at the time of their sexual debut.

• In general, 48.3 percent of women aged 

15–24 living in Honduras reported having 

ever been pregnant compared to 40.9 

percent in El Salvador and 38.5 percent in 

Guatemala. In Honduras, by the time women 

are 20 years of age, 57.8 percent have been 

pregnant. The corresponding percentages for 

El Salvador and Guatemala are 46.7 percent 

and 45.3 percent, respectively. At all ages, 

the percentage of pregnancies conceived 

after marriage is higher than those conceived 

before marriage.

• Of the women who have ever been pregnant, 

a substantial proportion did not believe that 

they could become pregnant at the time 
70 Sexual and Contraceptive Behavior of Young Adults

Reproductive, Maternal, and Child Health in Central America

they first became pregnant, ranging from 28 

percent in Honduras and El Salvador to 32.6 

percent in Guatemala.

• A surprising 45.0 to 67.7 percent of women 

who were less than 15 years of age at 

first pregnancy actually wanted their first 

pregnancy. 

• The probability of young adults receiving 

information on various topics related to 

sexuality and reproductive health from talks 

or courses on sexual education is particularly 

low in Guatemala and Honduras. It appears 

that the most important source of information 

on sexual matters for many young people is 

friends and peers.
HIV/AIDS 71

Trends and Challenges Facing Women and Childern

 CHAPTER

HIV/AIDS

The first HIV/AIDS cases in El Salvador 

and Guatemala were registered in 1984, 

while the first cases in Honduras and 

Nicaragua were recorded in 1985 and 1987, 

respectively. Since then, the number of persons 

infected with HIV has increased at an accelerated 

pace, particularly in Honduras, Guatemala, and 

El Salvador. As of year 2002, Honduras had 

officially reported the most cases (17,199), 

followed by Guatemala (4,923), El Salvador 

(4,278), and Nicaragua (997). In all of the 

countries, the main transmission route of HIV 

is by sexual contact, principally heterosexual. 

Also, in all of the countries, men account for the 

majority of the cases, however, the male/female 

ratio of reported cases is rapidly reaching 

parity. The men and women most affected by 

the epidemic are 20–34 years of age. In general, 

the epidemic is concentrated in the urban and 

commercial areas of each country. The results of 

sentinel surveillance studies conducted in each 

country show that HIV infection is relatively 

high among commercial sex workers and men 

who have sex with men.

This chapter examines knowledge of sexually 

transmitted infections (STIs) and HIV/AIDS, 

how HIV/AIDS is transmitted, and what can be 

done to prevent it. Since many questionnaire 

items were different for Nicaragua, and similar 

for the other three countries, data and discussion 

focus on El Salvador, Guatemala, and Honduras. 

Whenever the Nicaraguan data is comparable it 

is included in the following presentation.

6
72 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Knowledge of Gonorrhea 

and Syphilis

In the most recent surveys in El Salvador, 

Guatemala, and Honduras, respondents were 

asked if they had ever heard of a number of 

specific STIs and of HIV/AIDS. In Nicaragua, 

respondents were asked if they had ever heard 

of any STI other than HIV/AIDS, without 

specifying the various infections. The results of 

the Nicaragua survey show that 49.9 percent of 

women aged 15–49 have heard of at least one 

STI and that knowledge is higher in urban areas 

(60.8 percent) than in rural areas (31.1 percent) 

(data not shown).

Table 6.1 and Graph 6.1 show the percentage 

of women and men living in El Salvador, 

Guatemala, and Honduras who have heard 

of gonorrhea and syphilis. These two classic 

STIs are the most recognized STIs in each of 

the countries, indicating that knowledge of the 

other STIs that were investigated is relatively 

low. Knowledge of gonorrhea among women 

Table 6.1

Knowledge of Gonorrhea and Syphilis, According 

to Area of Residence: Women of Fertile Age 

and Men Aged 15–59 (Most Recent Survey)

Country/Area Year of Survey

Women Men

Gonorrhea Syphilis Gonorrhea Syphilis

El Salvador* 2002/03

Total 61.4 55.5 79.9 77.9

Urban 72.9 66.7 88.5 87.6

Rural 46.4 40.8 71.9 69.0

Guatemala* 2002

Total 46.1 33.0 76.1 46.0

Urban 61.2 47.1 85.9 61.2

Rural 35.0 22.7 68.9 34.9

Honduras† 2001

Total 61.0 43.3 72.9 45.4

Urban 74.0 57.3 84.8 60.4

Rural 47.6 28.9 62.9 32.9

*Women aged 15–49.

†Women aged 15–44.
HIV/AIDS 73

Trends and Challenges Facing Women and Childern

ranged from 46.1 percent in Guatemala to 

approximately 61 percent in El Salvador and 

Honduras. Similarly, knowledge of syphilis 

ranged from a low of 33.0 percent in Guatemala 

to a high of 55.5 percent in El Salvador. In 

all three of the countries, knowledge of both 

infections was lowest among women living in 

the rural area.

As shown in the table and graph, a higher 

percentage of men have heard of gonorrhea and 

syphilis compared to the women. Knowledge 

of both infections is highest and similar in 

El Salvador, while knowledge of syphilis is 

substantially lower than gonorrhea in Honduras 

and Guatemala. As was the case with the 

women, knowledge of both infections is lowest 

in the rural area.

Percentag

e

0

20

40

60

80

100

Syphilis

Gonorrhea

Graph 6.1

Knowledge of Gonorrhea and Syphilis:

Women of Fertile Age and Men Aged 15–59

(Most Recent Survey)

El Salvador Guatemala Honduras El Salvador Guatemala Honduras

Women Men
74 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Knowledge of HIV/AIDS

In Honduras, almost all women have heard of 

HIV/AIDS (Table 6.2 and Map 6.1). Knowledge 

of HIV/AIDS is lower in El Salvador (96.1 

percent), Nicaragua (92.8 percent), and in 

Guatemala (85.6 percent). While knowledge 

is consistently high in all regions of Honduras 

the other countries indicate divergent regional 

patterns. Nicaragua is the most pronounced 

with the northwest Pacific coast region showing 

high levels of knowledge while the Northern 

Atlantic Autonomous Region (RAAN) showed 

the lowest. In all four countries, knowledge of 

this infection is greater in urban areas, which 

suggests a need to promote awareness in rural 

areas, especially in Guatemala and Nicaragua. 

Table 6.2

Knowledge of HIV/AIDS and Percent Who Know That HIV Infections 

Can be Asymptomatic, and that no Cure Exists for AIDS, According to Area

of Residence: Women of Fertile Age and Men Aged 15–59 (Most Recent Survey)

Women Men

Country/

Area

Year of 

Survey

Have 

Heard of 

HIV/AIDS

Know HIV 

Can be 

Asymptomatic

Know that 

No Cure 

Exists for 

AIDS 

Have 

Heard of 

HIV/AIDS

Know HIV 

Can be 

Asymptomatic

Know that 

No Cure 

Exists for 

AIDS 

El Salvador* 2002/03

Total 96.1 74.4 87.1 98.0 83.7 86.7

Urban 98.1 80.8 88.4 99.7 89.5 89.3

Rural 93.5 66.1 85.4 96.4 78.4 84.3

Guatemala* 2002

Total 85.6 68.8 84.0 94.8 75.3 82.4

Urban 93.7 75.8 86.5 97.6 80.2 83.4

Rural 79.7 62.7 81.8 92.8 71.6 81.6

Honduras† 2001

Total 99.2 82.5 86.7 99.6 91.8 87.1

Urban 99.8 87.6 88.8 99.5 95.3 90.0

Rural 98.6 77.3 84.5 99.6 88.8 84.8

Nicaragua* 2001

Total 92.8 75.0 na na na na

Urban 97.4 84.5 na na na na

Rural 84.7 58.8 na na na na

* Women aged 15–49.

†

 Women aged 15–44.

na: Not available.
HIV/AIDS 75

Trends and Challenges Facing Women and Childern

Women who had heard of HIV/AIDS were 

asked whether they believed that a person could 

be infected with HIV and be asymptomatic (not 

show any clinical symptoms of the disease). The 

knowledge that HIV/AIDS can be asymptomatic 

is an indication of women’s knowledge of 

HIV/AIDS rather than simple awareness of the 

disease. As shown in the third column of Table 

6.2, almost 83 percent of women in Honduras 

know that a person can be asymptomatic and 

have HIV. In the other countries, between 

68.8 percent (Guatemala) and 75.0 percent 

(Nicaragua) knew this. In all of the countries, 

there is a wide gap between urban and rural 

Map 6.1

Percent of Women Who had Heard of HIV/AIDS 

by Region / Department

(Last Survey)

<80

80-89

90-94

95-97

98+

%Heard of

HIV/AIDS
76 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

women in the knowledge that HIV can be 

asymptomatic, particularly in Nicaragua (Graph 

6.2 and Map 6.2).

In El Salvador, Guatemala, and Honduras, at 

least 84.0 percent of the women know that no 

cure exists for AIDS (fourth column of Table 

6.2). Knowledge of this fact is slightly higher 

among urban women.

Men also demonstrate high knowledge of HIV/

AIDS, with knowledge of HIV/AIDS being 

almost universal among Honduran men (Table 

6.2). Comparing men and women, a greater 

proportion of Guatemalan men are aware of 

HIV/AIDS than Guatemalan women, with a 

differential of about 10 percentage points. As 

shown in the sixth column of Table 6.2, almost 

92 percent of men in Honduras know that a 

person can be asymptomatic and have HIV 

(Graph 6.3). In the other countries, between 

75.3 percent (Guatemala) and 83.7 percent (El 

Salvador) knew this. By comparing the fourth 

column with the seventh column in Table 6.2, it 

can be seen that almost an equal percentage of 

women and men in each country know that no 

cure exists for AIDS.

Means of Preventing the 

Transmission of HIV/AIDS

The surveys in El Salvador, Guatemala, 

and Honduras used a question to ascertain 

women’s and men’s knowledge of HIV/AIDS 

prevention. Essentially, the respondents were 

asked to mention spontaneously the methods of 

prevention that they knew. In El Salvador the 

questionnaire design was adapted to conform 

with UNAIDS indicator needs and included 

specific probing on abstinence, monogamy, and 

condom use in all sexual relations. As a result 

in El Salvador, the indicators on “spontaneity” 

of responses may be low because interviewers 

may have not given respondents enough time 

to respond. For the purpose of the following 

comparison the focus is on the percentage of 

women and men who could mention two or more 

ways to prevent the transmission of HIV/AIDS 

spontaneously with some additional mention of 

probed response rates for El Salvador.

Percentag

e

Country

0

20

40

60

80

100

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua

Graph 6.2

Knowledge That HIV can be Asymptomatic,

by Area of Residence: Women of Fertile Age

(Most Recent Survey)
HIV/AIDS 77

Trends and Challenges Facing Women and Childern

Map 6.2

Percent of Women Who Know That HIV Can be

Asymptomatic by Region / Department

(Last Survey)

48–59

60–69

70–79

80–84

85–89

%Know HIV

Asymptomatic Percentag

e

Country

0

20

40

60

80

100

Urban

Total

Rural

El Salvador Guatemala Honduras

Graph 6.3

Knowledge That HIV can be Asymptomatic,

by Area of Residence: Men Aged 15–59

(Most Recent Survey)
78 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

As shown in Table 6.3, 44.8 and 41.2 percent 

of women in Guatemala and Honduras, 

respectively, could mention two or more ways 

to prevent the transmission of HIV/AIDS, 

compared to only 23.1 percent in El Salvador. 

With probing on specific means of prevention 

the percent in El Salvador rises to 87.5 percent. 

The urban/rural differential in El Salvador and 

Guatemala was 9 and 11 percentage points, 

respectively, in favor of the urban area, while it 

was 19 percentage points in Honduras. It should 

be noted that substantial proportions of women 

were unable to spontaneously mention any 

way to prevent the transmission of HIV/AIDS. 

The lowest percent reported is for Guatemala 

(11.1 percent) followed by Honduras with 18.1 

percent. Forty percent of women in El Salvador 

did not spontaneously mention any means 

of prevention, but this drops to 5.8 percent 

unfamiliar with any means of prevention when 

probing on specific methods.

A higher percentage of men than women in 

each country mentioned two or more ways of 

preventing the transmission of HIV/AIDS. The 

largest male/female differential was found to 

be in Honduras—20 percentage points. The 

percentage of men who mentioned two or more 

ways to prevent HIV/AIDS was lowest in El 

Salvador (29.6 percent), followed by Guatemala 

(47.2 percent), and highest in Honduras (61.2 

percent). With probing the percent in El Salvador 

rises to near 90 percent. As expected, urban men 

were more likely to mention two or more ways 

of prevention than rural men. The percent of the 

men unable to mention any means to prevent 

the transmission of HIV/AIDS is fairly low, 6.1 

and 4.0 percent in Guatemala and Honduras, 

respectively, but high (23.6 percent) in El 

Salvador. Again, with probing this percentage 

drops to 3.2 percent in El Salvador.

Table 6.3

Number of Means Mentioned Spontaneously to Prevent the 

Transmission of HIV/AIDS, According to Area of Residence: 

Women of Fertile Age and Men Aged 15–59 

(Most Recent Survey)

Country/

Area

Year of 

Survey

Women

Number of Means

Men

Number of Means

0 1 2+ 0 1 2+

El Salvador* 2002/03

Total 40.3 36.6 23.1 23.6 46.8 29.6

Urban 33.4 39.4 27.1 16.7 49.2 34.2

Rural 49.2 32.9 17.9 30.0 44.5 25.5

Guatemala* 2002

Total 11.1 44.1 44.8 6.1 46.6 47.2

Urban 7.3 42.0 50.7 3.5 45.5 51.0

Rural 14.4 46.0 39.7 8.8 47.5 44.3

Honduras† 2001

Total 18.1 40.7 41.2 4.0 34.8 61.2

Urban 9.0 40.4 50.6 2.1 30.4 67.5

Rural 27.5 40.9 31.6 5.5 38.6 55.9

* Women aged 15–49.

†

 Women aged 15–44.

na: Not available.
HIV/AIDS 79

Trends and Challenges Facing Women and Childern

Table 6.4 presents the percentage of women 

and men who mentioned the primary means 

of preventing the sexual transmission of 

HIV/AIDS—abstinence, monogamy, and the 

consistent and correct use of condoms. As 

shown in the table, the percentage of women 

who mentioned abstinence is relatively low in 

each of the countries, ranging from 13.0 percent 

in El Salvador to 25.0 percent in Guatemala. 

Approximately twice as many women 

mentioned monogamy in each country, while 

from 27.8 percent (El Salvador) to 54.3 percent 

(Guatemala) mentioned the use of condoms. 

With the exception of the use of condoms, the 

urban/rural differential for the other means 

of prevention is relatively small in Honduras 

and Guatemala. In El Salvador the urban/rural 

differential is large for both monogamy and 

use of condoms, favoring greater knowledge in 

urban areas.

A very small percentage of men in each country 

spontaneously mentioned abstinence as a way 

to prevent the transmission of HIV/AIDS. 

A higher percentage of men in Honduras 

mentioned monogamy (64.3 percent) than men in 

Guatemala (40.0 percent) and El Salvador (24.0 

percent). More men than women mentioned 

the consistent and correct use of condoms in 

Honduras and Guatemala, but the percentage of 

men who mentioned this means of prevention is 

surprisingly low in all three countries, ranging 

from 8.4 in El Salvador to 59.3 in Honduras. It 

is interesting to note that women, compared to 

men, are much more likely to mention condom 

use in El Salvador. Again, when probed, 70.2 

percent of women and 62.0 percent of men in 

El Salvador acknowledged that use of condoms 

was a means for preventing sexual transmission 

of HIV/AIDS (data not shown). As was the case 

with the women, the urban/rural differential for 

abstinence and monogamy is relatively small in 

all three countries.

Table 6.4

Percentage of Women and Men Who Mentioned Spontaneously the Primary Means 

to Prevent the Sexual Transmission of HIV/AIDS, According to Area of Residence: 

Women of Fertile Age and Men Aged 15–59 (Most Recent Survey)

Country/

Area

Year of 

Survey

Women Men

Abstinence Monogamy

Use 

Condoms Abstinence Monogamy

Use 

Condoms

El Salvador* 2002/03

Total 13.0 25.4 27.8 9.4 24.0 8.4

Urban 14.1 29.6 33.7 12.6 29.8 11.1

Rural 11.4 19.9 19.9 6.5 18.6 5.9

Guatemala* 2002

Total 25.0 42.2 34.7 5.0 40.0 42.2

Urban 23.4 43.7 41.0 7.9 39.7 50.7

Rural 26.8 41.0 29.3 2.9 40.3 35.7

Honduras† 2001

Total 22.6 43.6 54.3 6.3 64.3 59.3

Urban 23.4 44.8 60.1 8.0 66.3 63.5

Rural 21.7 42.3 47.5 4.8 62.5 55.5

* Women aged 15–49.

† Women aged 15–44.
80 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Knowledge and Use of 

the Test to Detect HIV

A significant proportion of women and men have 

heard of the test to detect HIV (Table 6.5 and 

Graph 6.4). Among the women, knowledge of the 

test is highest in El Salvador (72.1 percent) and 

lowest in Guatemala (56.7 percent), while among 

the men, knowledge is highest in Honduras (75.7 

percent) and lowest in Guatemala (61.3 percent). 

Important differences between urban and rural 

respondents should be noted for both the women 

and the men.

Table 6.6 shows the percentage of women and 

men who are aware of the HIV test, according 

to the educational level of the respondents. For 

both sexes in each country, knowledge of the 

test increases as the educational level of the 

respondents increases. Using Guatemala as an 

example, while only 30.1 percent of women with 

no formal education are aware of the test, 95.1 

percent of women who have attended a university 

have knowledge of this test. A similar pattern of 

knowledge was found for Guatemalan men.

Table 6.5

Knowledge of the Test to Detect HIV, 

According to Area of Residence: 

Women of Fertile Age and Men Aged 

15–59 (Most Recent Survey)

Country/Area

Year of 

Survey Women Men

El Salvador* 2002/03

Total 72.1 70.9

Urban 79.4 83.8

Rural 62.1 59.0

Guatemala* 2002

Total 56.7 61.3

Urban 67.6 72.9

Rural 47.1 52.4

Honduras† 2001

Total 71.5 75.7

Urban 79.7 84.8

Rural 62.9 68.1

* Women aged 15–49.

†

 Women aged 15–44.

na: Not available.

Percentag

e

Country

0

20

40

60

80

100

Urban

Total

Rural

Graph 6.4

Knowledge of the Test to Detect HIV, by Area of Residence and Sex:

Women of Fertile Age and Men Aged 15–59

(Most Recent Survey)

El Salvador Guatemala Honduras El Salvador Guatemala Honduras

Women Men
HIV/AIDS 81

Trends and Challenges Facing Women and Childern

In general, the percentage of all women and 

all men who have ever been tested for HIV 

is relatively small in the countries for which 

there is data (Table 6.6, Columns 3 and 4). The 

probability of having ever been tested is similar 

among women in El Salvador and Honduras at 

11.9 percent, while 13.1 percent of men in El 

Salvador and 17.0 percent in Honduras have 

been tested. The level of testing among women 

in Nicaragua is lower, with an overall percent of 

6.6. In all of countries the percentage of women 

and men who have ever been tested increases 

as the educational level of the women and men 

increases. This finding suggests that the selfperceived risk of contracting HIV/AIDS may be 

higher among more educated women and men 

than among less educated women and men.

Table 6.6

Knowledge of the Test to Detect HIV, and Ever Been Tested

For HIV/AIDS, According to Education: Women of Fertile

Age and Men Aged 15–59 (Most Recent Survey)

Country/

Education

Year of 

Survey

Knowledge of Test Ever Been Tested

Women Men Women Men

El Salvador* 2002/03

Total 69.4 70.9 11.9 13.1

None 50.4 49.0 6.1 4.5

0–3 55.8 56.8 6.5 4.1

4–6 62.6 71.6 7.7 8.9

7–9 73.4 73.9 11.0 12.4

10+ 86.2 92.1 20.8 27.3

Guatemala* 2002

Total 56.7 61.3 na na

None 30.1 32.0 na na

Primary 48.9 51.0 na na

Secondary 79.3 82.0 na na

Superior 95.1 90.2 na na

Honduras† 2001

Total 71.5 75.7 11.9 17.0

None 51.2 57.9 3.1 5.5

1 a 3 61.7 70.3 6.2 9.6

4 a 6 69.6 75.5 8.8 16.0

7+ 85.1 89.5 21.6 30.6

Nicaragua 2001

Total na na 6.6 na

None na na 1.8 na

1 a 3 na na 1.9 na

4 a 6 na na 4.7 na

Secondary na na 8.7 na

Superior na na 17.6 na

* Women aged 15–49.

†

 Women aged 15–44.

na: Not available.
82 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Stigma and Discrimination

With the spread of HIV infections throughout 

the world, there was also a rising wave of stigma 

associated with the spread. In the early days of 

the epidemic, there was much misinformation 

about HIV/AIDS, thus, the stigma linked to it. 

The social stigma surrounding AIDS was also 

due in part to its possible etiology of bisexuality 

or homosexuality, extramarital affairs, and drug 

use. However, in recent years, efforts have been 

made in many countries to decrease the stigma 

and discrimination against people living with 

the virus.

In the most recent survey conducted in the four 

countries analyzed in this report, there were 

a series of questions designed to measure the 

level of stigma and discrimination confronting 

people living with HIV/AIDS. In this report, 

it is not possible to present all of the findings 

for each survey, so only a sampling of some of 

the results are presented in Table 6.7. Readers 

interested in more information are referred to 

the individual country reports.

There was one question common to all four 

surveys: “Would you care for a family member 

living with HIV/AIDS in your own house?” 

As shown in Table 6.7, at least 70 percent of 

women living in El Salvador, Honduras, and 

Nicaragua would care for a family member 

in their house, while only 62.0 percent of 

Guatemalan women said that they would do 

this. In all of the countries, fewer rural women 

than urban women would care for a family 

member living with HIV/AIDS, with the largest 

urban/rural differentials found in Nicaragua and 

Guatemala.

Among El Salvadoran women, only 39.8 percent 

of the women would buy vegetables from a 

vendor who had AIDS, and in Guatemala and 

Honduras, less than 50 percent of the women 

would allow a person with HIV/AIDS to 

continue working. In El Salvador and Nicaragua

from 42.7 to 47.1 percent of the women would 

maintain as a secret that a family member has 

HIV/AIDS. Important urban/rural differences 

should be noted for these situations.

Turning to the men, about the same percentage 

of men as women in El Salvador, Guatemala, 

and Honduras would care for a family member 

living with AIDS. Fewer men than women in El 

Salvador would buy vegetables from a vendor 

living with AIDS, and fewer men than women 

in Honduras would allow a person with HIV/

AIDS to continue working. However, fewer 

men than women in El Salvador would keep 

secret that a family member has HIV/AIDS.

Based on the above analysis, rural women and 

men are more likely to be discriminatory against 

persons living with HIV/AIDS than urban 

women and men. Although there is not always 

a clear pattern with regard to gender, it appears 

that women are less likely to be discriminatory 

than men.
HIV/AIDS 83

Trends and Challenges Facing Women and Childern

Table 6.7

Acceptance of Persons Living With HIV/AIDS, According to Area of Residence:

Women Aged 15–49 and Men Aged 15–59 

(Most Recent Survey)

Country/Area

Year of 

Survey

Women Men

Care for a

Family Member*

Buy Vegetables

from a Vendor†

Permit Person

to Work‡

Keep Infection

a Secret§

Care for a

Family Member*

Buy Vegetables

from a Vendor†

Permit Person

to Work‡

Keep Infection

a Secret§

El Salvador¶ 2002/03

Total 74.6 39.8 na 42.7 72.8 34.8 na 35.6Urban 76.2 44.5 na 49.1 78.3 44.3 na 44.8Rural 72.4 33.4 na 33.8 67.6 25.7 na 26.9

Guatemala 2002

Total 62.0 na 49.8 na 63.4 na 48.1 naUrban 70.7 na 61.7 na 73.3 na 61.8 naRural 54.5 na 39.4 na 55.7 na 37.5 na

Honduras 2001

Total 74.1 na 42.5 na 75.1 na 32.4 naUrban 78.8 na 52.8 na 81.6 na 45.8 naRural 69.2 na 31.6 na 69.7 na 21.1 na

Nicaragua 2001

Total 70.5 na na 47.1 na na na naUrban 76.6 na na 52.7 na na na naRural 58.4 na na 36.0 na na na na

na: Not available.* Care for a family member living with HIV/AIDS.† Buy vegetables from a vendor who has AIDS.‡ Allow persons with HIV/AIDS to continue working.§ Maintain as a secret that a family member has HIV/AIDS.¶ Includes only percent of persons who have heard of HIV/AIDS.
84 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Knowledge and 

Use of Condoms

Between 93.5 percent and 97.6 percent of 

women aged 15–49 in El Salvador, Honduras, 

and Nicaragua were aware of condoms at the 

time of the last survey (Table 6.8 and Graph 

6.5). This compares with condom awareness in 

Guatemala of only 69.7 percent, which ranges 

from 59.6 percent among rural women to 83.4 

percent among urban women. Compared to 

knowledge of condoms, ever-use of condoms 

is low in every country, and current use is 

extremely low, ranging from a low of 1.7 percent 

in Guatemala to a high of 2.3 to 2.4 percent in 

the other countries.

Table 6.8

Knowledge and Use of Condoms, 

According to Area of Residence: Women Aged 15–49

and Men Aged 15–59 (Most Recent Survey)

Country/Area

Year of 

Survey

Women Men

Knowledge Ever-Use

Current 

Use* Knowledge Ever-Use

Current 

Use*

El Salvador 2002/03

Total 96.4 17.3 2.4 na 59.5 10.2

Urban 98.6 21.2 2.9 na 68.5 11.7

Rural 93.5 12.3 1.7 na 51.2 8.8

Guatemala 2002

Total 69.7 9.1 1.7 85.9 34.0 8.7

Urban 83.4 13.3 2.5 93.6 47.2 13.6

Rural 59.6 5.9 1.1 80.4 24.3 5.1

Honduras 2001

Total 97.6 18.6 2.3 98.7 44.2 6.8

Urban 99.4 23.0 2.8 99.6 56.1 7.7

Rural 95.7 14.0 1.7 98.0 34.3 6.1

Nicaragua 2001

Total 93.5 17.5 2.3 na na na

Urban 97.5 21.2 2.7 na na na

Rural 86.6 11.1 1.5 na na na

na: Not available.

* During the 30 days prior to interview.
HIV/AIDS 85

Trends and Challenges Facing Women and Childern

As expected, knowledge and use of condoms is 

higher among men compared to women (Graph 

6.5). Ever-use of condoms is also much more 

common among men with over a third of men 

in Guatemala to near 60 percent in El Salvador, 

having ever-used condoms. Current use of 

condoms, however, is relatively low in all three 

countries with male data. Only 6.8 percent of 

men in Guatemala, 8.7 percent in Honduras, and 

10.2 percent in El Salvador reported condom 

use during the 30 days prior to interview.

Percentag

e

Graph 6.5

Knowledge and Use of Condoms:

Women of Fertile Age and Men Aged 15–59

(Most Recent Survey)

El Salvador Guatemala Honduras Nicaragua El Salvador Guatemala Honduras Nicaragua

Women Men

0

20

40

60

80

100

Current use

Ever-use

Knowledge
86 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Number of Sexual Partners 

in the Past 12 Months 

and the Use of Condoms

Men in El Salvador, Guatemala, and Honduras 

who were sexually active during the 12 months 

prior to interview were asked how many sexual 

partners they had during the period. As shown 

in Table 6.9, the majority of the men in each 

country had only one sexual partner. Married 

men were more likely than unmarried men to 

report one sexual partner, which ranged from 

about 86 percent in El Salvador and Honduras 

to 96.2 percent in Guatemala. In each country, 

a higher percentage of unmarried men than 

married men had multiple sexual partners during 

the year (Graph 6.6). This is not to suggest that 

married men were always faithful to their wives, 

as approximately 13 percent of married men 

in El Salvador and Honduras had two or more 

sexual partners during the 12 month period. Of 

the men with multiple partners, the majority had 

two partners, although from 7.6 to 13.0 percent 

of unmarried men had four or more partners.

The men were also asked if they used condoms 

in the last sexual relation with their various 

sexual partners. In Table 6.10, the results of this 

analysis are presented. Using Honduras as an 

example, of the men who had only one sexual 

partner during the previous 12 months, 88.9 

percent did not use condoms with that partner, 

while 11.1 percent did. Of the men who had two 

sexual partners, 47.9 percent of the men did not 

use condoms with either partner, while 31.5 

percent used condoms with one of the partners, 

and 20.6 percent with both. And so on. The 

overall patterns of use according to numbers 

of partners are generally similar in El Salvador 

and Guatemala. Although the probability of 

using a condom increases as the number of 

sexual partners increases, a critical message of 

Table 6.10 is that use is neither universal nor 

consistent.

Table 6.9

Number of Sexual Partners in the 12 Months Prior to Interview, 

According to Marital Status: Men Aged 15–59 With Sexual Experience 

in the Previous 12 Months (Most Recent Survey)

Country/Marital 

Status Year of Survey

Number of Sexual Partners

1 2 3 4+

El Salvador 2002/03

Total 77.2 13.3 5.6 3.9

Married 86.5 8.0 3.3 2.2

Not married 55.9 25.6 10.9 7.6

Guatemala 2002

Total 87.6 6.5 2.9 3.0

Married 96.2 1.9 1.2 0.7

Not married 60.5 21.1 8.3 10.1

Honduras 2001

Total 73.7 13.5 7.1 5.3

Married 86.8 7.0 3.8 2.0

Not married 44.1 28.1 14.5 13.0

na: Not available.
HIV/AIDS 87

Trends and Challenges Facing Women and Childern

Percentag

e

Country

Graph 6.6

Percentage of Men With Two or More Sexual Partners in the 12 Months 

Prior to Interview, by Marital Status: Men Aged 15–59 Who Were

Sexually Active in the Last 12 Months (Most Recent Survey)

0

10

20

30

40

50

60

Not Married

Total

Married

El Salvador Guatemala Honduras

Table 6.10

Number of Sexual Partners in the 12 Months Prior to Interview With Whom 

Condoms Were Used in the Last Sexual Relation, According to Number 

of Sexual Partners: Men With Sexual Experience During the Previous 12 

Months (Most Recent Survey)

Country/No. of 

Partners Year of Survey

Number with Whom Used Condoms

None 1 2 3 Total

El Salvador 2002/03

No. of Partners

1 85.3 14.7 - - 100.0

2 40.6 29.8 29.6 - 100.0

3+ 18.9 15.6 29.1 36.4 100.0

Guatemala 2002

No. of Partners

1 88.2 11.8 - - 100.0

2 34.3 15.3 50.4 - 100.0

3+ 29.1 8.0 24.5 38.5 100.0

Honduras 2001

No. of Partners

1 88.9 11.1 - - 100.0

2 47.9 31.5 20.6 - 100.0

3 39.6 12.2 19.3 28.9 100.0

4+ 27.5 18.7 27.0 26.7 100.0
88 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Again using Honduras as an example, among 

the men with three sexual partners, nearly 40 

percent of the men did not use condoms with 

any of their partners, while only 28.9 percent 

used condoms with all three. The probability of 

using condoms when multiple sexual partners 

are involved appears to be highest in Guatemala 

and lowest in Honduras.

Use of condoms during the last sexual relation 

was also classified according to who was 

the sexual partner. Table 6.11 and Graph 6.7 

illustrate the differential use of condoms by 

type of relationship to sexual partner. In all three 

countries with data, use is highest when the 

sexual partner was a prostitute, although from 

22.5 to 32.5 percent of men in El Salvador 

Table 6.11

Use of Condoms in Last Sexual Relation, According to 

Relation to Sexual Partner: Men Aged 15–59 

(Most Recent Survey)

Sexual Partner

El Salvador

2002/03

Guatemala

2002

Honduras

2001

Total 30.6 23.7 26.0

Wife 3.7 4.0 3.9

Ex-Wife na na 18.6

Girl Friend/Fiance 65.5 56.5 45.8

Friend 55.5 59.1 48.8

Lover 50.9 na 43.3

Recent Friend 56.1 65.3 53.4

Prostitute 77.5 67.5 96.9

Other * 37.4 *

na: Not available.

* Less than 25 cases.

Percentag

e

Country

0

20

40

60

80

100

Wife

Recent Friend

Girl Friend/Fiance

Prostitute

Total

El Salvador Guatemala Honduras

Graph 6.7

Use of Condoms by Sexually Active Men in Last Sexual Relation:

According to Relationship to Sexual Partner (Selected Relationships)

(Most Recent Survey)
HIV/AIDS 89

Trends and Challenges Facing Women and Childern

and Guatemala did not use condoms during 

their last sexual encounter with a prostitute. 

Use of condoms is also relatively high when 

the partner is a recent acquaintance. In all three 

countries use of condoms is lowest when the 

sexual partner is the wife (below 5 percent).

The relative low use of condoms may be related 

to the perception that men have of condoms in 

preventing the transmission of STIs and HIV. 

As shown in Table 6.12, from 53.9 percent 

(Honduras) to 65.4 percent (Guatemala) of 

the men believe that condoms are effective 

in preventing the transmission of HIV. Only 

in Guatemala does this belief systematically 

increase as the educational level of the 

respondents also increases. It is surprising and 

alarming that a relatively small percentage of 

the more educated men believe that condoms 

are efficacious, in that it is this group of men 

who provide leadership to those who have had 

fewer educational opportunities.

Table 6.12

Percentage of Men Who Believe That 

Condoms are Effective in Preventing 

the Transmission of HIV, According to 

Education: Men Aged 15–59

(Most Recent Survey)

Country/Education

Year of 

Survey Percentage

El Salvador 2002/03

Total 58.3

0–3 59.7

4–6 63.6

7–9 57.1

10+ 53.5

Guatemala* 2002

Total 65.4

None 52.6

Primary 65.0

Secondary 68.3

Superior 73.7

Honduras* 2001

Total 53.9

None 45.2

1–3 55.1

4–6 55.3

7+ 54.8

* Includes very effective and effective.
90 HIV/AIDS

Reproductive, Maternal, and Child Health in Central America

Summary of Findings

· Knowledge of STIs other than HIV/AIDS 

is low among women and men in all of the 

countries surveyed. 

· In El Salvador, Honduras, and Nicaragua, 

at least 92 percent of women are aware 

of HIV/AIDS, while only 85.6 percent 

of women in Guatemala are aware of this 

infection. Almost all men in El Salvador 

and Honduras say that they have heard of 

HIV/AIDS, compared to 94.8 percent of 

Guatemalan men.

· Only 58.8 to 66.1 percent of rural women 

in Nicaragua, Guatemala, and El Salvador 

know that HIV/AIDS can be asymptomatic. 

Knowledge that a person can be infected 

with HIV and be asymptomatic is greater 

among men, especially in Honduras. Almost 

an equal percentage (over 80 percent) of 

women and men in each country know that 

no cure exists for AIDS.

· Less than 50 percent of the women in each 

country could spontaneously mention two 

or more ways to prevent the transmission 

of HIV. Among men, the percentage that 

could do this ranged from 29.6 percent in 

El Salvador to 61.2 percent in Honduras. 

Similarly, the percentage of women and 

men who spontaneously mentioned the three 

primary means of preventing the sexual 

transmission of HIV/AIDS is relatively low 

in each country with data.

· Among women, knowledge of the test to 

detect HIV is highest in El Salvador (72.1 

percent) and lowest in Guatemala (56.7 

percent), while among men, knowledge 

is highest in Honduras (75.7 percent) 

and lowest in Guatemala (61.3 percent). 

Important urban/rural differences exist 

for both women and men. In general, the 

percentage of women and men who have 

ever been tested for HIV is relatively small 

(less than 12 percent among women and 17 

percent among men).

· A high degree of stigma and discrimination 

against people living with HIV/AIDS still 

exists in the four countries. Rural women 

and men are more likely to be discriminatory 

than their urban counterparts. Conversely, 

women are less likely to be discriminatory 

than men.

· While knowledge of condoms is relatively 

high, current use of condoms (during the 30 

days prior to interview) by both men and 

women is very low in each country. Among 

men, the probability of using a condom 

increases as the number of sexual partners in 

the past year increases, but use of condoms 

is neither universal nor consistent. 

· The relative low use of condoms may be 

related to the perception that men have of 

condoms in preventing the transmission of 

HIV. Less than two-thirds of the men in El 

Salvador, Guatemala, and Honduras believe 

that condoms are effective in preventing the 

transmission of HIV.
Maternal Health 91

Trends and Challenges Facing Women and Childern

 CHAPTER

Maternal Health

Anumber of factors can have a 

considerable impact on the health of a 

woman, the health of her baby, and the 

outcome of her pregnancy, such as the use of 

health care services related to pregnancy, the 

place and type of assistance at delivery, and 

postpartum behaviors. The use of preventive 

health services such as cervical cancer screening 

and the receipt of tetanus toxoid vaccines can 

also save the lives of mothers and infants alike. 

These topics are examined in this chapter.

Prenatal Care

Prenatal care is important for preventing, 

identifying, and treating conditions that can 

affect the health of an expectant mother or her 

baby. For the optimal health of mother and 

child, it is recommended that every pregnant 

woman start seeing a health care provider 

for prenatal care examinations during her 

first trimester of pregnancy. The number of 

prenatal visits a woman should make during 

her pregnancy depends on the evolution of 

her pregnancy. Data presented in this chapter 

reflect the norm established by the Ministry 

of Health in El Salvador of 5 or more prenatal 

visits. In Nicaragua a minimum of 4 visits is 

recommended by the Ministry of Health.

7
92 Maternal Health

Reproductive, Maternal, and Child Health in Central America

Table 7.1 presents trends in the percentage of 

live births in the five years prior to the surveys 

for which the respondents reported that they 

received prenatal care. Focusing on the most 

recent survey, in all of the countries, over 82 

percent of the pregnancies received at least one 

prenatal care examination. The countries with 

the highest prenatal coverage were Nicaragua 

and El Salvador (about 86 percent), while 

the lowest coverage was in Honduras (82.6 

percent). With one exception, differences 

between urban and rural populations tended to 

be relatively small. The exception is Nicaragua, 

where the urban/rural differential was almost 

14 percentage points (Graph 7.1).

Since the early 1990s, the percentage of 

pregnancies that ended in a live birth that received 

prenatal care increased in two of the countries 

(El Salvador and Nicaragua) and decreased in 

the other two (Guatemala and Honduras). The 

increase in both El Salvador and Nicaragua is 

due primarily to increased coverage in the rural 

area. Lack of improvements in coverage in 

Guatemala appears to be related to a decrease in 

coverage in the rural area, while urban coverage 

deteriorated slightly in Honduras (data not 

shown).

Table 7.1

Trends in the Use of Prenatal

Care: Live Births in the Five

Years Prior to the Survey

Country Year of Survey Percentage

El Salvador 1993* 68.7

El Salvador 1998* 76.0

El Salvador 2002/03* 86.0

Guatemala 1995* 86.7

Guatemala 1998/99* 86.8

Guatemala 2002‡ 84.3

Honduras 1991/92§ 87.7

Honduras 1996† 83.9

Honduras 2001* 82.6

Nicaragua 1992/93* 71.5

Nicaragua 1998* 83.6

Nicaragua 2001* 86.4

* Live births to women aged 15–49 during the 5 years prior 

to the survey.

†

 Last live birth to women aged 15–49 during the 5 years 

prior to the survey.

‡

 Live births to married women aged 15–49 during the 5 

years prior to the survey.

§

 Last live birth to women aged 15–44 during the 5 years 

prior to the survey.

Percentag

e

Area of Residence

Graph 7.1

Use of Prenatal Care, by Area of Residence 

(Most Recent Survey)

0

20

40

60

80

100

Nicaragua

Honduras

Guatemala

El Salvador

Total Urban Rural
Maternal Health 93

Trends and Challenges Facing Women and Childern

According to the last survey conducted in each 

country, nearly two-thirds of women in El 

Salvador began receiving prenatal care during 

their first trimester of pregnancy, with Nicaragua 

not far behind at 61.0 percent (Table 7.2). 

Care tended to begin later in Guatemala (51.1 

percent), followed by Honduras (56.4 percent). 

However, in all of the countries, there is a trend 

in receiving the first prenatal examination at 

earlier gestational ages (data not shown).

Also shown in Table 7.2, the percentage of 

pregnancies receiving five or more prenatal 

care examinations is highest in Nicaragua 

(71.6 percent) and El Salvador (71.2 percent) 

and lowest in Honduras (58.6 percent) and 

Guatemala (56.6 percent). 

Urban women are more likely than their rural 

counterparts to begin prenatal care during the 

first trimester of pregnancy, and to receive five 

or more visits. Focusing only on rural women, 

rural women in El Salvador rank first on these 

measures, while Guatemala ranks last.

Table 7.2

Use of Prenatal Care, According to 

Area of Residence, By Trimester of First Visit and 

Number of Controls: Live Births in the 5 Years

Prior to the Survey (Most Recent Survey)

Country/Area Year of Survey

First

Trimester

5+

Controls

El Salvador 2002/03

Total 66.0 71.2

Urban 73.6 79.3

Rural 59.5 64.2

Guatemala 2002

Total 51.1 56.6

Urban 64.4 67.4

Rural 44.5 51.2

Honduras 2001

Total 56.4 58.6

Urban 64.1 67.2

Rural 51.3 53.1

Nicaragua 2001

Total 61.0 71.6*

Urban 69.7 82.1*

Rural 50.8 59.3*

* Four or more controls.
94 Maternal Health

Reproductive, Maternal, and Child Health in Central America

Maps 7.1 and 7.2 show the use of prenatal 

care for sub-national regions, according to the 

next-to-last and last surveys conducted in each 

of the four countries. In Nicaragua, there was 

little or no change between the surveys in the 

departments that are not adjacent to the Pacific 

Ocean. In Honduras, there is a notable change 

for the better in the health region that borders 

northern El Salvador, while the health region on 

Honduras’ northern coast lost coverage. With 

regard to El Salvador, each department appears 

to have enjoyed an increase in prenatal care, 

especially in those departments in the eastern 

part of the country. Guatemala presents a mixed 

picture in that some health regions increased 

prenatal coverage between the two surveys, 

while in others coverage decreased.

In the countries for which there are data (El 

Salvador, Guatemala, and Honduras), the 

Ministry of Health is the primary provider of 

prenatal care, according to the latest survey 

(data not shown). The second most important 

provider in El Salvador and Guatemala are 

their respective Social Security Institutes (ISSS 

and IGSS), while in Honduras it is private 

physicians.

<75

75–79

80–84

85–89

90+

% Births with

Prenatal Care
Maternal Health 95

Trends and Challenges Facing Women and Childern

Delivery Care

Skilled medical assistance during childbirth, 

whether at home or in a medical facility, can 

save women’s lives. Untreated or improperly 

treated complications of pregnancy, delivery, 

and the postpartum period are a leading cause 

of death for women in developing countries. 

To prevent maternal complications, skilled 

attendants are needed to provide assistance 

with delivery and monitoring of the postpartum 

period. Skilled attendants include doctors, 

nurses, and midwives trained to manage normal 

deliveries and who can also diagnose and refer 

or else manage obstetric complications.

Surveys measure skilled delivery care in two 

ways: by the percentage of women giving birth 

in a medical facility rather than at home, and 

by the proportion of all births that are attended 

by skilled personnel, whether at home or in a 

health facility. Usually, home deliveries are 

associated with lower skilled assistance. For all 

four countries, data exist on the percentage of 

births attended in a medical facility, while only 

Guatemala and Nicaragua have data on births 

attended by skilled personnel.

Map 7.2

Use of Prenatal Care for Births in the Previous 5 Years 

by Region / Department

(Last Survey)

<75

75–79

80–84

85–89

90+

% Births with

Prenatal Care
96 Maternal Health

Reproductive, Maternal, and Child Health in Central America

According to data from the last survey conducted 

in each country, over half of the women in El 

Salvador, Honduras, and Nicaragua who had at 

least one live birth in the five years prior to the 

survey delivered in a medical facility, ranging 

from 55.2 percent in Honduras to 69.4 percent 

in El Salvador (Table 7.3). The level was 

lowest in Guatemala, at 42.1 percent. However, 

it should be noted that deliveries outside of 

medical facilities are relatively common in all 

of the countries, ranging from 30 percent in 

El Salvador to 58 percent in Guatemala. Not 

surprisingly, births outside of medical facilities 

were far more frequent in rural areas than in 

urban areas, ranging from 46 percent in El 

Salvador to 70 percent in Guatemala (Graph 

7.2).

Each of the countries has experienced an increase 

in the proportion of births in medical facilities 

since the early 1990s (Table 7.3). Most striking 

was the increase in El Salvador, where in the 

Table 7.3

Trends in the Percentage of Deliveries 

Attended in a Medical Facility, By Area of Residence: 

Live Births in the 5 Years Prior to the Survey

Country Year of Survey Percentage

El Salvador 1993* 51.0

El Salvador 1998* 58.0

El Salvador 2002/03* 69.4

Guatemala 1995* 35.3

Guatemala 1998/99* 41.0

Guatemala 2002* 42.1

Honduras 1991/92‡ 45.6

Honduras 1996† 53.8

Honduras 2001* 55.2

Nicaragua 1992/93* 59.2

Nicaragua 1998* 63.6

Nicaragua 2001* 66.3

* Live births to women aged 15–49 during the 5 years prior to the survey.

†

 Last live birth to women aged 15–49 during the 5 years prior to the survey.

‡

 Last live birth to women aged 15–44 during the 5 years prior to the survey. 
Maternal Health 97

Trends and Challenges Facing Women and Childern

2002/03 survey 69.4 percent of women reported 

that their deliveries were in a medical facility, 

compared with 51.0 percent reported in 1993, 

for an 18 percentage point increase. El Salvador 

is followed by Honduras (10 percentage point 

increase) and by Nicaragua and Guatemala with 

a 7 percentage point increase.

With respect to who attended the deliveries, 

data exist for Guatemala and Nicaragua from 

the last survey conducted in these countries. In 

Guatemala, 37.0 percent of all births occurring 

in the five years prior to interview were attended 

by a physician, 4.4 percent by a nurse, and 47.5 

percent by a midwife. In Nicaragua, 45.2 percent 

were attended by a physician, 18.9 percent by a 

gynecologist, 2.8 percent by a nurse, and 22.7 

percent by a midwife (data not shown).

Percentag

e

Area of Residence

0

20

40

60

80

100

Nicaragua

Honduras

Guatemala

El Salvador

Total Urban Rural

Graph 7.2

Percentage of Births Attended in a Medical Facility,

by Area of Residence

(Most Recent Survey)
98 Maternal Health

Reproductive, Maternal, and Child Health in Central America

Maps 7.3 and 7.4 show the percentage of births 

attended in a medical facility, according to the 

next-to-last and last surveys in each country. 

What stands out when the two maps are 

compared is that in almost every department in 

El Salvador over 50 percent of the births are 

attended in a medical facility, according to the 

most recent survey. Excluding the Northern 

and Southern Atlantic Autonomous Regions 

(RAAN and RAAS) in Nicaragua, at least 50 

percent of births are attended in a medical 

facility in the remaining departments, with most 

of the departments that border the Pacific Ocean 

reaching 75 percent. Some improvement is 

noted in Honduras, but the health region on the 

northern coast suffered a decline between the 

two surveys. Guatemala’s situation improved 

slightly, especially in those departments that 

border the Pacific Ocean.

Map 7.3

Percent of Births in the Previous 5 Years Attended in a 

Medical Facility by Region / Department

(Next-to-Last Survey)

<30

30–39

40–49

50–74

75+

% Births with Medical

Facility Delivery
Maternal Health 99

Trends and Challenges Facing Women and Childern

Map 7.4

Percent of Births in the Previous 5 Years Attended in a 

Medical Facility by Region / Department

(Last Survey)

<30

30–39

40–49

50–74

75+

% Births with Medical

Facility Delivery
100 Maternal Health

Reproductive, Maternal, and Child Health in Central America

Cesarean Births

In its plan to reduce maternal mortality, the 

Pan American Health Organization (PAHO) 

indicates that the percentage of all births in a 

country by cesarean section should range from 

5 to 15 percent. If the percentage falls below 

5 percent, this indicates lack of accessibility to 

the procedure, while if it is above 15 percent, 

this indicates abuse in the use of this procedure. 

In Table 7.4, trends in the percentage of all 

deliveries that were by cesarean section are 

shown. Focusing on the most recent survey, 

El Salvador has the highest cesarean rate (22.0 

percent), while Honduras has the lowest rate 

(7.9 percent). As shown in Graph 7.3, the lowest 

cesarean rate was found to be among Honduran 

women who live in rural areas (4.7 percent) 

and the highest among El Salvador’s urban 

women (29.5 percent). Important urban/rural 

differentials exist. For example, in Nicaragua 

and Honduras, approximately three times more 

women who live in urban areas experienced 

a cesarean section than women who live in 

rural areas. In Guatemala and El Salvador the 

differential is approximately two times greater. 

The data indicate that, at least for Nicaragua 

and Guatemala, the trend in delivering births 

by cesarean section is beginning to level off, 

whereas in El Salvador there appears to be an 

upward trend.

Table 7.4

Trends in the Percentage of All 

Deliveries That Were By Cesarean 

Section: Live Births in the 5 Years 

Prior to the Survey

Country Year of Survey Percentage

El Salvador 1993* na

El Salvador 1998* 15.7

El Salvador 2002/03* 22.0

Guatemala 1995* 8.2

Guatemala 1998/99* 10.8

Guatemala 2002* 11.4

Honduras 1991/92‡ 6.5

Honduras 1996† 6.3

Honduras 2001* 7.9

Nicaragua 1992/93* 8.0

Nicaragua 1998* 15.4

Nicaragua 2001* 14.7

* Live births to women aged 15–49 during the 5 years prior 

to the survey.

†

 Last live birth to women aged 15–49 during the 5 years 

prior to the survey.

‡

 Last live birth to women aged 15–44 during the 5 years 

prior to the survey.

Percentag

e

Area of Residence

0

5

10

15

20

25

30

Nicaragua

Honduras

Guatemala

El Salvador

Total Urban Rural

Graph 7.3

Percentage of All Deliveries That Were Cesarean, 

by Area of Residence (Most Recent Survey)
Maternal Health 101

Trends and Challenges Facing Women and Childern

Postpartum Care

It is usually a joyful event when a woman 

gives birth to a baby she wants. Despite the 

pain and discomfort, birth is the long-awaited 

culmination of pregnancy and the start of a new 

life. However, birth is also a critical time for the 

health of the mother and her baby. Problems may 

arise that, if not treated promptly and effectively, 

can lead to ill-health and even death for one 

or both of them. Nonetheless, the postpartum 

period is often neglected by maternity care. The 

lack of postpartum care ignores the fact that 

the majority of maternal deaths and disabilities 

occur during the postpartum period and that 

early neonatal mortality is high. Postpartum 

care should include: the prevention and early 

detection and treatment of complications and 

disease, and the provision of advice and services 

on breastfeeding, birth spacing, immunization, 

and maternal nutrition.

According to the last survey conducted in 

each country, there was great variation in the 

proportion of women receiving postpartum care, 

ranging from 20.3 percent in Guatemala to 54.2 

percent in El Salvador (Table 7.5). As shown in 

Graph 7.4, postpartum care coverage was higher 

in urban areas than in rural areas in each country, 

but the percentage of urban women receiving 

postpartum care pales when compared with the 

percentage of women receiving prenatal care 

(see Table 7.1).Percentag

e

Area of Residence

0

20

40

60

80

100

Nicaragua

Honduras

Guatemala

El Salvador

Total Urban Rural

Graph 7.4

Use of Postpartum Care, by Area of Residence

(Most Recent Survey)

Table 7.5

Trends in the Use of Postpartum

Care: Live Births in the 5 Years

Prior to the Survey

Country Year of Survey Percentage

El Salvador 1993* 30.3

El Salvador 1998* 43.3

El Salvador 2002/03* 54.2

Guatemala 1995* na

Guatemala 1998/99* na

Guatemala 2002* 20.3

Honduras 1991/92‡ 33.6

Honduras 1996† 34.3

Honduras 2001* 34.0

Nicaragua 1992/93* 30.5

Nicaragua 1998* na

Nicaragua 2001* 28.4

* Live births to women aged 15–49 during the 5 years prior to 

the survey.

†

 Last live birth to women aged 15–49 during the 5 years prior 

to the survey.

‡

 Last live birth to women aged 15–44 during the 5 years prior 

to the survey.

na: Not available.

In general, it can be said that postpartum care is 

the least used maternal and child health service 

offered in the four countries. Only in El Salvador 

does one see a systematic increase in the use of 

postpartum care since the early 1990s.
102 Maternal Health

Reproductive, Maternal, and Child Health in Central America

Changes in the Use of 

Maternal Health Services

Graph 7.5 shows changes in the use of key 

maternal health services between the third-tolast survey conducted in the early 1990s and the 

most recent survey since 2000. El Salvador is 

notable for having the most pronounced increases 

for every health service shown. Guatemala 

registered a decline in prenatal care and almost 

a 20 percent increase in births attended in a 

medical facility. Honduras also registered a 

decline in prenatal care, a 21 percent increase 

in medical deliveries, and a very small increase 

in postpartum care. With regards to Nicaragua, 

this country enjoyed both an increase in prenatal 

care and in medical deliveries, but a decline in 

postpartum care.

Cervical Cancer Screening

Worldwide, cervical cancer is the second 

most common cancer of women, and is 

the most frequent cancer of women in 

developing countries. In countries where a 

decline in mortality due to cervical cancer 

has been recorded, much of the decline has 

been attributed to widespread use of cervical 

cancer screening (Papanicolaou smear test), 

resulting in detection at an earlier and therefore 

more curable stage with the treatment of 

premalignant lesions. Experts recommend that 

women who are sexually active, or at least 18 

years old, should have a Pap test annually or at 

least every three years. Although the validity 

of self-reported rates of Pap testing cannot be 

established without examining medical records, 

survey results are often used to estimate the 

extent of cervical screening in the general 

population. The last surveys conducted in El 

Salvador, Guatemala, and Honduras included a 

series of questions regarding Pap testing among 

the female respondents.

As shown in Table 7.6, the percentage of all 

sexually experienced women aged 15–49 who 

reported ever having a Pap test ranged from a 

low of 36.2 percent in Guatemala to a high of 

84.7 percent in El Salvador. In all three of the 

countries, Pap smear prevalence was higher 

in urban areas than in rural areas, with the 

smallest urban/rural differential in El Salvador 

(3.6 percent) and the largest in Honduras (17 

percent) and Guatemala (20 percent).

The proportion of sexually experienced women 

who reported at least one cervical cancer 

screening test increased dramatically in El 

Salvador and Honduras over the past decade. 

In El Salvador screening increased by 17 

percentage points between 1993 and 2002/03, 

while in Honduras screening increased by 10 

percentage points between 1996 and 2001 

(data not shown). In both countries, the largest 

increase occurred in the rural area.

Percent Change -10

0

10

20

30

40

50

60

70

80

Nicaragua

Honduras

Guatemala

El Salvador

Prenatal Care Medical Births Postpartum Care

Graph 7.5

Percent Change Since the Early 1990s in the Use of

Key Maternal Health Services
Maternal Health 103

Trends and Challenges Facing Women and Childern

Tetanus Toxoid Injections

Tetanus is the only vaccine-preventable 

disease that is not communicable but acquired 

through environmental exposure to the spores 

of Clostridium tetani. Neonatal (newborn) 

tetanus is the most common form of tetanus 

in developing countries. The disease is caused 

by contamination of the umbilical stump with 

spores following childbirth through cutting 

the cord with a non-sterile instrument or by 

application of animal dung to the cut cord. 

To protect the newborn with passive immunity, 

women should receive at least two doses of 

tetanus toxoid vaccine during their pregnancy. 

Also, clean practices should be used during 

delivery and for the care of the infant’s umbilical 

cord. The optimal program to protect newborns 

against neonatal tetanus via immunization of 

their mothers depends on the immunization 

history among women. When most women 

of childbearing age have not previously 

been immunized with TT in their infancy or 

adolescence, implementation of a TT five-dose 

schedule for women of childbearing age is of 

the utmost importance. Protective antibody 

levels are attained in 80–90 percent of women 

after the second dose, and in 95–98 percent 

after the third dose. This basic course provides 

protection for at least 5 years. Fourth and fifth 

doses of TT given later will prolong the duration 

of immunity for 10 and 20 years, respectively.

Table 7.7 shows the percentage of women living 

in El Salvador and Honduras who have received 

two or more doses of TT in their lifetime. In 

El Salvador and Honduras, over three-fourths 

of the women have received two or more doses. 

It should be noted that the differences between 

urban and rural women are small.

Table 7.6

Percentage of Women Who Have Ever Been 

Screened For Cervical Cancer, By Area of Residence: 

All Sexually Experienced Women Aged 15–49

(Most Recent Survey)

Country Year of Survey Total Urban Rural

El Salvador 2002/03 84.7 86.3 82.7

Guatemala 2002 36.2 48.0 27.7

Honduras 2001 60.9 69.5 52.6

Nicaragua 2001 na na na

na: Not available.

Table 7.7

Percentage of Women Who Have Received Two

Or More Doses of Tetanus Toxoid in Their Life,

By Area of Residence: Women Aged 15–49 

(Most Recent Survey)

Country Year of Survey Total Urban Rural

El Salvador 2002/03 76.9 78.2 75.3

Guatemala 2002 na na na

Honduras 2001 77.7 77.4 78.1

Nicaragua 2001 na na na

NA: Not available.
104 Maternal Health

Reproductive, Maternal, and Child Health in Central America

Summary of Findings

• The percentage of pregnancies ending in 

a live birth for which prenatal care was 

reported is relatively high in each country—

over 80 percent. Differences between urban 

and rural populations tended to be relatively 

small except in Nicaragua.

• Since the early 1990s, the percentage of 

pregnancies receiving prenatal care has 

increased in El Salvador and Nicaragua, but 

stagnated or deteriorated in Guatemala and 

Honduras.

• In all of the countries, there appears to be 

a trend in making the first prenatal visit at 

younger gestational ages and in receiving 

five or more controls.

• In El Salvador and Nicaragua, at least two out 

of three live births are attended in a medical 

facility. In Honduras and Guatemala, 55 

and 42 percent, respectively, are attended 

in a medical facility. Important urban/

rural differentials exist, with substantially 

more urban women delivering in a medical 

facility than rural women.

• Since the early 1990s, the percentage of 

live births attended in a medical facility has 

been increasing in each country.

• According to the most recent survey, El 

Salvador has the highest cesarean rate (22.0 

percent), while Honduras has the lowest (7.9 

percent), indicating that there may be abuse 

of this service in the former and that some 

women in the latter may not have access to 

this service.

• In all of the countries, less than 55 percent 

of the women reported that they received 

a postpartum examination following birth. 

Only El Salvador appears to be improving 

coverage of this service. More attention 

should be placed on access to post-partum 

care.

• The percentage of sexually experienced 

women who reported that they have ever 

been screened for cervical cancer ranges 

from a low of 36.2 percent in Guatemala 

to a high of 84.7 percent in El Salvador. 

The data suggest that less than half of the 

women are undergoing screening on an 

annual basis.

• In El Salvador and Honduras, more than 75 

percent of women aged 15–49 have received 

two or more doses of tetanus toxoid. 
Infant and Child Mortality 105

Trends and Challenges Facing Women and Childern

 CHAPTER

Infant and Child 

Mortality

The infant mortality rate (the probability of 

dying between birth and the first birthday, 

expressed per 1,000 live births), is an 

important measure of a nation’s health status, 

well-being, and development. Although life 

expectancy at birth has greatly increased over 

the past 50 years, around 40 thousand children 

under five die each year in the four countries 

considered in this report, many from causes 

preventable through a combination of good care, 

nutrition, and medical treatment.

8
106 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America

Map 8.1 shows the regional pattern of infant 

mortality during the 10 year period prior to the 

last survey in each country. Infant mortality is 

lowest in the metropolitan area of capital cities 

in each country. The largest differentials can be 

seen in Guatemala and somewhat in Nicaragua 

with more of a spatial gradient from the Pacificto-Caribbean coast. It is interesting to note the 

relatively low infant mortality of the northern 

Caribbean coast of Honduras, on par with the 

health region of Tegucigalpa. 

Table 8.1 and Graph 8.1 show survey mortality 

estimates for the 5-year periods preceding each 

of the last 3 surveys in each country. According 

to the most recent survey, infant mortality levels 

are highest in Guatemala (39 infant deaths per 

1,000 live births) and lowest in El Salvador (25 

deaths per 1,000). It should be noted that the 

infant mortality rates in Honduras and Nicaragua 

are both over 30 deaths per 1,000. 

In each of the countries, the neonatal mortality 

rate (the probability of dying within the first 

27 days of life) is higher than the postneonatal 

mortality rate (the probability of dying between 

the 28th day of life and the first birthday). This 

is not unexpected since, as infant mortality 

declines, the proportion of that mortality that 

occurs in the first 27 days of life (neonatal 

mortality) increases. 

The child mortality rate (the probability of dying 

between exact ages of 1 and 5), ranges from a low 

of 6 per 1,000 children surviving to age 1 in El 

Salvador to a high of 15 in Guatemala. Similarly, 

the under-5 mortality rate (the probability of 

dying between birth and exact age 5) ranges 

from 31 in El Salvador to 53 in Guatemala.

All of the countries examined in this report show 

a systematic decline in levels of infant mortality 

over the past decade. For example, Nicaragua’s 

infant mortality rate declined by 27 infant deaths 

Map 8.1

Infant Mortality Rate

for 10 Year Period Prior to Survey by Region

(Last Survey)

< 25

25–34

35–44

45–54

55+

Infant Mortality Rate

(per 1,000 Births)
Infant and Child Mortality 107

Trends and Challenges Facing Women and Childern

Table 8.1

Trends in Infant and Child Mortality 

Country 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant Child Under 5

El Salvador 1993 1988–1993 23 18 41 12 52

El Salvador 1998 1993–1998 17 18 35 8 43

El Salvador 2002/03 1997–2002 13 12 25 6 31

Guatemala 1995 1990–1995 26 25 51 18 68

Guatemala 1998/99 1993–1998 23 22 45 14 59

Guatemala 2002 1997–2002 22 16 39 15 53

Honduras 1991/92 1986–1990 19 20 39 16 55

Honduras 1996 1991–1995 19 17 36 13 48

Honduras 2001 1996–2000 19 15 34 11 45

Nicaragua 1992/93 1987–1992 20 38 58 15 72

Nicaragua 1998 1993–1998 17 22 39 11 50

Nicaragua 2001 1996–2001 16 15 31 7 38

* Neonatal, postneonatal, infant and under–5 mortality rates are per 1,000 live births. Child mortality rates are per 

1,000 children surviving to age 1.

0

10

20

30

40

50

60

70

80 Child

Postneonatal

Neonatal

1996-

2001

1993-

1998

1987-

1992

1996-

2000

1991-

1995

1986-

1990

1997-

2002

1993-

1998

1990-

1995

1997-

2002

1993-

1998

1988-

1993

El Salvador Guatemala Honduras Nicaragua

Deaths per 1,000

Graph 8.1

Trends in Under-Five Mortality, Last Three Surveys

Country/Period
108 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America

per 1,000 live births between the periods 1987–

1992 and 1996–2001, with the sharpest decline 

occurring between 1987–1992 and 1993–1998. 

The largest decline in El Salvador’s infant 

mortality rate occurred between 1993–1998 

and 1997–2002, while Guatemala’s decline has 

been constant over the years. Honduras’ decline 

has been less accelerated than that of the other 

countries. 

With the exception of El Salvador, most of the 

decline in infant mortality has been due to a 

decline in postneonatal mortality. It should be 

noted that in Honduras there has been no decline 

in the neonatal mortality rate since the 1986–

1990 period. In Nicaragua, while postneonatal 

mortality declined by 23 deaths per 1,000 live 

births between the first and the last period 

shown in the table, neonatal mortality declined 

by only four deaths. Corresponding figures for 

Guatemala are nine and four deaths, respectively. 

El Salvador emerges as the only country with 

a substantial decline in neonatal mortality, from 

23 infant deaths per 1,000 live births in 1988–

1993 to 13 deaths per 1,000 in 1997–2002.

Mortality Differentials

Table 8.2 shows mortality rates by area of 

residence, according to the last survey conducted 

in each country. El Salvador is the only country 

where the urban and rural infant mortality rates 

do not differ. In all of the other countries, the 

rural rates exceed urban rates, ranging from nine 

deaths per 1,000 live births in Honduras to 15 

deaths per 1,000 in Guatemala, with Nicaragua 

not far behind with a differential of 14 deaths per 

1,000. With the exception of El Salvador, child 

mortality rates are also higher in the rural area 

compared to the urban area. The lack of a rural/

urban difference in El Salvador appears to be 

related to general improvements in education, 

Table 8.2

Infant and Child Mortality Estimates, According to Area of Residence 

(Most Recent Survey) 

Country/Area 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant Child Under 5

El Salvador 2002/03 1997–2002

Total 13 12 25 6 31

Urban 14 11 24 6 31

Rural 13 11 24 6 30

Guatemala 2002 1997–2002

Total 22 16 39 15 53

Urban 20 9 29 12 40

Rural 24 20 44 16 59

Honduras 2001 1996–2000

Total 19 15 34 11 45

Urban 15 14 29 8 36

Rural 22 16 38 13 51

Nicaragua 2001 1996–2001

Total 16 15 31 7 38

Urban 14 10 24 3 27

Rural 18 20 38 12 49

* Neonatal, postneonatal, infant and under-5 mortality rates are per 1,000 live births. Child mortality rates are per 

1,000 children surviving to age 1.
Infant and Child Mortality 109

Trends and Challenges Facing Women and Childern

socioeconomic conditions, prenatal care and 

hospital delivery services, as well as, fertility 

declines in rural areas in recent years. Analysis 

of trends in infant mortality by area of residence 

for El Salvador indicates that mortality decline 

took place primarily in rural areas since the mid 

1990s.

Table 8.3 shows mortality rates according to 

mother’s education. In all of the countries, infant 

mortality generally decreases as the education 

of the mother increases. The differentials can 

be substantial. For example, in Honduras, the 

differential between the lowest and highest 

educational level shown in the table is 45 infant 

deaths per 1,000 live births, while in Guatemala 

it is 43 infant deaths. In Nicaragua, Honduras, 

and Guatemala, postneonatal mortality rates 

also show a very pronounced inverse relation 

with mother’s education. For example, in 

both Nicaragua and Honduras, the difference 

Table 8.3

Infant and Child Mortality Estimates, According to Education of 

Mother (Most Recent Survey)

Country/

Education 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant Child Under 5

El Salvador 2002/03 1997–2002

Total 13 12 25 6 31

None 26 11 36 5 41

1–3 14 16 30 5 34

4–6 10 5 16 8 23

7–9 13 6 20 10 30

10+ 6 17 23 3 26

Guatemala 2002 1997–2002

Total 22 16 39 15 53

None 32 23 55 22 76

Primary 20 15 34 11 45

Secondary+ 9 4 12 5 17

Honduras 2001 1996–2000

Total 19 15 34 11 45

None 30 34 63 23 85

1–3 21 19 40 12 51

4–6 18 10 28 9 37

7+ 12 6 18 4 22

Nicaragua 2001 1996–2001

Total 16 15 31 7 38

None 23 30 53 14 66

1–3 15 19 34 9 42

4–6 14 11 26 7 32

7–9 8 7 16 2 17

10+ 20 1 22 2 23

* Neonatal, postneonatal, infant and under-5 mortality rates are per 1,000 live births. Child mortality rates are 

per 1,000 children surviving to age 1.
110 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America

between the least and most educated women 

is 28–29 deaths per 1,000. Neonatal mortality 

differentials are less pronounced, with a high of 

23 deaths per 1,000 in Guatemala, followed by 

successively smaller differentials in El Salvador, 

Honduras and Nicaragua, respectively.

Table 8.4 shows mortality rates, according to 

age of mother at the time of the birth. Infant 

mortality is lowest among children of mothers 

aged 20–29, the prime ages of childbearing. In 

all of the countries, there is excess mortality 

for children born to women under age 20 and 

to women age 30 or older, especially to women 

aged 40–49.

Table 8.4

Infant and Child Mortality Estimates, According to Age of Mother at Birth

(Most Recent Survey) 

Country/Age 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant Child Under 5

El Salvador 2002/03 1997–2002

Total 13 12 25 6 31

<20 17 9 26 14 40

20–29 10 12 22 5 27

30–39 12 8 20 2 21

40–49 56 24 80 0 80

Guatemala 2002 1997–2002

Total 22 16 39 15 53

<20 27 18 45 12 56

20–29 20 13 33 15 48

30–39 19 19 38 14 52

40–49 62 29 91 31 119

Honduras 2001 1996–2000

Total 19 15 34 11 45

<20 20 23 43 8 51

20–29 15 10 25 10 34

30–39 22 17 39 17 55

40–49 50 37 87 11 97

Nicaragua 2001 1996–2001

Total 16 15 31 7 38

<20 22 12 33 7 41

20–29 13 12 25 6 31

30–39 15 23 38 9 47

40–49 14 29 42 21 63

* Neonatal, postneonatal, infant and under-5 mortality rates are per 1,000 live births. Child mortality rates are per 

1,000 children surviving to age 1.
Infant and Child Mortality 111

Trends and Challenges Facing Women and Childern

Studies in many countries have found that the 

length of the preceding birth interval is strongly 

associated with infant mortality risks and that 

the interval of three to five years is optimal. 

Births occurring after a short birth interval, i.e., 

less than 24 months, have substantially higher 

mortality than births occurring after a longer 

interval. As shown in Table 8.5 and Graph 8.2, 

results from the most recent survey conducted 

in each country are consistent with these 

Table 8.5

Infant and Child Mortality Estimates, According to Previous Birth

Interval (Most Recent Survey) 

Country/

Interval 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant Child Under 5

El Salvador 2002/03 1997–2002

Total 13 12 25 6 31

< 2 Years 21 15 36 10 45

2–2.9 Years 7 8 14 8 22

3–3.9 Years 6 10 15 6 21

4+ Years 11 14 25 3 28

Guatemala 2002 1997–2002

Total 22 16 39 15 53

< 2 Years 25 25 50 16 66

2–2.9 Years 21 19 40 15 55

3–3.9 Years 16 7 22 12 35

4+ Years 15 10 25 14 39

Honduras 2001 1996–2000

Total 19 15 34 11 45

< 2 Years 26 24 50 16 66

2–2.9 Years 11 14 25 10 34

3–3.9 Years 16 18 35 9 43

4+ Years 27 10 36 13 48

Nicaragua 2001 1996–2001

Total 16 15 31 7 38

< 2 Years 25 33 58 14 71

2–2.9 Years 11 13 24 10 34

3–3.9 Years 7 19 26 5 31

4+ Years 15 7 22 5 27

* Neonatal, postneonatal, infant and under-5 mortality rates are per 1,000 live births. Child mortality rates are 

per 1,000 children surviving to age 1.
112 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America

studies. In Nicaragua, the infant mortality rate 

of children with a birth interval of less than 24 

months is 58 while in Honduras and Guatemala 

it is at 50 infant deaths per 1,000 live births. 

Interestingly, the rate in El Salvador is only 

36 deaths per 1,000, but remains substantially 

higher than children born with a preceding birth 

interval of 2 to 3 years.

As shown in Table 8.6, infant mortality generally 

increases as birth order of the child increases. 

The children at highest risk of dying are those 

who are the seventh or higher birth order child.

Finally, one would expect that infant mortality, 

and particularly neonatal mortality, would 

be lower to infants born in a medical facility 

compared to infants born outside of a medical 

Deaths per 1,000 Births

0

10

20

30

40

50

60

70

< 2 2 3 4+ < 2 2 3 4+ < 2 2 3 4+ < 2 2 3 4+

El Salvador Guatemala Honduras Nicaragua

Birth Interval (Years)

Graph 8.2

Infant Mortality by Previous Birth Interval

(Most Recent Survey)
Infant and Child Mortality 113

Trends and Challenges Facing Women and Childern

Table 8.6

Infant and Child Mortality Estimates, According to Birth Order

(Most Recent Survey) 

Country/Birth 

Order 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant Child Under 5

El Salvador 2002/03 1997–2002

Total 13 12 25 6 31

1 12 10 22 6 27

2–3 12 11 23 9 31

4–6 9 13 23 4 26

7+ 33 10 43 4 46

Guatemala 2002 1997–2002

Total 22 16 39 15 53

1 29 14 43 13 55

2–3 17 13 30 11 41

4–6 23 20 43 18 61

7+ 24 21 46 19 63

Honduras 2001 1996–2000

Total 19 15 34 11 45

1 16 11 28 6 33

2–3 21 17 38 11 48

4–6 18 11 29 10 39

7+ 21 29 50 25 74

Nicaragua 2001 1996–2001

Total 16 15 31 7 38

1 17 8 25 3 29

2–3 16 12 28 6 34

4–6 11 16 26 7 33

7+ 22 37 59 18 76

* Neonatal, postneonatal, infant and under-5 mortality rates are per 1,000 live births. Child mortality rates are per 

1,000 children surviving to age 1.
114 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America

facility. According to the data shown in Table 

8.7 and Graph 8.3, this is not necessarily the case 

in at least two of the countries. In El Salvador 

and Guatemala, there is no difference in the 

neonatal mortality rate between births occurring 

in a medical facility and those outside a medical 

facility, while in Nicaragua the difference (in 

favor of hospital births) is only four deaths 

per 1,000 live births, and increases to seven in 

Honduras. It is interesting to note the advantages 

accrued to infants born in medical facilities 

during the postneonatal period in all four 

countries. With the exception of El Salvador, 

the associated advantages in survivorship by 

age 1 are substantial. In Guatemala, Honduras, 

and Nicaragua the infant mortality rates of 

children born outside medical facilities are 11, 

15, and 17 deaths per 1,000 live births higher, 

respectively, than their counterparts born in 

medical facilities.

Table 8.7

Infant Mortality Estimates, According to Place 

of Birth (Most Recent Survey) 

Country/Place of 

Birth 

Year of 

Survey Time Period

Mortality Rates per 1,000*

Neonatal Postneonatal Infant

El Salvador 2002/03 1997–2002

Total 13 12 25

Medical Facility 13 11 23

Other 13 13 26

Guatemala 2002 1997–2002

Total 22 16 39

Medical Facility 22 9 30

Other 21 20 41

Honduras 2001 1996–2000

Total 19 15 34

Medical Facility 16 13 28

Other 23 20 43

Nicaragua 2001 1996–2001

Total 16 15 31

Medical Facility 14 9 23

Other 18 21 40

* Neonatal, postneonatal and infant mortality rates are per 1,000 live births. 
Infant and Child Mortality 115

Trends and Challenges Facing Women and Childern

Perinatal Mortality

The perinatal mortality rate measures the 

number of perinatal deaths per 1,000 births. 

The perinatal period starts at 28 weeks 

gestation and ends at the end of the seventh 

day after delivery. Perinatal deaths are the 

sum of stillbirths plus early neonatal deaths. 

Perinatal mortality rates have long been used 

as an indicator of the standard of maternal and 

newborn care. The incidence of perinatal deaths 

is generally higher among the babies of mothers 

who do not receive prenatal care, among male 

babies, and among first births and fifth or more 

pregnancies. Maternal age is another important 

factor associated with perinatal mortality. The 

high risk groups are mothers over the age of 40 

and teenage mothers. Rates can be as low as 6 

per 1,000 births in some developed countries, 

but are considerably higher in the developing 

world.

Deaths per 1,000 Births

0

10

20

30

40

50

Medical Other

Facility

Medical Other

Facility

Medical Other

Facility

Medical Other

Facility

El Salvador Guatemala Honduras Nicaragua

Medical Attention / Country

Graph 8.3

Infant Mortality by Place of Delivery
116 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America

According to the last survey conducted in each 

country, perinatal mortality varied from a low 

of 23 deaths per 1,000 births in El Salvador to 

a high of 35 deaths in Guatemala (Table 8.8). 

In general, there are more stillbirths than deaths 

to infants during the first seven days of life. In 

each country, the rural perinatal mortality rate is 

greater than the urban rate, although the urban/

rural differential in Guatemala is relatively 

small. 

Table 8.8

Perinatal Mortality Estimates, According to Area of Residence 

(Most Recent Survey) 

Country/Area 

Year of 

Survey Time Period

Perinatal Mortality Rates* 

Stillbirth Died 0–7 Days Total

El Salvador 2002/03 1997–2002

Total 12 11 23

Urban 6 12 18

Rural 18 9 27

Guatemala 2002 1997–2002

Total 18 17 35

Urban 16 17 33

Rural 19 18 36

Honduras 2001 1996–2000

Total 16 14 30

Urban 13 12 25

Rural 18 14 32

Nicaragua 2001 1996–2001

Total 10 11 21

Urban 9 11 20

Rural 10 12 22

* The number of early neonatal deaths (first seven days of life) and still births (defined 

as pregnancy losses occurring after the sixth month of pregnancy) per 1,000 viable 

pregnancies (live births and still births) that occurred during the reference period.
Infant and Child Mortality 117

Trends and Challenges Facing Women and Childern

Summary of Findings

• Survey estimates of mortality were 

computed for the 5-year period preceding 

the last survey conducted in each country. 

Infant mortality estimates were lowest 

for El Salvador and Nicaragua (25 and 31 

deaths per 1,000 live births) and higher for 

Honduras and Guatemala (34 and 39 deaths 

per 1,000).

• All of the countries have experienced 

a systematic decline in levels of infant 

mortality over the past decade and a half, with 

the largest decline taking place in Nicaragua 

and the smallest decline in Honduras.

• With the exception of El Salvador, most 

of the decline in infant mortality has been 

due to a decline in postneonatal mortality. 

Currently, the neonatal mortality rate in 

each of the countries is higher than the 

postneonatal mortality rate. 

• The most significant infant mortality 

differentials were associated with the 

mother’s education, followed by previous 

birth interval and area of residence. In all 

of the countries, infant mortality generally 

decreases as the education of the mother 

increases and as the previous birth interval 

increases. The data suggest that the best 

time to have a baby is between 20 and 29 

years of age.

• Perinatal mortality is relatively high in the 

four countries, ranging from 23 deaths per 

1,000 births in El Salvador to a high of 35 

deaths per 1,000 in Guatemala.
118 Infant and Child Mortality

Reproductive, Maternal, and Child Health in Central America
 Child Health 119

Trends and Challenges Facing Women and Childern

 CHAPTER

Child Health

Since the early 1990s, there have been 

improvements in child survival in the four 

countries examined in this report. Despite 

these improvements, much work remains to be 

done in reducing levels of infant and under-five 

mortality and morbidity.

This chapter covers a number of topics related 

to the health of the child, such as birth weight, 

the use of well-baby care, child immunizations, 

the prevalence of diarrhea and acute respiratory 

infections during the 15 days prior to interview, 

the use of oral rehydration salts to treat the 

most recent episode of diarrhea, and the use of 

antibiotics to treat acute respiratory infections.

9
120 Child Health

Reproductive, Maternal, and Child Health in Central America

Birth Weight

A healthy birth weight is very important for a good 

start in life. Low birth weight babies are at high 

risk of experiencing health and developmental 

problems, and are more likely to get sick or 

die in their first year of life than normal weight 

babies. Since birth weight is a major predictor 

of infant morbidity and mortality, it should be 

monitored closely.

The proportion of live births during the five years 

prior to interview that were weighed at birth or 

during the 7 days following birth ranged from a 

low of 64.5 percent in Honduras to a high of 

86.8 percent in El Salvador (Table 9.1 and Graph 

9.1). In all of the countries, the probability of a 

newborn being weighed is substantially higher 

among newborns whose mothers live in urban 

areas than whose mothers live in rural areas. 

This is due to the fact that many deliveries in the 

rural areas of these countries still occur outside 

of a medical facility.

Well-Baby Care

Well-baby care consists of several visits to a 

medical facility during the child’s first few years 

to monitor whether growth and development are 

proceeding normally, recognize problems early 

and supply appropriate intervention, provide 

immunizations, provide information about 

breastfeeding, diet and general care, and other 

important advice and information for parents. 

Because the health of the baby in the first year 

lays the foundation for later childhood, wellbaby visits made during the first year are very 

important.

In the surveys conducted in the four countries 

profiled in this report, the questions asked about 

the use of well-baby care services refer to the 

first visit to a medical facility following birth. In 

general, the Ministry of Health in each country 

recommends that the first visit be made within 

30 days of the birth of the child.

Table 9.1

Percentage of Children Weighed at 

Birth Or During the 7 Days Following 

Birth, By Area of Residence: Live Births 

During the 5 Years Prior to the Survey 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 86.8 95.3 79.5

Guatemala 2002 78.2 92.9 70.8

Honduras 2001 64.5 88.2 49.1

Nicaragua 2001 74.6 92.9 56.5

0

20

40

60

80

100

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua

Percentag

e

Country

Graph 9.1

Percentage of Children Weighed at Birth Or During the Seven Days 

Following Birth, By Area of Residence: Live Births in the Five Years 

Prior to Survey (Most Recent Survey)
 Child Health 121

Trends and Challenges Facing Women and Childern

According to the last survey conducted in each 

country, the percentage of live births receiving 

well-baby care is very high in El Salvador and 

Honduras, where over 90 percent of newborns 

received this care (Table 9.2 and Graph 9.2). 

The use of well-baby care is relatively low in 

Guatemala, as only 43.2 percent of newborns 

were seen in a medical facility. As noted in the 

graph, the urban/rural differential is very small 

in El Salvador, but slightly larger in Honduras, 

while the differential in Guatemala is almost 17 

percentage points. Since the early 1990s, the use 

of well-baby care has increased in El Salvador 

and Honduras, with the largest increase occurring 

in El Salvador (about 14 percentage points), and 

the smallest increase occurring in Honduras (6 

percentage points).

Child Immunization

The World Health Organization (WHO) 

Expanded Program on Immunization focuses 

on six common childhood diseases that can 

be prevented by immunization: diphtheria, 

pertussis, and tetanus (DPT), measles, polio, and 

tuberculosis (BCG). Full immunization includes 

three doses of DPT vaccine, three doses of the 

oral polio vaccine, a measles vaccination, and a 

BCG vaccination. In this section, levels of full 

Table 9.2

Trends in the Use of Well-baby

Care: Live Births During The Five 

Years Prior To The Survey To 

Women Of Fertile Age

Country Year of Survey Percentage

El Salvador 1993* 80.8

El Salvador 1998* 89.9

El Salvador 2002/03* 95.0

Guatemala 1995a na

Guatemala 1998/99* na

Guatemala 2002* 43.2

Honduras 1991/92‡ 84.6

Honduras 1996† 77.7

Honduras 2001* 90.7

Nicaragua 1992/93* 82.9

Nicaragua 1998* na

Nicaragua 2001* na

* Live births to women aged 15–49 during the 5 years prior to the 

survey.

†

 Selected live birth to women aged 15–49 during the 5 years prior 

to the survey.

‡

 Last live birth to women aged 15–44 during the 5 years prior to 

the survey.

na: Not available.

0

20

40

60

80

100

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua

Percentag

e

Country

Graph 9.2

Use of Well-Baby Care, By Area of Residence: Live Births in the 

Five Years Prior to Survey (Most Recent Survey)
122 Child Health

Reproductive, Maternal, and Child Health in Central America

immunization of children aged 12–23 months 

are examined (in Nicaragua the age range 18–29 

months was used in the report for the most recent 

survey and this is the information presented 

here).

Among the four countries surveyed, full 

childhood immunization varies from a low of 

62.5 percent of children aged 12–23 months in 

Guatemala to a high of 77.7 percent in Honduras, 

according to the most recent survey (last column 

of Table 9.3 and Graph 9.3). In each country the 

urban/rural differential is small. 

Comparing coverage by vaccine, BCG is highest 

in every country, while measles vaccine, which 

also requires one dose to infer protection, has 

the poorest coverage (Graph 9.4). The data 

suggest that missing the third dose of vaccine 

in the polio and DPT series and the measles 

vaccine altogether is the reason that complete 

immunization levels are relatively low in each 

country. Incomplete vaccinations can reflect 

problems with service delivery and logistics 

systems, as well as lack of health services in 

remote locations.

Graph 9.4 also shows that coverage of BCG 

and DPT is high and similar in El Salvador and 

Honduras. Honduras is in first place with regards 

to polio (91 percent) while the other countries 

present a range from a low of 78 percent in 

Guatemala to 85 percent in Nicaragua. Measles 

coverage is highest in Nicaragua (86 percent) 

followed by Honduras (83 percent), El Salvador 

(80 percent) and Guatemala (75 percent). 

For each of the vaccines shown in Graph 9.4, 

Guatemala has the lowest coverage.

Table 9.3

Percentage of Children Aged 12–23 Months Who are 

Fully Immunized, According to Area of Residence, By Vaccine

(Most Recent Survey)

Country/Area Year of Survey BCG Polio DPT Measles All

El Salvador 2002/03

Total 98.3 83.3 89.2 79.9 69.8

Urban 98.3 84.9 90.3 76.9 69.9

Rural 98.2 81.8 88.2 82.9 69.7

Guatemala 2002

Total 91.9 78.1 76.7 74.7 62.5

Urban 91.9 74.0 74.3 75.9 62.7

Rural 91.9 80.2 77.9 74.1 62.3

Honduras 2001

Total 98.2 91.1 90.6 83.1 77.7

Urban 98.2 92.3 90.5 81.3 74.6

Rural 98.1 90.4 90.7 84.2 79.6

Nicaragua* 2001

Total 95.5 84.7 82.7 86.4 71.6

Urban 98.7 86.9 84.7 89.8 73.9

Rural 92.5 82.7 80.7 83.1 69.4

* Based on ages 18-29 months
 Child Health 123

Trends and Challenges Facing Women and Childern

Percentag

e

Country

0

20

40

60

80

100

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua*

*18–29 months

Graph 9.3

Percentage of Children Who are Fully Immunized With BCG, Polio,

DPT, and Measles Vaccines, By Area of Residence: Children Aged 

12–23 Months (Most Recent Survey)

Percentag

e

Vaccine

0

20

40

60

80

100

Nicaragua

Honduras

Guatemala

El Salvador

BCG Polio DPT Measles

Graph 9.4

Percentage of Children Aged 12–23 Months Who are 

Completely Immunized (Most Recent Survey)
124 Child Health

Reproductive, Maternal, and Child Health in Central America

As shown in Table 9.4, between the next-tolast and last survey, gains in full childhood 

immunization appears to be slowing or even 

declining. Between the early 1990s and the late 

1990s, both El Salvador and Guatemala made 

significant gains in immunization coverage. But 

since the late 1990s a slowing, or even decline, in 

coverage related to measles vaccine has affected 

overall immunization coverage, as the coverage 

of the other vaccines has been increasing.

Table 9.4

Trends in the Percentage of Children Aged 12–23 Months Who

 are Fully Immunized, By Vaccine

Country Year of Survey BCG Polio DPT Measles All

El Salvador 1993* 87.0 78.1 78.0 82.1 70.6

El Salvador 1998* 96.3 85.7 85.9 85.6 77.0

El Salvador 2002/03* 98.3 83.3 89.2 79.9 69.8

Guatemala 1995* 78.2 55.9 59.4 75.1 42.6

Guatemala 1998/99* 90.3 66.7 70.4 80.6 59.5

Guatemala 2002* 91.9 78.1 76.7 74.7 62.5

Honduras 1991/92† 94.0 94.2 93.4 80.3 na

Honduras 1996* 96.4 85.6 85.5 88.0 81.6

Honduras 2001* 98.2 91.1 90.6 83.1 77.7

Nicaragua 1992/93* 91.2 84.0 80.8 83.4 na

Nicaragua 1998* 95.0 83.0 79.7 85.7 72.6

Nicaragua 2001*‡ 95.5 84.7 82.7 86.4 71.6

* Based on vacination cards and mother’s responses

†

 Based on vacination cards and those reporting never having a vacine

‡

 Based on ages 18-29 months
 Child Health 125

Trends and Challenges Facing Women and Childern

Map 9.1 illustrates the regional coverage of the 

vaccination program within countries. It shows 

percent of children, 12–59 months, who had 

received the recommended doses of BCG, DPT, 

Polio and measles vaccines, according to the most 

recent survey. For Nicaragua, data are presented 

for children ages 18–29 months. It is noteworthy 

that a coverage of 80 percent or greater has been 

achieved for all health regions in Honduras, with 

three regions immunizing more than 90 percent 

of children. In Guatemala, none of the regions 

had exceeded 80 percent, and three regions had 

less than 70 percent coverage. In El Salvador 

all but 4 regions exceed 80 percent, but none 

had reached 90 percent, and Nicaragua exhibits 

a broad range in coverage with the autonomous 

northern and southern regions of the Atlantic 

coast (RAAN and RAAS regions) having less 

than 60 percent coverage. 

Map 9.1

Complete Immunization of BCG, DPT/Penta, Polio and Measles,

Childern 12–59 Months (18–29 Months in Nicaragua), 

(Last Survey)

< 60

60–69

70–79

80–89

90+

% Children with

complete Immunization
126 Child Health

Reproductive, Maternal, and Child Health in Central America

Prevalence and Treatment 

of Diarrhea and Acute 

Respiratory Infections

In the four countries profiled in this report, the 

primary causes of infant and child morbidity 

and mortality are respiratory infections and 

diarrhea. As a result, the DHS and RHS surveys 

conducted in these countries have included 

modules that investigate the prevalence of these 

diseases, their severity, and what was done to 

treat children with a recent episode of diarrhea 

or acute respiratory infection.

Addressing diarrhea first, according to the 

results of the last survey conducted in each 

country, from 13.1 percent (Nicaragua) to 22.5 

percent (Honduras) of children under age 5 were 

reported to have had diarrhea during the two 

weeks prior to interview (Table 9.5 and Graph 

9.5). The difference in prevalence may be due to

when fieldwork was conducted in each country, 

or to the living conditions in each country, 

or both. It is difficult to distinguish which is 

more important here. In all of the countries, 

rural prevalence rates exceed urban rates, with 

Guatemala presenting an urban/rural differential 

of almost 10 percentage points.

Table 9.5

Percentage of Children With Diarrhea 

During the Two Weeks Prior to 

Interview, By Area of Residence: 

Children Less Than 5 Years of Age 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 13.9 11.7 15.9

Guatemala 2002 22.2 15.8 25.4

Honduras 2001 22.5 21.1 23.4

Nicaragua 2001 13.1 11.7 14.4

Percentag

e

Country

0

5

10

15

20

25

30

Rural

Total

Urban

El Salvador Guatemala Honduras Nicaragua

Graph 9.5

Percentage of Children With Diarrhea During the Two Weeks

Prior to Interview, By Area of Residence: Children Less

Than Five Years of Age (Most Recent Survey)
 Child Health 127

Trends and Challenges Facing Women and Childern

In general, prevalence rates are lowest among 

children aged 0–5 months and highest among 

children aged 12–23 months (Table 9.6 and 

Graph 9.6), possibly reflecting a beneficial 

effect of breastfeeding among the younger 

age group. As children 6–11 months of age 

are weaned and are exposed to other foods 

and become more active in contaminated 

environments, the prevalence of diarrhea 

begins to increase.

Table 9.6

Percentage of Children With Diarrhea During 

the Two Weeks Prior to Interview, By Age of Child (In Months): 

Children Less Than 5 Years of Age (Most Recent Survey)

Country

Year of 

Survey Total

Age of Child

0-5 6-11 12-23 24-35 36-47 48-59

El Salvador 2002/03 13.8 13.8 22.9 19.6 11.8 12.0 8.4

Guatemala 2002 22.2 15.0 29.9 33.1 26.2 15.9 12.8

Honduras 2001 22.5 15.1 32.8 37.3 22.8 16.5 9.8

Nicaragua 2001 13.1 13.1 19.6 19.1 14.2 7.7 7.5 Percentag

e

Age in Months

Graph 9.6

 Percentage of Children With Diarrhea, By Age of Child (In 

Months): Children Less Than 5 Years of Age

 (Most Recent Survey)

0

5

10

15

20

25

30

35

40

45

Nicaragua

Honduras

Guatemala

El Salvador

0-5 6-11 12-23 24-35 36-47 48-49
128 Child Health

Reproductive, Maternal, and Child Health in Central America

From 41 to 50 percent of the mothers with a 

child who had a recent episode of diarrhea 

consulted with someone about the disease 

(Table 9.7). The urban/rural differential in 

each country was small, but urban mothers 

were more likely to consult with someone than 

rural mothers. In El Salvador and Honduras, 

the probability of consulting with someone 

increased as the duration and severity of the 

diarrhea increased (data not shown). 

As shown in Table 9.8 and Graph 9.7, the 

percentage of children with diarrhea who 

were treated with oral rehydration salts (ORS) 

was highest in El Salvador (51.4 percent) 

and Nicaragua (50.0 percent), and lowest in 

Guatemala (33.8 percent) and Honduras (29.6 

percent). In Guatemala and Honduras, use of 

ORS was greater in the rural area than in the 

urban area. Between the last two surveys, 

use of ORS increased slightly in El Salvador 

and Guatemala, remained about the same in 

Honduras, and decreased slightly in Nicaragua 

(data not shown).

Table 9.8

Percentage of Children With Diarrhea 

During the Two Weeks Prior to 

Interview, Whose Mothers Treated 

Them With Oral Rehydration Salts, 

By Area of Residence: Children Less 

Than 5 Years Of Age

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 51.4 55.0 49.0

Guatemala 2002 33.8 32.2 34.3

Honduras 2001 29.6 18.6 36.6

Nicaragua 2001 50.0 53.9 45.7

Table 9.7

Percentage of Children Less Than 5 

Years of Age With Diarrhea During 

the Two Weeks Prior to Interview, 

Whose Mothers Consulted With 

Someone About Their Recent Episode 

of Diarrhea, By Area of Residence: 

Children Less Than 5 Years of Age 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 50.4 57.0 46.2

Guatemala* 2002 41.6 46.6 40.1

Honduras 2001 48.8 51.4 47.1

Nicaragua* 2001 44.1 45.4 43.1

* Includes only health providers. Percentag

e

Country

0

10

20

30

40

50

60

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua

Graph 9.7

Percentage of Children With Diarrhea Who Were Treated With

Oral Rehydration Salts, By Area of Residence: Children Less

Than Five Years of Age (Most Recent Survey)
 Child Health 129

Trends and Challenges Facing Women and Childern

In all of the countries, less than 50 percent of 

the mothers increased the amount of liquids that 

they gave to their children with diarrhea (Table 

9.9 and Graph 9.8). The probability of increasing 

liquids was highest in Guatemala (48.2 percent) 

and lowest in Honduras (30.9 percent). As 

shown in the graph, a higher percentage of 

urban mothers increased the amount of liquids 

given to their children than rural mothers.

Table 9.9

Percentage of Children With Diarrhea 

During the Two Weeks Prior to 

Interview, Whose Mothers Increased 

the Amount of Liquids Given to 

Them During Their Recent Episode 

of Diarrhea, By Area of Residence: 

Children Less Than 5 Years of Age 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 46.2 50.2 43.6

Guatemala 2002 48.2 51.6 47.2

Honduras 2001 30.9 33.8 29.2

Nicaragua 2001 39.2 46.3 33.4

Percentag

e

Country

0

10

20

30

40

50

60

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua

Graph 9.8

Percentage of Children With Diarrhea Who Were Given More Liquids 

By Their Mothers, By Area of Residence: Children Less Than Five

Years of Age (Most Recent Survey)
130 Child Health

Reproductive, Maternal, and Child Health in Central America

Turning to acute respiratory infections (ARI), the 

prevalence of ARI varied considerably across the 

four countries (Table 9.10 and Graph 9.9). The 

variance may be due to when the last survey was 

conducted in each country. While Guatemala 

reported the lowest prevalence of ARI (18.2 

percent), Honduras reported the highest (48.6 

percent). As expected, prevalence of ARI was 

highest in the rural areas of each country, but the 

urban/rural differences are small.

Table 9.10

Percentage of Children With 

Respiratory Infections During the 

Two Weeks Prior to Interview, 

By Area of Residence: Children Less 

Than 5 Years of Age 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 42.3 39.3 45.0

Guatemala 2002 18.2 14.4 20.2

Honduras 2001 48.6 45.4 50.7

Nicaragua 2001 30.9 28.5 30.2

Percentag

e

Country

Graph 9.9

Percentage of Children With Respiratory Infections During the 

Two Weeks Prior to Interview, By Area of Residence: Children

Less Than Five Years of Age (Most Recent Survey)

0

10

20

30

40

50

60

Urban

Total

Rural

El Salvador Guatemala Honduras Nicaragua
 Child Health 131

Trends and Challenges Facing Women and Childern

As was the case with diarrhea, prevalence of 

ARI was lowest among children aged 0–5 

months, again reflecting the protective effect of 

breastfeeding (Table 9.11 and Graph 9.10). In 

general, the highest prevalence was recorded for 

children aged 6–11 months, followed closely by 

children aged 12–23 months.

Table 9.11

Percentage of Children With Respiratory Infections During 

the Two Weeks Prior to Interview, By Age of Child (In Months): 

Children Less Than 5 Years of Age (Most Recent Survey)

Country

Year of 

Survey Total

Age of Child

0-5 6-11 12-23 24-35 36-47 48-59

El Salvador 2002/03 42.3 35.5 49.6 48.5 40.9 41.5 39.5

Guatemala 2002 18.2 13.0 22.5 21.9 18.7 16.9 15.6

Honduras 2001 48.6 46.3 55.4 51.9 49.1 47.8 42.2

Nicaragua 2001 30.9 22.6 36.0 37.4 32.6 28.2 25.6 Percentag

e

Age in Months

Graph 9.10

Percentage of Children With Respiratory Infections,

By Age of Child (In Months): Children Less Than 5 Years of Age

 (Most Recent Survey)

0

10

20

30

40

50

60

Nicaragua

Honduras

Guatemala

El Salvador

0-5 6-11 12-23 24-35 36-47 48-49
132 Child Health

Reproductive, Maternal, and Child Health in Central America

From 52.0 to 64.3 percent of the mothers with 

a child with a recent episode of ARI consulted 

with someone about the disease (Table 9.12). 

Unlike diarrhea, the urban/rural differential 

in each country was relatively large, reaching 

almost 20 percentage points in Guatemala. In 

El Salvador, the probability of consulting with 

someone increased as the duration and severity 

of the ARI increased, but in Honduras, more 

mothers of children with a moderate episode of 

ARI consulted with someone than those with 

children experiencing a severe case of ARI (data 

not shown).

As shown in Table 9.13, the use of antibiotics 

to treat ARI was relatively high in El Salvador 

(52.9 percent) and relatively low in Honduras 

(25.5 percent). In El Salvador, almost 40 percent 

of children who were classified with having only 

a cold were given antibiotics, while in Honduras, 

20 percent of the children with a mild form of 

ARI were treated with antibiotics (data not 

shown). On the other hand, a sizeable proportion 

of children in both countries with a severe ARI 

were not treated with antibiotics. It appears that 

there is inappropriate use of antibiotics in both 

countries.

Table 9.12

Percentage of Children Less Than 

5 Years of Age With Respiratory 

Infections During the Two Weeks 

Prior to Interview, Whose Mothers 

Consulted With Someone About Their 

Illness, By Area of Residence: Children 

Less Than 5 Years of Age 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 61.6 74.3 52.0

Guatemala* 2002 64.3 78.9 59.0

Honduras 2001 52.0 57.0 48.5

Nicaragua* 2001 57.4 64.4 51.0

* Includes only health providers.

Table 9.13

Percentage of Children Less Than 5 

Years of Age With Respiratory 

Infections During the Two Weeks Prior 

to Interview, Who Were Treated With 

Antibiotics, By Area of Residence 

(Most Recent Survey)

Country

Year of 

Survey Total Urban Rural

El Salvador 2002/03 52.9 61.4 46.4

Guatemala 2002 na na na

Honduras 2001 25.5 34.3 19.3

Nicaragua 2001 na na na

na: Not available.
 Child Health 133

Trends and Challenges Facing Women and Childern

Summary of Findings

· Less than 87 percent of live births are weighed 

at birth or during the 7 days following birth. 

This proportion decreases to less than 80 

percent among live births occurring to rural 

women.

· Over 90 percent of live births in El Salvador 

and Honduras received well-baby care, 

compared to 43.2 percent of live births in 

Guatemala. Urban/rural differentials are 

small in El Salvador and Honduras, but about 

17 percentage points in Guatemala.

· Full childhood immunization of children 

age 12–23 months varies from 62.5 percent 

in Guatemala to 77.7 percent in Honduras. 

Missing the third dose of vaccine in the polio 

and DPT series and the measles vaccine 

altogether are probably the reasons that 

complete immunization levels are relatively 

low in the four countries. The fact that urban 

and rural immunization coverage within each 

country is relatively similar is a good example 

of improving equity in access to this service. 

· Prevalence of diarrhea and acute respiratory 

infections (ARI) varies from country to 

country, and may be due to the time of 

year the last survey was conducted in each 

country. As expected, prevalence of both 

diseases was higher in rural than in urban 

areas. Breastfeeding appears to provide some 

protection against both diseases in children 

aged 0–5 months.

· The probability that a mother would consult 

with someone if the child was sick is greater 

if the child was suffering from an ARI than 

from a bout of diarrhea.

· The use of oral rehydration salts is low in 

the countries examined, as is increasing the 

amount of liquids given to children with 

diarrhea. Both issues need to be addressed 

in future public education campaigns, 

particularly in Guatemala and Honduras.

· The data suggest that there may be 

inappropriate use of antibiotics to treat ARIs 

in some of the countries.
134 Child Health

Reproductive, Maternal, and Child Health in Central America
Infant Feeding Practices and Nutrition Status of Childern 135

Trends and Challenges Facing Women and Childern

CHAPTER

Infant Feeding 

Practices and 

Nutrition Status of 

Children

This chapter covers three topics: 

breastfeeding of infants, nutritional 

status of children, and anemia in children 

and mothers.

Breastfeeding

Infant feeding practices influence the health of 

both the child and the mother. Breastfeeding is 

a primary determinant of an infant’s nutritional 

status and its susceptibility to morbidity. Early 

initiation of breastfeeding permits the newborn 

to benefit immediately from colostrum, which 

is highly nutritious and contains the antibodies 

necessary to protect babies from infection before 

their immune systems are fully mature. The health 

of a woman is also affected by breastfeeding 

because it delays the return of ovulation and 

provides a period of time in which she is not 

susceptible to the risk of another pregnancy.

10
136 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

Table 10.1 and Graph 10.1 show that 94 percent 

or more of infants were breastfed, according to 

the last survey. In all of the countries, the percent 

of children who were breastfed has exceeded 90 

percent since the early 1990s. In Nicaragua, 

76.3 percent of infants were breastfed within 

the first hour, followed by Guatemala at 60.1 

percent. The percentage of children breastfed 

within the first hour following birth is relatively 

low in Honduras (48.9 percent) and El Salvador 

(31.8 percent). In Nicaragua, Honduras, and 

Guatemala, over 80 percent of the children are 

breastfed within the first day, while only 60.2 

percent of children are in El Salvador.

Table 10.1

Trends in the Initiation of Breastfeeding: Live 

Births in the 5 Years Prior to the Survey 

Country 

Year of 

Survey

Ever

Breastfed

Within

First Hour

Within

First Day*

El Salvador 1993 91.2 13.6 37.9

El Salvador 1998 94.0 26.3 56.1

El Salvador 2002/03 94.4 31.8 60.2

Guatemala 1995 95.6 54.6 76.5

Guatemala 1998/99 96.5 48.5 77.0

Guatemala 2002 96.1 60.1 80.2

Honduras 1991/92 na 38.0 88.6

Honduras 1996 96.0 43.4 76.9

Honduras 2001 95.7 48.9 81.5

Nicaragua 1992/93 91.9 40.5 66.2

Nicaragua 1998 92.4 79.5 87.0

Nicaragua 2001 94.5 76.3 86.8

* Includes children breastfed in the first hour.

na: Not available.

Percentag

e

Country

Graph 10.1

Initiation of Breastfeeding: Live Births in the Five Year Period

Prior to the Most Recent Survey

0

20

40

60

80

100

Within First Day

Within First hour

Ever Breastfed

El Salvador Guatemala Honduras Nicaragua
Infant Feeding Practices and Nutrition Status of Childern 137

Trends and Challenges Facing Women and Childern

Table 10.2 and Graph 10.2 show data on the 

mean durations of breastfeeding. The duration 

of any breastfeeding, according to the last 

survey, is highest in Guatemala (20.5 months) 

and lowest in Honduras and Nicaragua (17.6 

months). The durations of full breastfeeding 

(either exclusive breastfeeding or breastfeeding 

with water or liquids other than milk) were 

between 3.1 months in El Salvador and 4.1 

months in Guatemala. The duration of exclusive 

breastfeeding ranges between 1.4 and 3.5 months. 

As expected, the percentage of children who are 

Table 10.2

Trends in the Mean Duration of Breastfeeding (in 

months): Live Births in the 5 Years Prior to the Survey 

Country 

Year of 

Survey

Any

Breastfeeding

Full

Breastfeeding*

Exclusive

Breastfeeding†

El Salvador 1993 15.5 2.8 0.8

El Salvador 1998 17.7 2.7 0.9

El Salvador 2002/03 19.2 3.1 1.4

Guatemala 1995 19.8 4.4 3.9

Guatemala 1998/99 19.9 3.7 3.4

Guatemala 2002 20.5 4.1 3.5

Honduras 1991/92 17.2 na na

Honduras 1996 17.3 3.4 2.3

Honduras 2001 17.6 3.9 2.3

Nicaragua 1992/93 12.3 2.0 0.6

Nicaragua 1998 15.0 2.6 2.1

Nicaragua 2001 17.6 3.5 2.5

* Includes breastmilk alone, or breastmilk with water of other liquids but not including other types of milk.

†

 Just breastmilk.

na: Not available.

Months

Country

Graph 10.2

Mean Duration of Breastfeeding (In Months): Live Births in the 

Five Years Prior to the Most Recent Survey

0

5

10

15

20

25

Exclusive

Full

Any Breast- feeding

El Salvador Guatemala Honduras Nicaragua
138 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

percent), while in Honduras less than 90 percent 

are breastfed at these ages. Rates of exclusive 

breastfeeding among children aged 0–5 months 

range from a low of 24.0 percent in El Salvador 

to a high of 50.6 percent in Guatemala, rates 

far from the ideal. Predominant breastfeeding 

ranges from 14.9 percent in Nicaragua to 22.1 

percent in El Salvador. Focusing on infants 6–9 

months of age, more than 60 percent of infants 

in this age group are given complementary foods 

in addition to breast milk, as is recommended 

from the age of 6 months onward. For children 

12–15 months of age, the indicator of main 

interest is the proportion of children still 

breastfeeding, also known as the first-year 

breastfeeding continuation rate. Guatemala has 

the highest first-year continuation rate (81.1 

percent) compared with the other countries. The 

percentage of children 20–23 months who are 

still breastfeeding ranges from a low of 33.5 

percent in Honduras to a high of 47.4 percent in 

Guatemala.

As expected, the percentage of children aged 

0–5 months being breastfed and exclusively 

breastfed is higher in the rural area than in the 

urban area. This reflects in part the need for 

urban mothers to return to the workplace more 

often than rural mothers and, therefore, begin 

weaning earlier. Among children aged 6–9 

months, a higher percentage of rural children 

than urban children receive complementary 

foods. This reflects the greater likelihood that 

urban infants are weaned somewhat earlier than 

rural infants. Similarly, first-year continuation 

rates are higher in the rural area than in the 

urban area, as are the percentage of children who 

continue to breastfeed at ages 20–23 months, 

reflecting again the fact that urban children are 

weaned earlier.

Nutrition Status 

of Children

In order to objectively assess the nutritional 

status of children, the height and weight of 

children were measured in the surveys. Those 

measurements, in conjunction with a child’s 

age, allowed for the calculation of three standard 

measures of physical growth: height-for-age, 

weight-for-height, and weight-for-age.

being exclusively breastfed decreases rapidly as 

the age of the children increases (Table 10.3). In 

El Salvador and Nicaragua, by the time children 

are 4–5 months of age, only 8.1 and 12.0 percent, 

respectively, are being exclusively breastfed. 

Children were classified into one of several 

feeding categories based on current feeding 

practices, as reported by their mothers, according 

to age groupings that correspond to World Health 

Organization (WHO) infant feeding indicators. 

The categories are shown in Table 10.4, where 

children are classified as to whether they are not 

being breastfed, whether they are exclusively 

breastfed, predominantly breastfed, given 

complementary foods (breast milk and solid or 

semisolid foods), and whether children are still 

being breastfed at 12 to 15 months and 20–23 

months.

As shown in Table 10.4, in Guatemala, nearly 

all children aged 0–5 months are breastfed (94.5 

Table 10.3

Percentage of Children Who 

are Currently Being Exclusively 

Breastfed, According to Age of 

Child in Months 

(Most Recent Survey)

Country/Age

Year of 

Survey Percentage

El Salvador 2002/03

0–1 36.8

2–3 22.1

4–5 8.1

6–7 2.7

Guatemala 2002

0–2 61.2

3–5 40.6

6–8 12.3

Honduras 2001

0–2 47.2

3–5 21.6

6–8 6.1

Nicaragua 2001

0–1 46.9

2–3 33.6

4–5 12.0

6–7 3.2
Infant Feeding Practices and Nutrition Status of Childern 139

Trends and Challenges Facing Women and Childern

The nutritional status of children as measured 

by these indices can be evaluated by comparing 

their distributions on a specific index to that of a 

well-nourished, healthy population of children. 

The reference population used is that developed 

by the U.S. National Center for Health Statistics 

(NCHS) and accepted by the World Health 

Organization (WHO).

Height-for-age is a measure of physical growth 

over the child’s life. A child whose height is 

more than 2 standard deviations below the mean 

of the NCHS reference population is considered 

stunted or very short for his or her age. Stunting 

is a condition that results from prolonged 

inadequate food intake or from recurrent 

episodes of illness.

Weight-for-height indicates the appropriateness 

of a child’s weight given his/her height. A child 

whose weight is more than 2 standard deviations 

below the NCHS reference mean is referred to 

as wasted or too thin. This condition may reflect 

a recent period of inadequate food intake or a 

recent episode of illness.

Weight-for-age is a general indicator of a child’s 

nutritional status. A child who falls more than 2 

standard deviations below the NCHS reference 

mean on this index is referred to as underweight. 

The child may have suffered from chronic 

malnutrition (stunting) or acute malnutrition 

(wasting), but the index does not distinguish 

between those conditions.

Table 10.4

Type of Breastfeeding (Indicators of the World Health Organization), According to 

Area of Residence, by Age of Child (In Months): Children Aged 0–23 Months

(Most Recent Survey)

Country/

Area

Year of 

Survey

Not 

Breastfeeding

Exclusive 

Breastfeeding

Predominant 

Breastfeeding

Complementary 

Breastfeeding

Continued 

Breastfeeding

0–3 0–5 0–3 0–5 0–3 0–5 6–9 12–15 20–23

El Salvador 2002/03

Total 5.6 8.0 29.5 24.0 23.9 22.1 75.9 67.4 43.2

Urban 7.6 11.2 24.5 18.7 26.4 23.9 75.0 57.1 36.5

Rural 3.6 4.4 34.4 29.8 21.5 20.1 76.8 75.5 50.6

Guatemala 2002

Total 4.6 5.5 56.3 50.6 18.8 19.2 67.3 81.1 47.4

Urban 9.1 11.0 35.3 34.7 30.5 25.7 61.8 76.8 40.3

Rural 2.5 2.7 65.8 58.5 13.5 15.9 70.3 83.4 51.3

Honduras 2001

Total 7.7 10.5 43.3 34.9 15.5 16.4 60.6 75.8 33.5

Urban 12.9 18.0 32.0 22.7 12.4 13.6 55.1 67.2 27.0

Rural 4.3 5.5 50.7 43.2 17.5 18.3 64.7 80.7 38.1

Nicaragua 2001

Total 5.4 7.4 39.1 30.7 15.3 14.9 67.4 63.8 39.6

Urban 8.2 10.5 28.8 21.6 13.7 13.5 62.6 54.3 36.3

Rural 2.8 4.2 48.9 40.3 16.8 16.3 73.3 74.1 42.5
140 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

Table 10.5 and Graph 10.3 show the three 

indices of nutritional status for children aged 

3–59 months, according to the last survey. The 

statistic shown for each index is the percentage 

of children who were more than 2 standard 

deviations below the mean value for the NCHS 

reference population. 

Table 10.5

Percent of Children Classified as Undernourished by Three 

Anthropometric Indices*, According to Area of Residence: 

Children Aged 3–59 Months 

(Most Recent Survey)

Country/Area 

Year of 

Survey

Stunted

(height-for-age)

Wasted

(weight-for-height)

Underweight

(weight-for-age)

El Salvador 2002/03

Total 18.9 1.4 10.3

Urban 11.0 1.3 6.9

Rural 25.6 1.4 13.2

Guatemala 2002

Total 49.3 1.6 22.7

Urban 36.5 1.2 16.2

Rural 55.5 1.8 25.9

Honduras 2001

Total 29.2 1.0 16.6

Urban 17.6 0.6 9.1

Rural 36.4 1.2 21.3

Nicaragua† 2001

Total 20.2 2.0 9.6

Urban 12.0 1.3 6.1

Rural 28.8 2.7 13.2

* Percentages are for children at least 2 standard deviations below the median of the NCHS/CDC/WHO International 

Growth Reference Population (WHO, 1995).

† 0 to 59 months Percentag

e

Country

Graph 10.3

Percentage of Children Classified as Low Height-for-age, Low 

Weight-for-height and Low Weight-for-age: Children Aged 3–59 Months

(Most Recent Survey)

0

10

20

30

40

50

60

Low weightfor age

Low weightfor-height

Low heightfor-age

El Salvador Guatemala Honduras Nicaragua
Infant Feeding Practices and Nutrition Status of Childern 141

Trends and Challenges Facing Women and Childern

In El Salvador and Nicaragua, 18.9 and 20.2 

percent of children were classified as stunted 

while 29.2 and 49.3 percent were stunted in 

Honduras and Guatemala, respectively. The 

percentage of children suffering wasting ranged 

from a low of 1.0 percent in Honduras to a high 

of 2.0 percent in Nicaragua, while the percentage 

of children found to be underweight ranged 

from a low of 9.6 percent in Nicaragua to a high 

of 22.7 percent in Guatemala. In general, it is 

quite clear that substantially more children were 

classified as undernourished in Guatemala than 

in the other countries. 

In general, the nutritional status of children 

has improved in each of the countries since the 

late 1980s (Table 10.6 and Graphs 10.4 and 

10.5). For example, the percentage of children 

classified as stunted in El Salvador decreased 

by almost 13 percentage points between 1988

Table 10.6

Trends in the Percentage of Children Classified as 

Undernourished by Three Anthropometric Indices*: Children 

Aged 3–59 Months

Country 

Year of 

Survey

Stunted

(height-for-age)

Wasted

(weight-for-height)

Underweight

(weight-for-age)

El Salvador 1988 31.7 2.1 16.1

El Salvador 1993 22.8 1.3 11.2

El Salvador 1998 23.3 1.1 11.8

El Salvador 2002/03 18.9 1.4 10.3

Guatemala 1987 57.9 na 33.5

Guatemala 1995 49.7 3.3 26.6

Guatemala 1998/99 46.4 2.5 24.2

Guatemala 2002 49.3 1.6 22.7

Honduras 1987† 43.8 1.9 24.1

Honduras 1991/92† 42.4 1.8 21.4

Honduras 1996† 37.8 1.4 24.3

Honduras 2001† 32.9 1.0 18.4

Nicaragua 1998‡ 24.9 2.2 12.2

Nicaragua 2001‡ 20.2 2.0 9.6

* Percentages are for children at least 2 standard deviations below the median of the NCHS/CDC/WHO International 

Growth Reference Population (WHO, 1995).

† Children aged 12-59 months.

‡ 0 to 59 months
142 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

 and 2002/03. In Honduras, the decrease was 

almost 11 percentage points between 1987 and 

2001. In Guatemala, the percentage of children 

found to be underweight decreased by almost 11 

percentage points since 1987, but it appears that 

there has been difficulty since 1995 in reducing 

the percentage of children who are stunted.

In terms of the stunting index or low height-forage, greater levels of malnutrition are evident 

among children in rural as opposed to urban 

areas (Graph 10.6). Levels of underweight also 

tend to be greater among children who reside in 

rural areas (Graph 10.7).

Percentag

e

Survey

Graph 10.4

Trends in the Percentage of Children Classified as Low Height-for-Age, 

According to Last Four Surveys: Children Aged 3–59 Months

(12–59 Months for Honduras)

0

10

20

30

40

50

60 El Salvador

Guatemala

Honduras

Nicaragua

First Second Third Fourth

Percentag

e

Survey

Graph 10.5

Trends in the Percentage of Children Classified as Low Weight-for-Age,

According to Last Four Surveys: Children Aged 3–59 Months

(12–59 Months for Honduras)

0

10

20

30

40

50

60 El Salvador

Guatemala

Honduras

Nicaragua

First Second Third Fourth
Infant Feeding Practices and Nutrition Status of Childern 143

Trends and Challenges Facing Women and Childern

Percentag

e

Country

Graph 10.6

Percentage of Children Classified as Low Height-for-Age,

By Area of Residence: Children Aged 3–59 Months

(Most Recent Survey)

0

10

20

30

40

50

60

Rural

Total

Urban

El Salvador Guatemala Honduras Nicaragua

Percentag

e

Country

Graph 10.7

Percentage of Children Classified as Low Weight-for-Age, 

By Area of Residence: Children Aged 3–59 Months

(Most Recent Survey)

0

10

20

30

40

50

60

Rural

Total

Urban

El Salvador Guatemala Honduras Nicaragua
144 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

Maps 10.1 and 10.2 illustrate regional variations 

within countries in the percent of children 

classified as low height-for-age (stunted) and 

low weight-for-age (underweight). Using either 

indicator, most areas of Guatemala experience 

high levels of malnutrition. Western Honduras 

appears to be worse off than the rest of the country 

and Nicaragua experiences the most severe 

problems in the northeast part of the country. El 

Salvador is generally better throughout, as is the 

Pacific coast of Nicaragua. 

Anemia in Children

Anemia is a condition characterized by inadequate 

red blood cell volume and a low concentration of 

hemoglobin in the blood. Although many causes 

of anemia have been identified, nutritional 

deficiency, primarily due to a lack of dietary 

iron, accounts for most cases. According to the 

World Health Organization, 43 percent of young 

children are affected by anemia worldwide.

Iron-deficiency anemia in children is associated 

with impaired cognitive performance, 

motor development, coordination, language 

development, and scholastic achievement. 

Anemia increases morbidity from infectious 

diseases because it adversely affects several 

immune mechanisms.

There are several ways to improve iron status in 

children. A long-term goal is overall nutritional 

improvement through selection of iron-rich 

foods. Fortification of staples with iron allows 

increased iron intake with the usual diet, or 

children can be given either liquid or tablet 

supplements.

Map 10.1

Percent of Childern 3–59 Months of Age with Low 

Height for Age (Stunting) by Region / Department

(Last Survey)

< 10

10–19

20–29

30–39

40+

% Children Stunted
Infant Feeding Practices and Nutrition Status of Childern 145

Trends and Challenges Facing Women and Childern

Map 10.2

Percent of Childern 3–59 Months of Age with Low 

Weight for Age (Underweight) by Region / Department 

(Last Survey)

< 5

5–9

10–14

15–19

20+

% Children Underweight
146 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

Table 10.7 presents anemia rates for children 

aged 12–59 months in El Salvador, Guatemala, 

and Honduras, according to the last survey 

conducted in each country. The highest overall 

rate of anemia was observed in Guatemala (39.7 

percent) and the lowest in El Salvador (19.8 

percent). 

Anemia rates in each country vary according 

to area of residence, sex of the child and age 

of the child. The prevalence of anemia among 

children living in rural areas was higher than 

among children living in urban areas. Also, boys 

were more likely to be anemic than girls, but 

the differences are small. In all of the countries, 

Table 10.7

Percentage of Children With Anemia, According to 

Selected Characteristics: Children Aged 12–59 Months

(Most Recent Survey)

Selected Characteristics

El Salvador

2002/03

Guatemala* 

2002

Honduras

2001

Nicaragua

2001

Total 19.8 39.7 29.9 na

Area of Residence

Urban 15.8 35.2 29.4 na

Rural 23.1 41.8 30.2 na

Sex

Male 21.1 41.2 30.5 na

Female 18.2 38.1 29.3 na

Age of Child

12–23 33.4 55.6 45.3 na

24–35 20.2 38.5 30.7 na

36–47 15.4 30.1 23.0 na

48–59 10.9 21.4 18.7 na

Birth Order

1 19.1 37.4 27.3 na

2–3 17.9 39.5 31.4 na

4–6 23.2 39.3 29.9 na

7+ 22.9 42.4 30.8 na

na: Not available.

* Children 6–59 months
Infant Feeding Practices and Nutrition Status of Childern 147

Trends and Challenges Facing Women and Childern

as the age of the children increases, the percent 

with anemia decreases (Graph 10.8). There are 

no significant differences in the anemia rates 

among children by their birth order. 

As shown in Table 10.8, anemia rates tend to 

be lower among children whose mothers have 

7 or more years of formal education and higher 

among children whose mothers have no formal 

education.

Percentag

e

Age (in months)

Graph 10.8

 Percentage of Children With Anemia, By Age of Child (In Months): 

Children Aged 12–59 Months

0

10

20

30

40

50

60

Honduras

Guatelmala

El Salvador

Total 12-23 24-35 36-47 48-59

Table 10.8

Percentage of Children With Anemia, 

According to Education of Mother: 

Children Aged 12–59 Months

(Most Recent Survey)

Country/Education Year of Survey Percentage

El Salvador 2002/03

Total 19.8

None 23.2

1–3 24.4

4–6 22.1

7–9 16.8

10+ 12.9

Guatemala* 2002

Total 39.7

None 41.4

Primary 41.3

Secondary+ 28.9

Honduras 2001

Total 29.9

None 33.1

1–3 30.0

4–6 31.8

7+ 23.2

Nicaragua 2001

Total na

None na

1–3 na

4–6 na

Secondary na

Superior na

na: Not available.

* Children 6–59 months
148 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America

Anemia in Mothers

According to the World Health Organization, 

35 percent of women are affected by anemia 

worldwide. The most common cause of iron 

deficiency anemia in women is menstrual blood 

loss. Pregnancy and breastfeeding also drain 

iron stores, and low dietary intake (or poor iron 

absorption) also plays a part. Most women are 

unaware of the symptoms of anemia—shortness 

of breath, fatigue, weakness, headaches, and 

lapses of concentration—and tend to attribute 

such mild symptoms to the stresses of modern 

life. Yet, if anemia remains undiagnosed, it can 

lead to infertility in women of childbearing age 

and premature delivery in pregnant women.

Tables 10.9 and 10.10 show the percentage of 

non-pregnant women aged 15–49 in El Salvador, 

Guatemala, and Honduras who are anemic. The 

sampling methodology of the surveys was such 

that only women with at least one child aged 3–

59 months were tested for anemia. The highest 

overall rate of anemia was found in Guatemala 

(20.2 percent) and the lowest in El Salvador (8.5 

percent). In all three countries, mothers residing 

in rural areas were more likely to be anemic 

than mothers living in urban areas. As shown in 

Table 10.9, anemia rates vary according to age. 

The rates are relatively high among teenagers, 

then decline among women aged 20–29, only 

to increase among women aged 30–44. In 

general, women aged 45–49 present the lowest 

rates in each country. Finally, as expected, the 

percentage of women who are anemic decreases 

as the educational level of the women increases 

(Table 10.10). In Guatemala, the difference 

between women with no formal education and 

women with at least some secondary education 

is 13 percentage points.

Table 10.9

Percentage of Women With Anemia, According to Selected 

Characteristics: Non-Pregnant Women Aged 15–49 Years With 

Children Aged 3–59 Months

(Most Recent Survey)

Selected 

Characteristics

El Salvador

2002/03

Guatemala 

2002

Honduras

2001

Nicaragua

2001

Total 8.5 20.2 14.7 na

Area of Residence

Urban 8.2 16.5 13.9 na

Rural 8.8 22.3 15.2 na

Age

15–19 8.8 28.1 14.3 na

20–24 7.7 18.2 13.8 na

25–29 6.9 17.1 12.7 na

30–34 9.8 23.7 17.0 na

35–39 9.4 20.0 18.0 na

40–44 13.6 20.9 15.7 na

45–49 8.7 16.2 10.1 na

na: Not available.
Infant Feeding Practices and Nutrition Status of Childern 149

Trends and Challenges Facing Women and Childern

Summary of Findings

• In all of the countries, more than 94 percent 

of infants were breastfed. The percentage 

of infants who were breastfed within the 

first hour after birth ranged from a low of 

31.8 percent in El Salvador to a high of 

76.3 percent in Nicaragua. Similarly, the 

percentage of children who were breastfed 

within the first day ranged from a low of 

60.2 percent in El Salvador to a high of 

86.8 percent in Nicaragua.

• Exclusive breastfeeding rates indicate that 

the practice is far from ideal. The fact 

that predominant breastfeeding rates are 

low indicates many children are receiving 

complementary foods earlier in life than is 

recommended by the WHO. 

• Anthropometric measures of physical 

growth were presented to assess the 

nutritional status of children. Significant 

differences were found between Guatemala 

and the other three countries. Stunting 

ranged from a low of 18.9 percent in 

El Salvador to a high of 49.3 percent in 

Guatemala, while levels of underweight 

children ranged from a low of 9.6 percent 

in Nicaragua to a high of 22.7 percent in 

Guatemala. 

• Although the nutritional status of children 

has improved in each of the countries 

since the late 1980s, important urban/rural 

differentials in favor of the urban area still 

exist.

• The percentage of children aged 12–59 

months with anemia in El Salvador, 

Guatemala, and Honduras is 19.8, 39.7 

and 29.9 percent, respectively, while the 

percentage of women aged 15–49 with 

anemia is 8.5, 20.2 and 14.7 percent, 

respectively. For both groups, the 

prevalence of anemia is higher in the rural 

area than in the urban area.

Table 10.10

Percentage of Women With 

Anemia, According to Education: 

Non-Pregnant Women Aged 15–49 

Years With Children Aged 3–59 

Months (Most Recent Survey)

Country/Education 

Year of 

Survey Percentage

El Salvador 2002/03

Total 8.5

None 7.7

1–3 9.3

4–6 10.0

7–9 9.8

10+ 5.6

Guatemala 2002

Total 20.2

None 24.7

Primary 20.5

Secondary+ 11.2

Honduras 2001

Total 14.7

None 18.7

1–3 15.3

4–6 14.2

7+ 12.8

Nicaragua 2001

Total na

None na

1–3 na

4–6 na

Secondary na

Superior na

na: Not available.
150 Infant Feeding Practices and Nutrition Status of Childern

Reproductive, Maternal, and Child Health in Central America
Education Status of Children Aged 7–14 Years 151

Trends and Challenges Facing Women and Childern

CHAPTER

Educational Status 

of Children Aged 

7–14 Years

Education is one of the principal 

determinants of the economic and social 

development of a country. The last 

surveys conducted in El Salvador, Guatemala, 

and Honduras presented an opportunity to 

provide basic information on the education 

system of these countries from a populationbased perspective. With this objective, the 

individual questionnaire included a module of 

questions regarding school attendance by the 

respondents’ own children aged 7–14. For each 

child in the appropriate age range, the mother 

was asked if the child had ever attended school, 

the age at which he/she began first grade, the 

highest grade completed, and whether the child 

was attending in the current school year. For 

those children not in school, the mother was 

asked the age when the child last attended and 

his/her reason for leaving school.

11
152 Education Status of Children Aged 7–14 Years

Reproductive, Maternal, and Child Health in Central America

Tables 11.1 thru 11.3 give a profile of school 

attendance during the current school year 

for El Salvador, Guatemala, and Honduras, 

respectively. The children were classified in 

the following four categories: Those who had 

never attended school; those who had dropped 

out of school system; those who were currently 

attending a grade lower than expected for their 

age; and those who were attending a grade equal 

to or higher than the one expected for their age. 

Table 11.1

Educational Status of Children Aged 7–14 Years, According to Selected 

Characteristics: El Salvador, 2002/03

Selected

Characteristics

Never

Attended

Dropped 

Out

In Grade Less

Than Expected

In Expected

Grade or Higher Total

Total 5.6 6.0 26.7 61.7 100.0

Area of Residence

Urban 4.1 3.9 19.9 72.1 100.0

Rural 7.1 7.9 33.0 51.9 100.0

Sex

Male 5.8 5.3 29.0 59.9 100.0

Female 5.5 6.7 24.1 63.7 100.0

Age

7 14.6 0.7 0.0 84.7 100.0

8 7.0 1.2 19.4 72.4 100.0

9 3.8 1.8 27.7 66.7 100.0

10 4.3 2.6 34.9 58.2 100.0

11 3.2 4.3 34.9 57.6 100.0

12 3.6 8.5 35.8 52.1 100.0

13 3.0 13.1 35.8 48.2 100.0

14 3.6 20.4 32.0 44.1 100.0

Education of Mother

None 11.6 10.8 39.9 37.7 100.0

1-3 6.2 8.2 33.5 52.1 100.0

4-6 3.9 5.0 26.9 64.2 100.0

7-9 2.4 2.7 15.7 79.2 100.0

10+ 2.4 0.7 8.7 88.1 100.0

No. of Siblings

0-1 2.8 2.6 14.3 80.3 100.0

2-3 4.9 4.5 22.7 67.9 100.0

4-6 6.5 7.8 36.4 49.3 100.0

7+ 11.6 13.8 42.9 31.6 100.0
Education Status of Children Aged 7–14 Years 153

Trends and Challenges Facing Women and Childern

Table 11.2

Educational Status of Children Aged 7–14 Years, According to Selected 

Characteristics: Guatemala, 2002

Selected

Characteristics

Never

Attended

Dropped 

Out

In Grade Less

Than Expected

In Expected

Grade or Higher Total

Total 7.8 9.8 27.8 54.5 100.0

Area of Residence

Urban 5.0 6.5 20.8 67.8 100.0

Rural 9.5 11.7 31.8 47.0 100.0

Sex

Male 6.2 8.7 30.4 54.7 100.0

Female 9.7 11.0 24.9 54.4 100.0

Age

7 12.1 0.9 0.0 87.0 100.0

8 9.8 1.9 20.8 67.5 100.0

9 7.1 2.5 31.9 58.6 100.0

10 6.5 4.5 38.5 50.5 100.0

11 7.1 7.2 38.7 47.0 100.0

12 5.2 18.0 35.5 41.4 100.0

13 7.5 25.1 32.4 35.0 100.0

14 5.5 35.7 30.2 28.6 100.0

Education of Mother

None 14.1 13.5 38.2 34.2 100.0

Primary 3.9 8.6 24.3 63.3 100.0

Secondary+ 0.2 1.8 5.7 92.3 100.0

No. of Siblings

0-1 2.9 2.8 12.4 81.9 100.0

2-3 4.5 5.7 18.0 71.8 100.0

4-6 9.2 12.6 34.2 44.1 100.0

7+ 12.8 14.4 38.6 34.2 100.0
154 Education Status of Children Aged 7–14 Years

Reproductive, Maternal, and Child Health in Central America

Graphs 11.1 and 11.2 also provide summary 

information on school attendance in the most 

recent school year (2001 in Honduras and 2002 

in El Salvador and Guatemala). As seen in Graph 

11.1 school attendance for children ages 7 thru 

11 is very similar in El Salvador and Honduras, 

but starting with age 12 children in Honduras 

are more likely to leave school such that by age 

13 a smaller proportion of Honduran children 

are in school than in Guatemala. 

Overall, 61.7 percent of the children aged 7–14 

years in El Salvador, 54.5 percent of the children 

in Guatemala, and 59.3 percent of the children 

in Honduras were attending the grade expected 

or higher, and 38.3, 45.5, and 40.7 percent, 

respectively, had experienced one or more of 

three barriers to timely school attainment—

late entry, dropping out, or not progressing to 

successive grades (Tables 11.1, 11.2, and 11.3). 

The relative importance of these three factors is 

better appreciated by considering the distribution 

of the school age population across these 

categories at different ages. Using El Salvador 

as an example (Table 11.1), among 7 year-olds, 

84.7 percent were attending the expected grade 

or higher, but this declines considerably to just 

Table 11.3

Educational Status of Children Aged 7–14 Years, According to Selected 

Characteristics: Honduras, 2001

Selected

Characteristics

Never

Attended

Dropped 

Out

In Grade Less

Than Expected

In Expected

Grade or Higher Total

Total 3.9 10.7 26.1 59.3 100.0

Area of Residence

Urban 2.6 5.5 19.8 72.1 100.0

Rural 4.8 14.3 30.5 50.5 100.0

Sex

Male 3.8 11.4 27.9 56.9 100.0

Female 3.9 9.9 24.3 61.9 100.0

Age

7 10.1 1.6 0.0 88.3 100.0

8 4.7 2.0 19.9 73.4 100.0

9 2.3 3.3 29.2 65.3 100.0

10 2.3 2.7 36.3 58.6 100.0

11 1.6 6.4 34.9 57.1 100.0

12 2.6 13.9 38.7 44.8 100.0

13 2.5 32.9 27.8 36.7 100.0

14 3.5 43.5 28.2 24.8 100.0

Education of Mother

None 10.1 16.6 39.4 34.0 100.0

1-3 4.8 14.6 34.0 46.6 100.0

4-6 1.6 8.8 21.7 67.9 100.0

7+ 0.4 1.9 8.0 89.8 100.0

No. of Siblings

0-1 1.9 2.2 11.7 84.1 100.0

2-3 2.1 6.6 19.2 72.0 100.0

4-6 4.5 13.8 31.9 49.8 100.0

7+ 7.7 18.8 38.7 34.8 100.0
Education Status of Children Aged 7–14 Years 155

Trends and Challenges Facing Women and Childern

44.1 percent of 14 year olds. The corresponding 

statistics for Guatemala and Honduras are 87.0 

and 28.6 percent (Table 11.2), and 88.3 and 24.8 

(Table 11.3) percent, respectively.

In El Salvador, school abandonment becomes 

important above age 11, while in Guatemala 

and Honduras it becomes important above age 

10. Using Honduras as an example (Table 11.3), 

school abandonment rises quickly from 6.4 

percent of 11 year-olds to 43.5 percent of 14 

year-olds.

In all three countries, rural children fare worse 

than urban children on all four categories. 

With respect to gender, in El Salvador and 

Honduras, girls seem to fare better than boys, 

while in Guatemala the opposite appears to be 

the case. It important to note that children with 

well-educated mothers and with few siblings 

are considerably more likely to have attended 

school, stayed in school, and to have been 

attending the expected grade level or higher. 

Percent attending

Age

Graph 11.1

Percent Attending School by Age at Start of School Year

(Most Recent Survey)

0

20

40

60

80

100

Honduras

Guatemala

El Salvador

7 8 9 10 11 12 13 14

Percent at expected grade

Age

Graph 11.2

Percent Attending Expected Grade or Higher for Their Age,

by Age at Start of School Year

(Most Recent Survey)

0

20

40

60

80

100

Honduras

Guatemala

El Salvador

7 8 9 10 11 12 13 14
156 Education Status of Children Aged 7–14 Years

Reproductive, Maternal, and Child Health in Central America

Map 11.1 provides sub-national estimates of 

the percent of children ages 7–14 not attending 

school and Map 11.2 provides estimates of the 

percent delayed in grade for age. The problem 

of children not being in school (either because 

they never entered or have dropped out) is most 

pronounced throughout Guatemala and in the 

western part of Honduras. Children delayed in 

grade for age (either because they started late 

or have had to repeat one or more grades) are a 

more widespread problem throughout the three 

countries. Most departments (or regions) have 

at least 25 percent of children in this age range 

who are attending a lower grade than expected 

for their age. 

An important factor associated with attending 

a grade lower than expected for age and the 

abandonment of school is repetition of grades. As 

shown in Table 11.4, the percentage of children 

repeating a grade during the current school year 

ranged from 13.6 percent in El Salvador to 22.9 

percent in Guatemala. 

Map 11.1

Percent of Childern 7–14 Years Old Not in School

by Region / Department 

(Last Survey)

< 10

10–12.4

12.5–14.9

15–17.4

17.5 +

% Children

Not in School
Education Status of Children Aged 7–14 Years 157

Trends and Challenges Facing Women and Childern

Map 11.2

Percent of Childern Ages 7–14 Years Old

Who are Behind Expected Grade of Schooling

by Region / Department 

(Last Survey)

18–19

20–24

25–29

30–34

35 +

% Children Behind

Expected Grade

Table 11.4

Percentage of Children Repeating a 

Grade During the Year of the Survey, 

According to Age at Beginning of 

School Year: Children Aged 7–14 Who 

Were Attending School

(Most Recent Survey)

Age

El Salvador

2002

Guatemala

2002

Honduras

2001

Total 13.6 22.9 20.5

7 8.9 23.5 19.5

8 15.0 27.3 23.5

9 15.7 25.0 22.6

10 17.5 25.2 22.9

11 15.4 24.4 19.8

12 13.2 19.4 19.0

13 10.7 15.1 15.0

14 10.3 12.4 14.0
158 Education Status of Children Aged 7–14 Years

Reproductive, Maternal, and Child Health in Central America

Table 11.5 presents information on reasons 

given by the mother for children leaving school 

for children aged 7–14 years who had attended 

school, but did not attend in the current school 

year. The three most important reasons in each 

country were: “Didn’t want to study anymore,” 

“economic problems,” and “poor grades.” The 

order of these reasons varied from country to 

country. Less frequently mentioned reasons 

in each country included “had to work” and 

“problems in school.”

Summary of Findings

• Over 82 percent of all children aged 7–

14 years in each country were attending 

school during the current school year, 

but only 55 to 62 percent were either at 

their expected grade level or in one more 

advanced. The remaining proportions had 

experienced at least one of the barriers to 

normal progression within the education 

system (started late, dropped out, or did not 

progress through the grades as expected). 

The percentage of children who were not 

in school (either had never been or had 

dropped out) increases in El Salvador 

from 6.9 percent among children 10 years 

of age to 24.0 percent among children 14 

years of age, from 11.0 to 41.2 percent in 

Guatemala, and from 5.0 to 47.0 percent 

in Honduras.

• In general, school abandonment becomes 

important around 10 to 11 years of age. 

• Repetition of grades appears to be 

an important factor associated with 

abandoning school. 

• Children with better-educated mothers and 

with fewer siblings are considerably more 

likely to have attended school, stayed in 

school, and to have been attending the 

expected grade level or higher. 

• The three most important reasons in each 

country for abandoning school included 

“didn’t want to study anymore,” “economic 

problems,” and “poor grades.”

Table 11.5

Primary Reasons For Dropping Out of 

School Children Aged 7–14 Who Have 

Dropped Out of School

Country/Reason

Year of 

Survey Percentage

El Salvador 2002/03

Didn’t want to study anymore 32.2

Economic problems 19.7

Poor grades 11.1

Family problems 9.2

Problems in the school 6.2

Had to work 5.3

Guatemala 2002

Economic problems 29.0

Didn’t want to study anymore 25.7

Poor grades 12.3

Had to work 7.2

Problems in the school 4.7

Honduras 2001

Economic problems 27.0

Poor grades 15.9

Didn’t want to study anymore 15.0

No higher grades taught 8.4

Problems in the school 6.6

Had to work 5.1
References 159

Trends and Challenges Facing Women and Childern

References

Reports Referenced in This Document:

El Salvador:

Asociación Demográfica Salvadoreña y Centers for Disease Control and Prevention, 

Division of Reproductive Health. El Salvador:Encuesta Nacional de Salud Familiar 

(FESAL-88), Informe Final, 1989.

Asociación Demográfica Salvadoreña y Centers for Disease Control and Prevention, 

Division of Reproductive Health. El Salvador: Encuesta Nacional de Salud Familiar 

(FESAL-93), Informe Final, 1994.

Asociación Demográfica Salvadoreña y Centers for Disease Control and Prevention, 

Division of Reproductive Health. El Salvador: Encuesta Nacional de Salud Familiar 

(FESAL-98), Informe Final, 2000.

Asociación Demográfica Salvadoreña y Centers for Disease Control and Prevention, 

Division of Reproductive Health. El Salvador: Encuesta Nacional de Salud Familiar 

(FESAL-2002/03), Informe Final, 2004.

Honduras:

Honduras Ministry of Public Health, Association for Family Planning in Honduras, 

Management Sciences for Health and Family Health International. Epidemiology and 

Family Health Survey, Honduras, 1987, Final Report, 1989.

Ministerio de Salud Pública. Encuesta Nacional de Epidemiología y Salud Familiar, 

Honduras 1991/92, (ENESF-91/92) Borrador del Informe Final, 1992. 

Ministerio de Salud, Asociación Hondureña de Planificación de Familia y Centers for 

Disease Control and Prevention, Division of Reproductive Health. Encuesta Nacional de 

Epidemiología y Salud Familiar (ENESF-96), Honduras 1996, Informe Final, 1997. 

Ministerio de Salud, Asociación Hondureña de Planificación de Familia y Centers for 

Disease Control and Prevention, Division of Reproductive Health. Encuesta Nacional de 

Salud Masculina (ENSM-96), Honduras 1996, Informe Final, 1998. 

Secretaría de Salud, Asociación Hondureña de Planificación de Familia y Centers for 

Disease Control and Prevention, Division of Reproductive Health. Honduras: Encuesta 

Nacional de Epidemiología y Salud Familiar (ENESF-2001) y Encuesta Nacional de 

Salud Masculina (ENSM-2001), Informe Final, 2002. 
160 References

Reproductive, Maternal, and Child Health in Central America

Guatemala:

Ministerio de Salud Pública y Asistencia Social, Instituto de Nutrición de Centro América 

y Panamá y Institute for Resource Development, DHS. Guatemala: Encuesta Nacional de 

Salud Materno Infantil, 1987 (ENSMI-87), Informe Final, 1989. 

Instituto Nacional de Estadística, Ministerio de Salud Pública y Asistencia Social y Macro 

International Inc., DHS. Guatemala: Encuesta Nacional de Salud Materno Infantil, 1995 

(ENSMI-95), Informe Final, 1996. 

Instituto Nacional de Estadística, Ministerio de Salud Pública y Asistencia Social y Macro 

International Inc., Measure/DHS+. Guatemala: Encuesta Nacional de Salud Materno 

Infantil, 1998-1999 (ENSMI-98/99), Informe Final, 1999. 

Ministerio de Salud Pública y Asistencia Social, Universidad del Valle y Centers for 

Disease Control and Prevention, Division of Reproductive Health. Guatemala: Encuesta 

Nacional de Salud Materno Infantil, 2002 (ENSMI-2002), Volumen I: Mujeres, 2003. 

Ministerio de Salud Pública y Asistencia Social, Universidad del Valle y Centers for 

Disease Control and Prevention, Division of Reproductive Health. Guatemala: Encuesta 

Nacional de Salud Materno Infantil, 2002 (ENSMI-2002), Volumen II: Hombres, 2003. 

Nicaragua:

Asociación Pro-Bienestar de la Familia Nicaragüense y Centers for Disease Control and 

Prevention, Division of Reproductive Health. Encuesta sobre Salud Familiar, Nicaragua 

1992-93, Informe Final, 1993.

Instituto Nacional de Estadísticas y Censos, Ministerio de Salud y Macro International, 

Inc., DHS. Encuesta Nicaragüense de Demografía y Salud 1998 (ENDESA-98), Informe 

Final, 1999.

Instituto Nacional de Estadísticas y Censos, Ministerio de Salud y Macro International, 

Inc., DHS+. Encuesta Nicaragüense de Demografía y Salud 2001 (ENDESA-2001), 

Informe Final, 2002.

General:

World Health Organization (WHO). WHO Global Data Bank on Breastfeeding – 

Breastfeeding: The best start in life, 1996.