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E/00HFol3/96 Meeting Noo 8 ORIGlMLs MG^SH

THE PATTEEW OF BIKTH COHTRDL IN PUERTO RICO

í';' r

J« íiayono Styoos

in jdemógraphio "tejníaSji,- th© trend of Puerto Eican fertility has not left room for great optSjBiíni»

The crud© birth rat© of 40 oharacteristic of the past half centJiry

has bseia lóWefed oxily withln the past two years, and may only refLect the taaporaiy

bfeahüp of faiallies due tp a large soale a&ígration« Varicus studies haT© iadicated iaodost deoriaapats lo iiarital fertility, but these have been ccmpensated for. by eárlier Coótes aod Oayis in. ioterpréting the lower age at marriag® ahd tha cons®='

^eiit

of flflt ordor births hoped that it refleeted a modero type respoose to

epooo^io óoOditiió®^, bot feared, in the absenoe of wide soale birth control practico,

that It atiglht ooly aoan Inoreased fertility. They suggest, in the light of *th6 rapid o#

C;05ñiónwealthp that '^family limitation sufficient

hlftk rato snbstantially »ay b© just arouad th© comer."^ It will b© tha fuaction of thl#

tó^ efptoro SOSSO of the faotors influeatial ia sustaiaing high fertility,

of the ©xtent aod effeotiTeness of birth control practic#

ihffippg djiffér^É groups io the islandés population. .iJftn

;:i;í:i]|ív';,yy

Souree of th© Data

ioléOtd'if«eareh DéOtpr of th© Ih^troralty of Puerto Ileo .hai fb'ií' the la stttdioB ©f attitudes relotant te fertility afid birth

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a' , .

fe'rtillty,®' Ppfulatioa

Hareh,

fhe total projeot can be divided into three phasest

1« An exploratory study involving intensive qualitative interviews with a atall nunber of families*

2a A large scale, objective type interviewing study to verify ot nullify hypotkeses developed in Part 1»

Part A: Brief screening interviews with a sajnple 6f 3000» Part B: Longer interviews with a sub^sample of 1000»

3»- A series of controlled experiments designed to test the concíusions of Pha» ses 1 and 2 by employing various techniques of persuasión on selected groups in the populatioña

Fiéld work has been completad for parts 1 and 2, and analysis has been cómpleted

for parte 1 and 2Aa The present papar will lean chiefly on the latter for its data, áesoriblng the other phases briefly in subsequent sections*

phaso 2A, condupted by Heuben Hill and the writer, secured informatioa on tho

knowledge and use of birth control of 3000 Puerto Ricans. A five to ten minute inter-

wliii tras oonducted with men and womon mseting the criteria of married (or matad) and fertlle (at least one pregnancy) t»ho enterad nine of the islandés publio health Centers

between August and Ootober of 1953# These centers give free medical care of practical-

ly all types to ány individual desiring it« Tabla 1 compares several oharacteristios of the sample group with the total popdlation*

Table Is -^ge, Eduoation, Fertility and Residenoe, Sample and 1950 CensuS

Median Age

Sample

1950 Census

29,8

33,8

Mádian Eduoation

4,2

4,1

Median Live Births

4«2

Fef €@nt Üí1>aa

4Ó t

fho sámplo draws a somewhat younger group probably because intorviewers tended ¡apt to seléct easei who appeared ®too oid®" Conáaqpiontíy, whereai-cióse to ntee per

cáht of the total poptalatioa of «arriod women is 55 yoars of age or more, tes# than

ofte per cent of our smaple falte la thi# óategorya Moréover, while tlie moitán# for edupatioa ate idéntlGalj, tho sampie has a dearth of caseS' in the OiStrtme:.grodit'^^ao

fduo&tioa and high schoot ©ducatioa, probably because these tw# grov^s are: tesa likelp' 2 ®

to take advant^age of froe facilitiea. However, in general, the samplé correappnds falrly well to the general population, although the possible bias InTol-ved In deal-

ing wlth a ''health orloited'* population cannot be detemined* Differential FértilItyLet US first aee to vhat extent the membera of the sample eTidenoe differential fertillty

Tablé' 2i

Median Pregnanciea Preaent Unión, by Age, fieaidenoe and Education

Age Hesidence

ürban

2*8

Ho Eduoation

(22) 1--3 yra»

3,2

(54) 4—5 yra.

3,2

(66)

6/ yra»

2.6

(144)

35/

25—34

Leas than 25

Rural

Urban

Sural

Urban

Sural

2.8

5.6

6.0

7.1

9.0

(61)

(43)

2.8

5.3

(143)

(101) 4.9

2.9

(137)

(115)

2.6

4.1

(141)

(145)

(113) 5.6

(242) 5.0

(228) 4.6

(142)

(80) . 7.0

(175) 8.9

(109) 6.3

(235) 8.6

(92) 5.7

(190| 6.8

(68)

(66)

In tbe youngeat age group eduoation and reaidence appear to bear little relation

to fertilityi» perhapa indieating that in all groupa, family linitation ia not initia> ted early in marriage*

Thia ia in aocord with Batt's attitude data vhich shows that

well ewer half the population, with little difference by educatioh or eeonomie level.

belieire that the firat ehild ahould eome aa soon as poaaible, and with our ewn guali^

tatife data indieating that many woaen deaire to gét child bearing oyer witíi aa soon

Fer wyideñéea of differential fertility in the total population aee J« I #gati|ie and iayis, ''Differential Fertility in Puerto Meo," Pepuiatioa jtuiieie, ley«, 19611 and Paúl iiatt, Baekgrounds of ituaen ih

(frincotong "^Prlnceton Uniyeraity Prosa, IDfZt Ul^fter Tío Jtett, eps jiit-s a Tablea 164 and 166, pp 186^7«

piiiillpiliililillf áii |i$s8i'b|®« S&wefér, as age increases, the differences la fertility. inorease, both edpeatidn and residence appearlsg iz^luent^ial»

Maximmi fertility is achleved by the

respondents of no education, and miTiímiim fertility by the,urban vell educated*

Siñee these factors are of suoh importance» a brief examination of the treuds iñ edaoatioh and residence for Puerto Rico would séem relerant»

Table 3 shows that the

island has been mo7ing steadily toward those factors associated with low fertility» Table 3? Residence and Literacy in Puerto Rioo« 1910-"1950 (Source; U« S» Census Repoirbs) Per Cent ürban

19^

Í9f0

Í940 ItSO

Per C«it Literato

33»5

45,0

59»6

30 40

68.5 75.7

The Practioe of Birth Control

Oifferential fertility is noxmally the product of differential use of birth con

trola büt we do not usually associate Puerto Rico with birth control. Actually a good

deai of faally IJmitation is practiced. In the present sample, despite Catholicisni, lew aTerag# education and youthfulness» 53 per cent have at scme tine in their narria-

ges praeticed some fosa of birth control, and 37 per cent are currently using a

aéthod» A third ©f the sample has used or is using nechanical or cbamioal methods. a í

flfth haré used or are tuilng natural methods and a fifth are sterilised.^

So other reéent data on the fregúency of birth control use is avaiiable»

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ín 1947..

Satt reported that 6.6 per cent of a represeintatiTe sample of the ialani*s women were

atefilised« Hbwerér. the rate of sterilization in the past fire years has prebably íhc^ased oenslderabíy. Hore iafortant, it is felt that látt*s intsrtiewlng wép9 not sueh as te elloit maximtím reliabilit|^ of response on thts sabjeot# Ih onr sámpie'ij 500 interviews oenduoted by nurses t^ther than trained inté'rwiewers ^shewed a

aheh lower propórtion of hnowledgñ and usíe of birth control<i, Iñ'dícati'ag, th# iñpiO'rtane#' .©f oafeful iateffi®S!ií^o . for more detaiied ©onsideratioiis ©f sterllitaMon» see iatt. ©I0; dita a pp «nd JÉ. Mayone stycosa "femalé: fterilirzation is' 3%effeo JUé©»,'" O^rtérlya fortheoming." .

Education, iriileh aas seen to be such an important córreía^e óf ferfcility, shows a

similar relation to birth control use. Porty threé per cent of those with no edubatión

and 60 per cent bf those with six years or more of education have used birth.control*

Only a slight difference is shown by residence* but the combination of residence

education indicates that the latter has a greatbr impact on urban respondents*

Since education is strongly correlated ^th age in Puerto fiico* Table 4 shows the effect of education when age is held constant*

Table 4: Per Cent Hího Have Ever üsed a Birth Control Method by Education and Age Ags

Hov Ed*

1-3 Trs.

4-6 Yrs*

6/ Yrsfc

15—24

25—34

68 .

35/ .

In general the middle age group is the one most likely to hawe practiced birth bontrol^ This is not surprising, since they are moro or less of the younger generaticn which is less eonsersatire and has had more birth control materials awailable* Üpre-

ower, unlüce the younger group, they are oxperiencing considerable fertility pressure.

By and large, edubatión continúes to affeot birth control use regardless of age, but iti impáct ie most striklng among the eider groups, íbr younger individuáis who have

not yet felt the pressure of fertility, education makes relatively little differeaoer fhu», if »n iadlHáual is well eduoated, once he feels the pinch of numbers on re-

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starbeSf he is síich more likely to act than is the individual of the same age but i^ti little eduostima* .

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the Btffectiveness cf Birth Control

«hile the mi^eJÉt óf hirth control practice is of course Impórtant, the vital piitión i* he» efftetlirely ^ methods are used* Table 6 gives seme iadi®at|en o# ■ -

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the ilf eetlvimiii of tarious eategories of oontraceptors*

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Table 6i ifodian Pragnanciés Current TJñion by Birth Control Use Marriéd Ldss Than

lí^rrled 10 Yrs.

10 Yrs.

or More

?o« of Cases

Cufrént Users, Hodem Methods^ 0to!iweB?t isrersc "latural" Methods®

2.9

7,4

(293)

2.9

(196)

^ast IfSers, Modem Hethods Páat Wserst "Natural" Methods Sterlllsed, i^st Birtíi Control

3.8 3.0 3.7

7.2 7.9 7.4 6.6

Merlllsed Only

3.6

6.7

Mémr ¥sed Birth Control

2.8

8.1

(364) ( 91) (29?)

Experienoe

(816) (1«4)

Modem oethods reüer to the asnal ehemioal aeehaaioal teohniquesf "natural*

aethods to aithdraval aad rhytha. the latter representlng a rery asuill pro*

portion of the *hatural" oategory. Where ooobinations of "natural" and aodera aethods oocur# they are ineluded in the latter category.

ftetoral points should be aotedi (1) The fertili-fy of the nerer users le not as

''MiÉferaab fren, the users as oight be <^peétaid. In the éarlier aarriage period their fOftlIlty ia Oítreeely Ipr, and-ln tdñ'oidsr group» the dlfference in pregnanoies be* tatii eúrfent usera ot atodem áiethods and hon-uaera ia only 0.7. Thia oay be partly

% the faet that indiriduala with loarer fertility feel lesa need to practioe birth Móreoe'érí eren within

tna leigth of jnrrlage groupa. they toad tennard

lÉie loiiyir age iinlta. (2) (hirmnt efweúiaeeptlTe users haré only aligbtly loeer fer* tiSl^ than past users* (8) Currant maera ,'of nédem aethoda haré the saae fertili*

ty #a userá of "natural" atethoda. Ih the past usara gz*oup. their fertility ia airea . '

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highaf* (4) Stariliaatioá, ahile the moat affeetire method.^ ia undergooa too lata

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to be of iianinutni affeetireness. (Thirty eight per oent aere sterilixed aftar at laaat i i

.ili ffighiaoiai. fh" oaia oanhar of ohll^a borne by enipletioa of ohildbearing if | a|x ém ^la total p^uiation)* Iba jeain oaaolttaioii to be raáohad frtñ .

foragoing vould aeaÉ to be that d9a40

pite aide apraad piuotioe of bir^ oontiol* the dtsthoda ara usad so lata or ao Inp affaotiaaly tl^t ^air affeet on fertility la aiñimal. Aaong ahioh group# ín tha :;0 itorlliaari |pa# an tügti^aotodly high -üiMibor of' piognauoia# la- tha "la##,than- tan yeara aarrled" group beOauae of a biraoMng toaará the end of thia period. fbr oaoll

fii#; yottp' pifioii of nafriagii o«ooft 'tha firatg .they róoa faaor froinaneias thl® 000#'g#oup#B

mMM&ci:

0ple Is blrth control most ineffectiTe and what accounts for this ineffectíTeness? ble 6 answers the firat part of this question.

Tabla 6: Median Pregnanciea Current Unión by Birth Control lype, Eduoation« Residence and Length of Marriage

Sterilized Lo Ed.

. Md.

rried

EL Ed. H.

Hd.

Other Birth Control Lo Ed. Hi Ed. lid. H. Md. H.

Urban

4.2

(17)

3.6

(77)

3.5

(61)

3.1

(131)

Sural

5*8

(55)

3.5

(84)

3.3

(108)

' 2.9

(163)

Urban

6.3

(32)

5.1

(65)

6.5

(50)

6.4

(66)

Baral

7.0

(85)

5.8

(92)

7.5

(116)

6.7

(96)

11.0 (77)

9.6

(59)

9 Yrs.

rriéd 1-19 Yrs.

irried

9.8 (50) 9.4 (39)

(/ YrSi a.

Insufficient oases to divide by residence

Tablé 6 shows that in general, the better odacated are more suocessful as reirds blrth oontrol. Thoy appear to have their sterillsations at an earlier.date

lan the less educated, and practico birth oontrol somowhat moré effectively, Among le more récently married, residence appears to make little difference in effectivejsst but in the older group, urban cases appear to practico birth control with oon-

.der&bly íSore offectivenees.

The explaaatioa for the erratic and ahort-lived utillzation of birth control

)tMés appasrB to have little to do wlth availabillty of materials. Sgventy six tio Setlth faits aní as

sub-tmits are seattored over thó small islaad and offer ■

|@ IfÁf ihesf fliáíes diatributed> ajiíoñg olher inétheds, about 40,000 doznns of c >1-

ma* -Sy ifl§ Vme figup.í had tnoreaacd by oniy 7000, ín láiO', tho'élinlsg'showed n"

ase lóád bf S'1,000, bit in tkat year alone, Sdc-O tóases drtpped óut of the dilaios,

^ap:aptmfnt lof Boal.tit Annaal leports)

;

d pdssible ea^iañation bóth for npn-uise ánd inaffeótire use of )>irth control ítouid be ignóíaace bf methods. In teras of sheer awarenoss of tho existonoe of ▼ariou? toehitiLtuea of contraceptipn, hbwoTér, thé present sample leaves llttle ¿o be desired.

sijt per cent sáid .they had never héard of a birth control metbod, and eren this effeiaate ta probably too higb (See footnote 4)« Nine out of ten know sterillzation« ouit of ten kno* at least oné mechanioal. or ohomtoal method, and six out of ten

Mb» Wi'^draeai* As laigbt be expobted^ a higher proportion of Ignozance is found wltb tbO rural, the peorly educated, and the young*

A ioore adrious áráwback,'especlally as regards tho effébtireaess of blrth control# ebneerns the time of inceptipn of knowledge»

In a culture where women are sheltered

bofore í^rrlafej ■trhere dtscussion of sexual matters -ie generally tabú» eren huabands

and ifiires are reluctant to discuss birth oontrol methoda*^ Gonsequentiy, women tend te leam about Mrth oontrol methoda relatively late in marriage».

In a aub^aample of

SiO wteea and 300 huabands (Drawn from Phase 2B) # 60 por cent of all methoda known by the wiires wero learned sometime BUbse^uent to ti» third proeoanoy»

cent were ¡toieen before marriage*

Only eijght per

In the case of the males,^ 50 per cent of all t

mefl^ode liaowu Wore knewn prior to aarriage*

Tho msthoda vdiioh would be oí greateat

use early in marriage are the ones leartted latest*

For example, sterilisation ia

lebmaed early, 22 per cent Imowing thla method prior to marriagej but other methoda are leamed muoh later, eapeoiaily the diaphragm* Jolly and withdraNil. jteother important deterrent to uae and offeotire uae wolili be laok of metira»

tion to praotioe fmily limitatioñ* or adwerae attitudoa tosnri the methoda i^em^ aeiros*

So terÉa of ideal faftlly alae» thero ia little «peatlon that ^üe aweiei|e

■Soren^ three per O'ont' of the wcieen: in -our _ ;j

amaple and ^ per oent of the women In '^tt*a aample gawe i^|r Ideal famiiy aiae aa f

The

jéot of conMnieution beteeen epeuaea I# giren fiilli^ tr^baent ih

paper at^ theae moeting#» -

S"#© alto

erenoe# In footnote 8» *-■ '8

thrpo or les». Moreorér, both Hatt*8 study and our o»n indícate thab religious cbA'.frI

jeoblons are mininial. There are, ñowovar, many other objeotions to blrth contról

whieh i||ke its adopticn ditficult and its practice short-lived.® , ni' f " ■

r ¡ti'

.f'i.

i Many women belleve thé methods to be harmfol and productive of dread diseasei. Qt^en they Hfill secare a diapbragm or a paelKige of oondoms from the olinio only bo be warned subsequently by neighbors or relatives that these vill cause canoor or* "get étúck in tbe wmb.'* Hasbands tiy the condcm and find it'unpleaeurable and dirby.

Tfais feeling is bolstered 'bf the idea that such things are for prostitutes and not, for decent woiaeñ. Moreover, the husband will tend not to trust the wife using a

metHod**it roba the oaie of authority over reproduction and makes infldelity a great->

er t^ptatlí^ for the fenaie. Finally, the methods are onerous and difficult for a peorly educated popuiation living in crowded quarters without plvi^ing and other sa*-

nltary faeilities* Indeed, if the methods.are trled, they tend elther to be abandoned or te fiil. the jBubsequent fertility leads many to adopt sterilisatlon ás the only .í

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sure and simple e^edient»

As one lower olass woman put it, "Sterilisation is only

ónceii sute, and thed you dnn*t have to use those dirty thlogs.'* By the timé then,

tlit a íiáHmn metas to sieriilEatlon she may have several more pregnancies than de*

Fbr the fUture

At tlii iocial ifienie Besearch Center we hope to be able to thtovr mote l^ht on ,

pt^hoiOjgleal ánd eoolál faotors assoeiated uíth fertili%, In Phase 2i, we ha^fi,

I,Mth mOrtei.'jiétcleié measureenf fe-Ftillty and birth-controi, more, 'áiiple 'Sysd' p,-teclfd; 'i'

r'';,fhfiddppieátation fot' nÉn, rtmaxtea uhich folioir'stsmis Irom' fhase 1 of the< pfo|oot., lá'

Uihioilt' '^Intfnfkva intet'fíeiii we#e ódnduoted with the husband»''and isirei of '7t' loner

■s§a,

lifailed. analyfi» of thete intetfiemi ii",prouidied m^'the isrltef*'» 'fóliuie!#. -tlajily a%d fertlllty ^ i^e-y|o Ibt hrlefo# . . ,

del

lá' sÉi^iai en la ciase Baja de Paetto, 'Bico,*

-ii»;'ÍÍ0i|0Í0g|aa' 'iol.. Bo« i, 1|53| iníith ROUbOn Moo,*^ .ü^nali O#, .tho- Ameftoih jfepadiiig if' Polltioal. :ai

sbM&má ■Mmk |f§t».

^r-

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'''fp'.

Jisiéá im smh psyiphólogloial and aooial faetors* Títiditiomlism» levels. of ^spii^tion.

aodaaty* faiolly size ideáis» and ooncem for ▼irlli^y are some ef the 'psycholpgica} irariaiíles we are worktng vith.

Our data on interpersox^l l-elations focus oñ im^ters

fnei ae eettaumlcatioif betvreen spouses» marital adjustment».and «apatice

The influeno

el réJerenóe groupa oh knowledge and attitudes with respeot to fami]^ size and family

limitatlon is also heing analyzed*

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the present» our information is probably sufficient to make a few general!» I

zatlohs and prediotions*

(1)

An interest in the small family is oharaoteristic oí*

I ']

tll*ie9ie*#ees^ie aad resldehee elasses isi the population^ (2) "

Birth eoatrol is

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attaepted by a large proportion of all groups in the sooiety, though to a greater ex®I

tent by the: better eduoated*

(3)' A low degree of success is áchieTed» partioularly I

by rural, poorly eduoated groupe,

•

(4)

A great nunber of objeotions to birth control |

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based on fáulty or insofficient information are among the deterrents to the effeotirel -■ ' ■ ; I

irtetiee o# ftoiiy limitation* There iS'

•

ináleatl^ that ohly a fair^sized push would malee' users oút of •

i I

;

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l '™

' i

save

isiand's fsmilies now being formod the aaguish of haying toO many ohildren

for their »e j^t aiim resouroes is another queotlon»

\F>-

College of iooial Soieaoos

tjniveralty of fHierlo Ileo