The role of contraceptive supply and demand in Mexican fertility decline: evidence from a microdemographic study

This paper uses retrospective life history data to assess the impact of family planning services on contraceptive use in a rural Mexican township. Between 1960 and 1990 contraceptive use rose and fertility declined dramatically. Both contraceptive supply and demand factors were influential in these trends. The start of the government-sponsored family planning programme in the late 1970s was associated with a sharp rise in female sterilization and use of the IUD. However, once we controlled for the changing socio-economic and demographic characteristics of the sample, the presence of family planning services had no significant effect on the likelihood that women used modern reversible methods compared to traditional methods. Men and women expressed concerns about the safety of modern methods such as the pill and the IUD. Efforts to increase modern contraceptive use should place greater emphasis on communicating the safety of these methods and improving the quality of services.     

Why women who don't want to get pregnant don't use contraception

In the developing world about 120 million women have an unmet need for contraception. They want to postpone childbearing, yet they do not use contraception, often because of the unavailability of services and supplies. However, according to a recent article by John Bongaarts, the primary factors are lack of knowledge about a contraceptive method, concern about side effects, and the disapproval of the male partner in developing countries. Lack of knowledge means inability to describe the uses of a contraceptive, its side effects, and the locale of its availability. An approximate knowledge index was calculated for such women, which showed that knowledge level positively correlated with contraceptive prevalence. Countries where the index was below 50% had a contraceptive prevalence of 8% only. The determinant reasons why women were reluctant to use the pill, IUD, and sterilization had to do with health and the fear of side effects, such as nausea and increased bleeding. The contraceptive prevalence among these women was reduced by 71% for the pill, 86% for the IUD, and 52% for sterilization. In Sub-Saharan countries nearly 70% of women cited partner disapproval of contraception, although they had never discussed family planning with their partners. The central concept for reducing unmet need is access with quality, which means that services are voluntary, safe, and appropriate in delivery. Some of the recommendations to reduce the unmet need for contraception include: one-on-one same-sex discussions to increase contraceptive knowledge and acceptability; sensitive responses by programs to their client's health concerns; support by service providers to women negotiating with male partners in order to mitigate male disapproval; and sex education and family planning services to reduce unwanted and early sexual contact and pregnancy while girls develop identities apart from mothering roles.     

Choosing a contraceptive method: why does it matter?

The use of contraceptives varies widely among Asian countries. Based on the most recent survey data available, the rate varies from nearly 8/10 married women aged 15-44 in Taiwan to fewer than 1/10 in Pakistan and Nepal. Women in East Asian countries are most likely to practice contraception, followed by those in Southeast Asia, with lower contraceptive prevalence rates found in South Asia. The rates of some East Asian nations now match those of the US and other developed nations, while in most South Asian nations contraception is spreading slowly. Contraceptive methods in use vary widely by country. The leading method in the greatest number of countries is sterilization, but in most countries several methods are nearly equal in popularity. Only in India is sterilization used by a majority of those people who practice contraception. Japan is the only country in which a majority of contraceptors use condoms, and only in China do 1/2 use IUDs. The choice of a particular contraceptive method is strongly influenced by 1) methods available through family planning programs, or promoted through the use of target systems; 2) religous and cultural factors; 3) concerns about side effects and safety; 4) ease of access to particular methods; 5) the medical profession; and 6) legality--in Japan the pill is illegal. In most countries the type of contraceptive that people prefer has changed since the introduction and promotion of modern methods of contraception. In general, there has been a shift to more effective methods. An increase in female sterilization at the expense of other methods such as the IUD or pill is the most common pattern. In countries where female sterilization is unpopular, use of such modern methods as the pill, IUD, or condom has increased at the expense of traditional methods.     

Expanding contraceptive choice: findings from Zambia

The Population Council's Expanding Contraceptive Choice program works to increase the contraceptive options available to women and men in developing countries. To achieve this goal, the Council is pursuing a new approach, one which begins with an assessment of contraceptive needs from which recommendations for upgrading contraceptive services are based. This new approach was tested in four countries including Zambia in which Stage I--contraceptive needs assessment--was completed. Results of the assessment indicated that despite the efforts of the national family planning program, 33% of Zambian women who do not want to get pregnant do not practice contraception. Only 9% of women use a modern contraceptive method. These results suggest that there is a need for introducing new contraceptive technologies and for expanding utilization of existing methods in the country. Also, stage I assessment yielded other positive outcomes which are enumerated in this paper. In response to this report, the Zambian government decided to proceed with stage II research on the viability of introducing new and underutilized contraceptive methods into the national family planning program.     

Family planning for new mothers in the Philippines

From November 1997 to February 1998, a survey was conducted to evaluate postpartum family planning (FP) services in the Philippines. Data were gathered from records at 86 clinics in 28 provinces and from interviews with 338 FP providers and 3452 clients who began to use FP within 6 months of delivery. Only 7% of women began using FP within 6 months of delivery, and most postpartum attention was devoted to child care issues. Among the women surveyed, most resumed sexual intercourse at 2.4 months postpartum and experienced a return of menses at 4.4 months postpartum despite breast feeding for 6.2 months. The most commonly recommended method to space births was the IUD followed by the injectable contraceptive. Very few providers recommended use of barrier methods. The results indicate that many breast-feeding women are receiving hormonal contraceptives too soon and that IUD insertion may not be occurring at the ideal time postpartum. While a significant percentage of providers recommended use of the lactational amenorrhea method (LAM) and 16% of the women relied on it, the providers lacked sufficient understanding of LAM. In addition, many women switched or discontinued methods. The study led to the recommendations that postpartum FP services be promoted as an essential part of maternal-child health care and that FP providers receive improved training about contraception and LAM.     

Assessing the impact of a family planning nurse training program in Egypt

In 1991 the Egyptian Ministry of Health introduced a new training program for family planning nurses. The training program stressed the development of nurses' counseling skills. As part of the Operations Research Program, sponsored by Family Health International in collaboration with the Egypt National Family Planning Board, managerial staff from family planning agencies designed and implemented a study to evaluate the impact of the new training program. The study objective was to assess the impact of nurse training on nurse performance in the clinic and on clients' family planning knowledge, attitudes and contraceptive use. The study was designed to provide usable information to family planning managers in the field within a time period of less than one year. The study results indicate that there is an association between improved family planning training for nurses and positive changes in family planning knowledge, attitudes and behavior among women attending MoH clinics in this study. The greatest relative change occurred in knowledge. Women in the experimental group, relative to the control group, displayed increased knowledge about contraceptives, particularly the pill and the IUD. Attitudinal change was less pronounced. Favorable attitudes toward oral contraceptives and condoms became more prevalent, and reports of husband-wife communication about family planning also increased. Finally, although contraceptive use was already high prior to the nurse training, IUD use increased significantly among women in one governorate.     

The dynamics of contraceptive adoption in Bohol,Philippines: 1976-1978

A researcher analyzed 1976 and 1978 data on 414 rural women who had never used a family planning method to prevent pregnancy and lived in the predominantly Catholic island province of Bohol in the Philippines to look at the influence certain aspects of the family planning program, begun in 1976, as predictors of changes in contraceptive behavior. 34.5% accepted contraception between 1976-1978. The researchers learned that couple traits (e.g., age, income, education, and religiosity) had only an indirect effect on change in contraceptive behavior. A desire to stop, limit, or space births (motivation) was a strong predictor of family planning method acceptance (p.001). Further couples who clinic providers contacted the most often or who had received more family planning services (services) were much more likely to use contraceptives (p.001). Indeed a significant relationship existed between motivation and services (p.001). Moreover couples who were truly motivated to use family planning methods did not let distance to family planning services prevent them from seeking these services (p.001). On the other hand, couples who confronted personal obstacles to family planning including social, psychological, and other subjective costs (cost index) tended not to accept family planning methods (p.001). A negative association existed between services and location of households vis a vis the intervention program (p.001) which indicated that the program did have an effect in the area of the province where it was located. In conclusion, the strongest predictors of change in contraceptive behavior included motivation, services, and cost index. Services and cost index indicated the great importance of interpersonal and/or client staff contact, especially since they were more important in influencing behavior change than distance and family planning site.     

Adding choice to the contraceptive mix: lessons from Indonesia

Researchers asked 1945 women of reproductive age living in East Java, Indonesia what contraceptive method they preferred during the women's 1st visit to a government family planning clinic. Soon after field workers introduced them to a method, the researchers asked the women what method the field workers suggested and what method the women planned to use. They again spoke to them 1 year later to determine contraception continuation. The field workers granted 86.3% of the women their method choice. Only 9% of these women had stopped using their chosen method while 72% of the women who were not allowed to use their chosen method stopped using the method assigned to them. Thus choice was a key factor in sustained use of contraceptives. Further if family planning workers stick to a mutual participation of both themselves and their clients, they respect clients' method choices and, by informing clients about the chosen method, they strengthen clients' decision making. In the early 1990s, another researcher had developed a system to determine contraceptive needs at various stages of the reproductive period (before 1st marriage, after 1st marriage but prior to 1st birth, after 1st birth but prior to last birth, and after last birth). She applied observed contraceptive preferences for women using contraception within each life cycle stage to the age specific contraception need, derived from data from the 1987 Contraceptive Prevalence Survey for Indonesia, to determine the ideal contraceptive mix. Her calculations demonstrated that oral contraceptive use was high, IUD use was low, particularly among older women, and too few sterilizations had occurred, particularly among older women. Thus Indonesia needed to broaden the contraceptive mix to encourage methods that better meet women's reproductive life cycle needs.     

Tonga: family planning survey

A survey was carried out in 1975 in Tonga to determine how many families are practicing family planning. Public health nurses visited every household except the Niuas and remote islands. 4253 women out of the total of 9307 married women aged 15-44 years were using a contraceptive (45.7%). The percentage of users ranged from 4.5% in Ha'afeva District to 63.6% in the district of Kolonga. 60% of the users practice effective methods such as the pill, Depo-Provera, IUD, or sterilization; 23% use the condom, and 17% rely on withdrawal, calendar ovulation, or rhythm.     

Quality of care in Peru: measuring its impact. Field report

A report published in 1995 by the Population Council described the impact of the quality of family planning services on the incidence of unplanned pregnancy in Peru. This report followed a 1994 study that assessed the impact of quality on contraceptive usage by linking data from Peru's 1991-92 Demographic and Health Survey (DHS) and a 1992 Peru Situational Analysis study of the status of family planning (FP) services at 3000 individual service delivery points. The 1995 study added data from a follow-up survey of a sample of the DHS respondents. The 1994 study used an innovative quality of care index that measured the quality of FP services available in a geographic area to women with partners living nearby. This index was then assigned to every woman in the area and correlated with her use of modern contraceptives. The analysis revealed that availability of high-quality FP services greatly increased the number of women using modern contraception. The 1995 study analyzed the impact of quality of care on rates of unintended pregnancy and found that the percentage of unwanted births was significantly higher in areas with low-quality FP services. The researchers note that these results only hint at a relationship between quality of care and reproductive behavior and that the findings should be interpreted conservatively. However, the studies support the importance of investing in quality FP care.     

Family planning in choiseul province,Solomon Islands

The results presented are from a rural prevalence survey on family planning in Choiseul Province, Solomon Islands. Married women aged 15–49 years with at least one living child and married men whose wife met the same criteria, provided data on knowledge, attitudes and practices of contraceptive use. Fifty one per cent of the female sample were using some form of contraception, 26 per cent reversible and 25 per cent non-reversible methods. Sixty-five per cent of men claimed that they or their spouse were using a method of family planning. Tubal ligation was the most common currently used method (25 per cent in the female survey). Desired family size was four for both males and females. Knowledge and approval of family planning was high, with 83 per cent of females and 81 per cent of males knowing of at least one method. Problems in accessing information and services for family planning include cultural and logistical constraints. Religious affiliation was the major variable affecting knowledge, use and approval of contraceptive methods. Nearly a quarter of the sample lived further than two hours travel time from the nearest health clinic supplying contraceptive methods. These clinics often have only an intermittent availability of supplies. A strong interest in family planning was demonstrated by both respondents and service providers.     

The marriage of mentally handicapped people and family planning services for them in Shanghai

This brief article discusses findings from a study by the Shanghai Population Information Center on marriage, fertility, and family planning among mentally handicapped adults in Shanghai, China, and population dynamics. The sample included 184 mentally handicapped persons aged 20-49 years (79 men and 116 women). 47 people had mild, 92 had moderate, and 45 had severe mental deficiencies. The mean age was 33 years. About 29% were married or ever married. 49 were married or ever married women. 6 spouses were mentally deficient. About 70% of the married or ever married had children. 43 had ever used contraception. The most commonly used method was the IUD. Several people had the approval of family members and were sterilized. Only 3 women were prevented from use of contraceptive services by family. 38% of the unmarried women's parents or relatives wanted their mentally deficient family members to be married before old age. 48% discouraged marriage because of the mental deficiency.     

Community-based contraceptive distribution: a Korean success story

The results of a community-based contraceptive distribution program using village women canvassers in Cheju Island province, Korea, are evaluated. This rural province had the highest fertility and lowest contraceptive use before the project began. After pre-testing in another area, township-level family planning field workers recruited 365 new female canvassers per 150 women at risk of pregnancy, compared to 10,000-25,000 per worker in the previous scheme. The canvassers were to contact every household, offering them pills or condoms, or vouchers for an IUD or sterilization from the clinic. The former target system, which in reality had limited the numbers of acceptors, was suspended, necessitating an increase in budget outlays for family planning in Cheju province. By 1985 the contraceptive prevalence had doubled, and fertility fell 40.1 and 32.4% in the 2 Cheju counties. Costs per couple-year for the Cheju program were lower than those in other areas. The results of this project suggested that increasing the number of community workers or canvassers in rural areas helps reduce barriers to the use of contraceptives.     

How Do Education and Family Planning Accelerate Fertility Decline?

Education and family planning can both be influenced by policy and are thought to accelerate fertility decline. However, questions remain about the nature of these effects. Does the effect of education operate through increasing educational attainment of women or educational enrollment of children? At which educational level is the effect strongest? Does the effect of family planning operate through increasing contraceptive prevalence or reducing unmet need? Is education or family planning more important? We assessed the quantitative impact of education and family planning in high-fertility settings using a regression framework inspired by Granger causality. We found that women's attainment of lower secondary education is key to accelerating fertility decline and found an accelerating effect of contraceptive prevalence for modern methods. We found the impact of contraceptive prevalence to be substantially larger than that of education. These accelerating effects hold in sub-Saharan Africa, but with smaller effect sizes there than elsewhere.     

Estimating unmet need for contraception by district within Ghana: an application of small-area estimation techniques

The importance of meeting the unmet need for contraception is nowhere more urgent than in the countries of sub-Saharan Africa, where the fertility decline is stalling and total unmet need exceeds 30 per cent among married women. In Ghana, where fertility levels vary considerably, demographic information at sub-national level is essential for building effective family planning programmes. We used small-area estimation techniques, linking data from the 2003 Ghana Demographic and Health Survey to the 2000 Ghana Population and Housing Census, to derive district-level estimates of contraceptive use and unmet need for contraception. The results show considerable variation between districts in contraceptive use and unmet need. The prevalence of contraceptive use varies from 4.1 to 41.7 per cent, while that of the use of modern methods varies from 4.0 to 34.8 per cent. The findings identify districts where family planning programmes need to be strengthened.     

Microcredit,Family Planning Programs,and Contraceptive Behavior: Evidence From a Field Experiment in Ethiopia

The impact of community-based family planning programs and access to credit on contraceptive use, fertility, and family size preferences has not been established conclusively in the literature. We provide additional evidence on the possible effect of such programs by describing the results of a randomized field experiment whose main purpose was to increase the use of contraceptive methods in rural areas of Ethiopia. In the experiment, administrative areas were randomly allocated to one of three intervention groups or to a fourth control group. In the first intervention group, both credit and family planning services were provided and the credit officers also provided information on family planning. Only credit or family planning services, but not both, were provided in the other two intervention groups, while areas in the control group received neither type of service. Using pre- and post-intervention surveys, we find that neither type of program, combined or in isolation, led to an increase in contraceptive use that is significantly greater than that observed in the control group. We conjecture that the lack of impact has much to do with the mismatch between women’s preferred contraceptive method (injectibles) and the contraceptives provided by community-based agents (pills and condoms).     

Secrecy and silence: why women hide contraceptive use

A recent Population Council survey of 1860 married women and 1056 of their husbands in urban Zambia found that many women who use contraception do so without their husbands' knowledge and that those women who hid their practice of contraception from their husbands did so because they found it very difficult to bring up the subject of family planning with them. These findings indicate that low levels of contraceptive use are not the result of a simple communication matter. Sex and sexuality are often the exclusive domain of African husbands. As such, if a wife initiates a discussion of family planning, she may threaten her husband's sense of control and create discord within the family. The culture of silence about sex and sexuality is very strong in Africa. 57% of women stated that were they to propose contraceptive use with their husbands and the husband opposed such practice, they would nonetheless use them without his knowledge. 7% of the women stated that if their husbands disapproved of contraceptive use, they would nonetheless openly use a method against his wishes. The majority of women correctly perceived their husbands' views on family planning use and fertility preferences. In focus groups, both men and women said that they did not believe that women have the right to independently act upon their reproductive preferences. A husband's inadequate financial support of his children could, however, justify clandestine contraceptive use. These findings point to the need to include easily hidden methods in the mix of contraceptives family planning programs offer. Moreover, service providers should not automatically encourage husbands' involvement. A client's right to privacy should always be respected.     

American Catholicism and the International Family Planning Movement

This paper examines the role of the American Catholic Church in the international family planning movement and discusses elements of the Catholic opposition to birth control. The paper argues that the reaction of American Catholics to government support for contraceptive services was based not only on the Church's condemnation of particular contraceptive methods, but also on a variety of other factors including class and ethnic hostility between Catholics and the promoters of family planning, jurisdictional disputes over what institutions would guide family life, the perceived threat that government support of family planning was to the authority of the Church and the Church's understanding of sex and women. The role of an American theology of political compromise and accommodation in mitigating the American Catholic Church's opposition to organized family planning is assessed.     

Effect of declines in mortality on the birth rate and related measures

In December 1961, the government of the Republic of Korea adopted a programme of family planning as part of its public health services. In 1962 a pilot research project was begun, under university auspices, with the object of demonstrating and assessing what can be achieved through intensive family planning education and services. Wondang Myun near Seoul, with a rural population of 9,000 in seven villages, was chosen for the study. A baseline survey covering attitudes and practices related to family planning was made of the population under study, as well as of a similar population in the control area of Kimpo Myun. This report outlines the design, the programme of education and services, and some of the preliminary results of the study. After eighteen months of the programme, acceptance of birth control measures increased fourfold among the married women in the fertile age range. Acceptance was highest among the 25–39 age group, and among high-parity women. Economic considerations were foremost among the reasons given for adopting family planning. Among the traditional methods offered, the condom was the favoured method of choice, indicating that husbands were taking the initiative in contraceptive practice. A decline in the crude birth index was observed; whether the decline was due more to contraceptive practice or to abortion, at least an increase is reflected in the effective desire for family limitation. The high failure rate among Users should be investigated further. Continued effort is needed to provide more information and detailed instruction to users, and to develop social circumstances that support the practice of family planning. Along with an effort to achieve more effective use of traditional methods, other methods, including intra-uterine devices, deserve trial.     

Contraceptive acceptance and pregnancy: a matrix approach to the analysis of competing risks

Abstract This paper represents an initial attempt to formalize the relationships among post-partum sterility, fecundability, and contraceptive acceptance in terms of absorbing Markov chains. Acceptance of contraception offered by family planning programmes is analyzed as a possible event in time for a cohort of recently delivered women as they pass through phases of temporary sterility and fecundability towards another possible pregnancy. The results of the study indicate that once a woman leaves the post-partum anovulatory stage, the probability of her becoming pregnant again is large compared to the competing rates of contraceptive acceptance currently in force. Unless highly fecund non-contracepting women are approached by family planning programmes shortly after a pregnancy has been terminated (by childbirth or abortion), they will quickly become ineligible to accept either the pill or IUD because of once again being 'currently pregnant'.