The multistate life table method: An application to contraceptive switching behavior

In many demographic behaviors (e.g., those relating to marriage, contraception, migration, and health), people change among multiple statuses through time, sometimes leaving and then returning to the same status. Data on such behaviors are often collected in surveys as censored event histories. The multistate life table (MSLT) can be used to properly describe, in a single analysis, these complex transitions among multiple states measured in such data, but MSLT is rarely applied in the demographic literature because practical guidance is lacking on how to compute MSLTs with such data. We provide methods for computing MSLT quantities using censored event-history data: namely, transition intensities and probabilities, "state occupancy" probabilities and standard errors, average time spent in specified states, and average number of visits to specified states. Applying these methods to contraceptive use, we find high levels of switching back and forth, particularly between barrier methods and non-use, resulting in high rates of unintended pregnancy.     

Male sterilization as a contraceptive method in Canada an empirical study

Abstract In 1851-61, the crude birth rate in Canada was 45. In 1972, it was approximately 16. Not only have birth rates decreased but the average family size has declined from five or six children per family at the turn of the century to two or three children in the 1970'S. In addition, women are completing their childbearing at an earlier age. 50 years ago, it was not uncommon for a woman to have a child in her late thirties or early forties. To-day, this is a relatively rare event. In fact, it is estimated that approximately 80% of all families have the number of children desired before the woman is 30 years of age. This new demographic pattern creates an important and crucial situation for Canadian couples. At age 30, with all the desired children and 15 more years of potential childbearing ahead of them, what can they do to prevent the occurrence of additional pregnancies?     

Community-level determinants of contraceptive use in the Philippines: A structural analysis

We use household and community data from the Philippines to estimate a multilevel model of contraceptive use. We go beyond previous efforts in this field by developing a structural model that recognizes joint endogeneity and the temporal ordering of variables, by considering a wider range of community influences on fertility behavior, and by employing an econometric procedure allowing for a multilevel error structure. The results suggest that there are significant effects on fertility behavior of community-level family planning services, labor-market conditions, and infrastructure development. These results provide insights regarding the structural determinants of contraceptive use and fertility that are useful for drawing policy implications.     

Impact of having a high-risk pregnancy on future postpartum contraceptive method choice

BackgroundTo compare the knowledge and preference of preconceptional contraception to future postpartum contraceptive method choice in high-risk pregnancies.Research questionDoes a high-risk pregnancy condition affect future postpartum contraceptive method choice?MethodWomen hospitalised at the High Risk Pregnancy unit of a tertiary research and training hospital were asked to complete a self-reported questionnaire that included demographic characteristics, presence of unintended pregnancy, contraceptive method of choice before the current pregnancy, plans for contraceptive use following delivery and requests for any contraceptive counselling in the postpartum period.FindingsA total of 655 pregnant women were recruited. The mean age, gravidity and parity of the women were 27.48 ± 6.25 years, 2.81 ± 2.15 and 1.40 ± 1.77, respectively. High-risk pregnancy indications included 207 (31.6%) maternal, 396 (60.5%) foetal and 52 (7.9%) uterine factors. All postpartum contraceptive choices except for combined oral contraceptives (COCs) usage were significantly different from preconceptional contraceptive preferences (p < 0.001). High-risk pregnancy indications, future child bearing, ideal number of children, income and education levels were the most important factors influencing postpartum contraceptive choices. While the leading contraceptive method in the postpartum period was long-acting reversible contraceptive methods (non-hormonal copper intrauterine device Cu-IUD, the levonorgestrel-releasing intrauterine system (LNG-IUS) (40%), the least preferred method was COCs use (5.2%) and preference of COCs use showed no difference between the preconceptional and postpartum periods (p = 0.202). Overall 73.7% of the women wanted to receive contraceptive counselling before their discharge.ConclusionA high-risk pregnancy condition may change the opinion and preference of contraceptive use, and also seems to affect the awareness of family planning methods.     

Appropriate methods for analyzing the effect of method choice on contraceptive discontinuation

The contraceptive method chosen is an important determinant of contraceptive discontinuation. However, method choice is endogenous to contraceptive discontinuation. Using data from the 1997 Indonesia Demographic and Health Survey, we apply a multilevel multi-process model to examine the impact of method choice on three types of contraceptive discontinuation. We confirm that method choice is endogenous to the processes of contraceptive abandonment and method switching, but not failure. Ignoring the endogeneity of contraceptive choice leads to various biases in the magnitude of estimated effects of method choice on abandonment and method switching, but the general conclusions are robust to these biases.     

A meta-analysis of research on adolescent contraceptive use

Meta-analysis was used to summarize the results of 134 studies of adolescent contraceptive use in relation to two major explanatory models, the career model and the decision model. There was evidence in support of both models, although there has been less research conducted on variables related to the decision model. The major variables found to affect young women's contraceptive use were partner influence to use contraception, acceptance of one's sexuality, future orientation, positive attitudes toward contraception, an exclusive sexual relationship, and frequency of intercourse. The major variables affecting young men's contraceptive use were partner influence, frequency of intercourse, and positive attitudes toward contraception; however, there was relatively little research on young men compared to young women. A number of possible future directions for research are noted.We would like to thank Nancy Adler and Catherine Chilman for their comments on an earlier version of this article. Portions of this research were presented at the 1984 meeting of the American Psychological Association.Requests for reprints should be addressed to Bernard E. Whitley, Jr., Department of Psychological Science, Ball State University, Muncie, Indiana, 47306.     

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.     

Child schooling and contraceptive use in rural Africa: A Ghanaian case study

In this study, I examine the contributions of childrens schooling to fertility decline in Africa. I use cross-sectional data collected in the late 1980s to look at how household child schooling patterns and community access to schools affect contraceptive use among rural Ghanaian women. My results indicate that the schooling of children is associated very strongly with increased use of modern and traditional contraceptive use and thereby suggest that educational policy has played a role in initiating and sustaining fertility decline in Ghana and possibly elsewhere in Africa.     

Community and contraceptive choice in rural Thailand: A case study of Nang Rong

This paper blends quantitative with qualitative data in an investigation of community and contraceptive choice in Nang Rong, Thailand. Specifically, it develops an explanation of 1) method dominance within villages, coupled with 2) marked differences between villages in the popularity of particular methods. The quantitative analysis demonstrates the importance of village location and placement of family planning services for patterns of contraceptive choice. The qualitative data provide a complementary perspective, emphasizing the importance of social as well as physical space and giving particular attention to the structure of conversational networks.     

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.     

Effect of provider characteristics on choice of contraceptive provider: A two-equation full-information maximum-likelihood estimation

We use surveys of households and health-care facilities conducted in the same area at the same time to determine which characteristics of providers attract users of contraceptives. By using the full-information maximum-likelihood technique to jointly estimate choice of contraceptive method and choice of provider, we avoid self-selection bias. Results support the need for modeling quality and for jointly estimating the choice of contraceptive method and the choice of provider to avoid biased estimates of coefficients. The results suggest that for the Cebu, Philippines region, small local clinics that focus on family planning tend to be most favored by clients.     

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.     

The contraceptive prevalence survey project: content and status

The United States Agency for International Development (USAID) selected Westinghouse Health Systems to carry out contraceptive surveys. The primary objectives of the Contraceptive Prevalence Surveys (CPS) are to determine periodically the levels of contraceptive use in the country; to examine the correlates of and differentials in these levels in order to assess the impact of various types of governmental and nongovernmental programs; to identify factors that will facilitate an increase in contraceptive use, particularly factors involved in program planning activities; and to institutionalize in each country the capability to design and implement studies of contraceptive prevalence, to be undertaken at regular intervals by an in-country agency. Each CPS generally collects data on the basic demographic background of the country concerned, knowledge of contraceptive methods, prior contraceptive experience and current method used, past fertility behavior and future fertility intentions, present utilization of various types of service delivery systems, perceived accessibility of contraceptives, and reasons for nonacceptance of contraception. In the CPS project, data collection and field operations have been strongly stressed. Efforts have recently been made to expand the extent and sophistication of CPS data analysis. For example, 2 countries are currently using a series of mathematical techniques called synthetic estimators to estimate subnational levels of contraceptive use by merging CPS and census data. Westinghouse, in cooperation with the University of Michigan, is currently working to develop community characteristics module for inclusion in future CPS projects.     

Racial differences in contraceptive choice: Complexity and implications

Previous research has failed to generate consensus about why black fertility has persistently exceeded that of whites in the United States. In an effort to shed light on this question, this article examines black/white differences in sociodemographic factors affecting contraceptive choice. Using data from the 1976 and 1982 National Surveys of Family Growth, we find a complex pattern of black/white differences. Not only does contraceptive choice vary by race, but the effects of such variables as age, marital status, and education also differ between blacks and whites. For example, compared with whites, black married women avoid coital methods, and compared with blacks, white women shift contraceptive behavior more as they change marital status. The complex nature of the racial differences in contraceptive choice are interpreted as reflecting differences in marriage patterns and trends.     

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.     

Antecedents to contraceptive innovation: Evidence from rural Northern Thailand

A number of different causal mechanisms have been proposed to explain the onset of fertility declines in populations with previously uncontrolled fertility, but they have never been adequately tested. The present study identifies and tests five antecedents to family limitation practices in a sample of 755 currently married couples resident in rural Northern Thailand. The loglinear multiple regression models estimated indicate that couples in more developed districts, more modern couples, couples in which wives have more equal roles, couples believing that intergenerational wealth transfers favor children rather than their parents, and more wealthy couples, were all significantly more likely to be early adopters of contraception. Local development levels appeared to have the greatest net effects on the timing of adoption of fertility control. In addition, couples in areas where contraceptive services were more readily available were also significantly more likely to be contraceptive innovators, net of these five variables.     

The determinants of the duration of contraceptive use in China: A multilevel multinomial discrete-hazards mdeling approach

Often in demography, individuals may change state over time for a variety of reasons. Competing-risks hazards models have been developed to model such situations. This paper describes the extension of the discrete-time competing-risks hazards model to a multilevel framework that allows for data at different levels of aggregation. The model is illustrated with data from the 1988 Chinese National Survey of Fertility and Contraceptive Prevalence, which collected complete contraceptive histories. Women may stop using a method of contraception for a number of reasons; this paper describes how one can control for correlations between the outcomes of repeated spells of contraceptive use.