Falling fertility in Indonesia: success in national family planning

This publication summarizes the findings of the National Indonesia Contraceptive Prevalence Survey (NICPS), which revealed a rapid decline in Indonesia's fertility rate. This article also describes how the successful Indonesia family planning program is designed and maintained. Since 1975, fertility rates have dropped from 5.5 to 3.3 children per woman. Those practicing contraception during the same period has risen from 400,000 couples to 17 million. Contraceptive education is high (e.g. 95% of all married Indonesian woman are familiar with a modern contraceptive method). The Indonesia family planning program cooperates with other government activities designed to improve people's health and welfare. It emphasizes access to contraceptive methods and promoting the idea small family. The program was structured to us extensive community involvement, and cultural beliefs were incorporated into program policy; Islamic leaders were consulted before program implementation. The program is flexible so that the differing needs of each region can be effectively met by the family planning program. The future main goal will be to contain a potential population boom when the 40% of the present population which is under 15 years of age becomes reproductively mature.     

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.     

Determinants of fertility and the unmet need for family planning in Indonesia

Indonesia's fertility has declined to an average of slightly more than 3 children/woman. The islands of Java and Bali have the lowest birth rates. Indonesia's family planning program has been a model of innovation, flexibility, and community involvement, and has been effective in reducing fertility, changing family preferences, and increasing contraceptive use. Fertility decline is also determined by factors other than contraceptive use, as provinces in Jakarta and East Java has low fertility and low contraceptive use. Recent research by Suyono and Palmore found that among cohorts of women in Jakarta lowest fertility rates were explained by greater nonexposure to pregnancy in an unmarried state or by a divorced or widowed status, and by infecundity. In East Java, fertility determinants were the same with the possible addition of lower coital frequency. The study estimated nonexposure due to marriage, infecundity, and contraceptive use. Policy considerations, however, are concerned with the exposed state of the percentage of time women are currently married, fecund, not using contraceptive, and sexually active. Suyono and Palmore also calculated the percentage of time spent in the exposed state by province. The estimates ranged from 12% in Yogyakarta to 25% in West Java and the Outer Islands. Exposed was further divided into groups with a manifest, latent, and no current need. Women with a manifest need for family planning are those who are aware of their contraceptive needs to stop or postpone childbearing and not using. Manifest need was highest in high fertility areas: 12% in Central Java, 13% in West Java, and 12% in the Outer Islands. Programs targeting these women should focus on wider availability of information and services. Women with latent needs are unaware of their need for family planning and are not using contraception. These women were also concentrated in high fertility areas. The percentage of years spent in the latent unmet need state was estimated at 23-24% in West Java and the Outer Islands. Program emphasis should be on education and motivation to show how family size can be controlled. Women with current need can be educated toward future acceptance.     

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.     

Is Maternal and Child Health Service use a Causal Gateway to Subsequent Contraceptive use?: A Multi-Country Study

The purpose of this study is to examine the relationship between MCH service utilization and contraceptive use in five countries: Bolivia, Guatemala, Indonesia, Morocco, and Tanzania. The analysis is carried out at the level of the individual woman, with contraceptive-use status modeled as a function of: (1) the availability, quality, and packaging of MCH and family planning services; (2) community- and individual-level determinants of health service and contraceptive use; and (3) intensity of prior MCH service use. Data for the analysis comes from DHS data on women of reproductive age linked with data from service-availability surveys. We use full-information, maximum-likelihood regression techniques to control for the effects of unobserved heterogeneity that might otherwise bias our estimates. In three of the five countries (Morocco, Guatemala, and Indonesia) the results of the analysis suggest that the intensity of MCH service use is positively associated with subsequent contraceptive use among women, even after controlling for observed and unobserved individual- and community-level factors. This result lends support to the proposition that, at least in the context of these three countries, the intensity of MCH service per se use does have a “causal” impact on subsequent contraceptive use, even after controlling for factors that “predispose” sample women to use health care services.     

Indonesia: family planning target stepped up for 1980; twofold success of integrated project

The recruitment of 3 million additional family planning acceptors for the fiscal year 1979/80 was the target of Indonesia's family planning program. Available data shows that Indonesia was the 1st country in the world to have consumed 200 million cycles of contraceptive since the program's inception 9 years ago. The achievement of a lower birth rate of between 20 and 22 per 1000 (present rate is approximately 38/1000) is possible within the next 10 years should the program maintain its present pace. Education of women; health of pregnant mothers, and nutrition of children are factors which strongly affect family planning. Current conditions are such that 30% of children aged 0 to 6 years and a large proportion of mothers are malnourished. A coordinated family planning-rural development project launched by the Indonesian Planned Parenthood Association and Indonesian Women's Association was launched 2 years ago and has proved successful. The project's core activity is the organization of income-generating projects such as poultry-raising, vegetable cultivation, handicrafts and small industries. Family planning and other health measures (eg, environmental sanitation) were also promoted. The project utilized selected cadres of married women who were then trained in community development. These women became trainers in their own villages. The project proved to be successful in terms of income-generating activities for the women and in terms of gaining 623 new family planning acceptors within a period of 5 months.     

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.     

Trends and determinants of contraceptive use in Kenya

This study uses the 1977-1978 Kenya Fertility Survey and the 1989 Kenya Demographic and Health Survey to examine trends and determinants of contraceptive use in Kenya. A substantial increase in contraceptive use occurred in Kenya over the decade. Yet although the increase was shared by all groups in the country, the amount of change differed greatly. A regression decomposition procedure revealed that shifts in population composition--that is, an increase in better educated women and in the proportion of women who want to cease childbearing--were the primary sources of aggregate change in contraceptive use.     

中国生殖健康方案的推进和已婚育龄人口避孕模式转变——ICPD 10:避孕方法的医控模式和自控模式有变化吗

避孕节育是生殖健康极为重要的内容。文章利用国家人口和计划生育委员会1988年至2001年全国生育节育抽样调查和全国计划生育/生殖健康调查数据,分析了已婚育龄人口在避孕模式上的时空变化特征,在此基础上进一步研究了在已婚育龄人口的年龄、子女数和生活的不同区域环境等方面避孕模式的时空变化。结果表明,在我国人口转变的过程中,低生育水平下的避孕模式以及推行避孕节育知情选择后已婚育龄人口的避孕模式,特别是医院控制的避孕方法与自己控制的避孕方法的构成已经发生了变化,有必要进一步改善生殖健康服务的技术服务等。     

Does Contraceptive Use Always Reduce Breast-feeding?

Previous studies suggest that access to modern contraceptives can reduce breast-feeding rates because women who had been using breast-feeding to avoid pregnancy substitute away from it. This article shows that contraceptive use can also have a positive effect on breast-feeding. A mother often weans a child if she becomes pregnant again, which can occur sooner than desired if she lacks access to contraceptives. Thus, by enabling longer birth spacing and preventing unwanted pregnancies, contraceptive use allows for a longer duration of breast-feeding. This positive effect should primarily affect infants who are past the first few months of life because their mothers are more fecund then, and the negative effect should affect infants who are very young because the contraceptive property of breast-feeding is strongest then. I test for these dual effects using Demographic and Health Survey data for Indonesia. I find evidence of the positive birth-spacing effect: contraceptive use increases the likelihood that children continue to be breast-fed past age 1. There is also suggestive evidence of a negative substitution effect among infants age 3 months and younger.     

Case study: fertility decline in Iran

Iran has experienced one of the most successful family planning programs in the developing world, with 64 percent decline in total fertility rate (TFR) between 1986 and 2000. This paper focuses on Iranians’ unique experience with implementation of a national family planning program. Recognition of sensitive moral and ethical aspects of population issues resulted in successful collaboration of technical experts and religious leaders. Involvement of local health workers, women health volunteers and rural midwives led to great community participation. Demographic and Health Survey (DHS) data in 2000 indicated a TFR of 2.0 births per women and 74 percent contraceptive use among married women. This case study will help policy makers and researchers in Moslem countries and other developing countries with high fertility rate to consider a successful family program as a realistic concept with positive impacts on nation’s health and human development.     

Women’s health and pregnancy outcomes: Do services make a difference?

We use data from the Indonesia Family Life Survey to investigate the impact of a major expansion in access to midwifery services on health and pregnancy outcomes for women of reproductive age. Between 1990 and 1998 Indonesia trained some 50,000 midwives. Between 1993 and 1997 these midwives tended to be placed in relatively poor communities that were relatively distant from health centers. We show that additions of village midwives to communities between 1993 and 1997 are associated with a significant increase in body mass index in 1997 relative to 1993 for women of reproductive age, but not for men or for older women. The presence of a village midwife during pregnancy is also associated with increased birthweight. Both results are robust to the inclusion of community-level fixed effects, a strategy that addresses many of the concerns about biases because of nonrandom program placement.     

Religion,social milieu,and the contraceptive revolution

This study examines how the social environment of religious congregations affects the spread of contraceptive use in developing contexts, using Mozambique as a case study. Analysis of qualitative data collected in urban areas of that country in 1998-99 and of the data from the 1997 Mozambique Demographic and Health Survey suggests that, in urban areas, the environment of more socioculturally diverse and inclusive Roman Catholic and mission-based Protestant congregations is more propitious to the spread and legitimization of modern contraception than the milieu of smaller, relatively homogeneous, independent churches. In rural areas, however, sociocultural diversity within and across different religious denominations is minimal, and membership in any formal congregation offers an advantage in contraceptive learning.     

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.     

Indonesia; World Bank assists Second Population Project

Indonesia's First Population Project, funded jointly by the International Development Association and UNFPA, was started in 1972 and provided for construction of service and training facilities, equipment, research and evaluation studies, education, and communication activities. The national family planning program has made progress in the last 20 years. Acceptor and family planning personnel statistics are given. The World Bank has recently awarded Indonesia a loan to fund its Second Population Project, to aid in reaching the goal of a 50% reduction in fertility by 2000.     

Dynamics of contraceptive use and breastfeeding during the post-partum period in Peru and Indonesia

This paper examines the interaction between contraceptive use and breastfeeding in relation to resumption of intercourse and duration of amenorrhea post-partum. We used data from the month-by-month calendar of reproductive events from Demographic and Health Surveys (DHS) in Peru and Indonesia. The analyses show that breastfeeding women were less likely than non-breastfeeding women to have resumed sexual intercourse in the early months post-partum in both countries. In Peru, but not in Indonesia, breastfeeding women had a significantly lower odds than non-breastfeeding women of adopting contraception. Although the likelihood of contraceptive adoption was highest in the month women resumed menstruation in both countries, about ten per cent of subsequent pregnancies occurred to women before they resumed menses. These results emphasize the importance of integrating breastfeeding counselling and family planning services in programmes serving post-partum women, as a means of enabling those who wish to space their next birth to avoid exposure to the risk of a pregnancy that may precede the return of menses.     

Strength of fertility motivation and contraceptive use in Nepal

The study's purpose was to test whether new survey questions on strength of fertility motivation, included in Nepal's 1986 Fertility and Family Planning Survey, enable improved prediction of current contraceptive use. Intent to use contraception in the future was also tested, over and above the effects of socioeconomic background. While controlling selected demographic and socioeconomic background characteristics of the respondents, the authors found the effect of the strength of fertility motivation on current contraceptive use to be substantial and highly significant statistically. Nevertheless, the background factors largely captured the effect of motivational strength on current use when motivational strength was deleted from the model, inasmuch as measures of global fit declined only slightly as a consequence of the deletion. These findings indicate that respondents' demographic and socioeconomic background characteristics affect motivational strength, so that motivational strength does not have a large independent effect on use. These results raise the question of whether strength of fertility motivation can be affected by educational efforts mounted by family planning programs to increase contraceptive use. The analysis shows that strength of motivation does have some independent effect on contraceptive use, and it is quite possible that this independent effect could be enhanced by educational programs operating independently of the socioeconomic characteristics of program recipients. Because the 1986 survey lacks relevant data, we have not been able to explore this possibility empirically.     

禀赋、场域与中国妇女生育意愿研究

利用2006年中国健康营养调查(CHNS)数据,构建模型,对中国18～52岁妇女的意愿生育决策、生育强度及其影响因素进行实证分析。在众多因素中,家庭已有孩子构成、能力禀赋、资本禀赋对妇女生育意愿有着显著影响,技术禀赋对妇女再生育的意愿和强度有重要影响。同时,将划分生育场域边界的地区变量纳入模型,显示不同区域间妇女的生育意愿存在较大差别,中西部地区妇女的生育意愿明显高于东北部地区;妇女禀赋条件越改善、禀赋水平越高、生育场域越优化,其生育意愿、生育强度越低,生育行为越趋理性。未来开展人口和计划生育工作,制定、调整人口和计划生育政策,应该对此予以充分考虑。     

Sex preference and fertility: what is the link?

It is argued that investment in programs for changing attitudes toward sex preference may not have the greatest impact on reducing fertility or increasing fertility control. Arnold's new method of analysis of determining sex preference was applied to data from a 1977 Egyptian survey of 36,000 rural households in Menoufia Governorate. Findings indicated that couples increased their use of modern contraceptives in direct proportion to an increase in the number of sons. Arnold determined that a large majority of all couples would have at least one boy early in their childbearing years. Thus sex preference would not have a large effect on fertility. Arnold's analysis among 27 countries found that without any sex preference, contraceptive usage would increase by an average of less than 3.7 percentage points. Arnold found that sex preference was strongest in Asia, particularly in South Korea and Taiwan that already have reduced fertility levels. In Africa, where fertility is high, the total elimination of sex preference would have only a 2.9 percentage point difference in contraceptive use. Sex preference had small effects on the percent of women who practice contraception, the percent who desire no more children, and the average number of additional children wanted. For example, in Bangladesh having no sex preference would show a percentage difference of 1.6 percentage points for contraceptive use, 4.7 percentage points difference for women desiring no more children, and -0.1 percentage point difference for the average number of additional children wanted. The effect of having no sex preference was strongest in India compared with Bangladesh, Indonesia, Nepal, the Philippines, Thailand, Ghana, Kenya, Costa Rica, Haiti, Paraguay, and Peru. The effect of no sex preference in India would have the respective percentage point effect of 3.7, 8.9, and -0.2. Public policy should be directed to information, education, and communication with other social goals.