Issue 21 | June 2010
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Family planning and contraceptive choice

C-Channel 21 highlights family planning and contraceptive choice.
Seven articles investigate contraceptive method choice with a special focus on women, men, and couples. Three articles examine the male role in family planning. Research for these articles was conducted in Afghanistan, Bangladesh, Eritrea, India, Indonesia, Nepal, and Nigeria.

Of Interest…

Of Interest photoA WHO technical consultation concluded that evidence supports expansion of community-based health workers providing injectable contraceptives.

In Albania, C-Change has launched a second mass media campaign to increase use of modern contraceptives to prevent unplanned pregnancies. Broadcast nationally on TV and radio and in ads in major Albania newspapers, "A Happy Life" campaign provides information to young women and men about contemporary contraceptive methods and counters misconceptions about side effects. See the C-Change/Albania web page for additional information.


In this issue

Contraceptive Method Choice: Women, Men, and Couples

1. Modern contraceptive use among young women in developing countries

2. Women's autonomy and reproductive preferences-Eritrea

3. Health communication interventions and its effect on contraceptive use-India

4. Wives' and husbands' education levels and contraceptive method choice-Nepal

5. Achieving success with family planning in rural Afghanistan

6. Indonesian couples' pregnancy ambivalence and contraceptive use

7. Family planning practice and acceptance-northwestern Nigeria


Male Role in Family Planning



8. Male perceptions of female sterilization-India

9. Family size and family planning-South Asia

10. Spousal communication and contraceptive use-southwest Nigeria

Contraceptive Method Choice: Women, Men, and Couples

1. Limits to modern contraceptive use among young women in developing countries: A systematic review of qualitative research

Authors: Williamson LM 1; Parkes A 1; Wight D 1; Petticrew M 2; Hart GJ 3
Institutions: 1 MRC Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, UK; 2 Public and Environmental Health Research Unit, Keppel Street, London School of Hygiene and Tropical Medicine, London, UK; 3 Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London, London, UK
Source: Reproductive Health, 19 Feb 2009; 6:3. [Open Access]


BACKGROUND: Improving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses.

METHODS: Literature searches of 23 databases, including Medline, Embase and POPLINE(R), were conducted. Literature from 1970-2006 concerning the 11-24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data.

RESULTS: Of the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13-19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health.

CONCLUSION: Increasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

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2. Women's autonomy and reproductive preferences in Eritrea

Author: Woldemicael G
Institution: Department of Sociology, Stockholm University, Sweden
Source: Journal of Biosocial Science, Mar 2009; 41(2): 161-81. [Epub before print]


Current research and policies on reproductive behaviours in many East African countries focus primarily on proxy indicators of women's autonomy, and very little emphasis is placed on direct indicators of women's autonomy. In this paper, data from the 2002 Eritrea Demographic and Health Survey (EDHS) are used to address some of the most frequently raised questions about the link between women's autonomy and reproductive behaviour. The results from the multivariate logistic models show that although the relationship between women's autonomy and reproductive preferences in Eritrea is complex, some clear, broad patterns exist that have implications for theory and policy. First, although the different dimensions of women's autonomy influence the outcome variables differently in terms of magnitude and statistical significance, most of them have a strong connection; in particular, women's final say in decisions regarding day-to-day household purchases and spousal communication are significant explanatory variables in fertility preferences and ever-use of modern contraception. Second, many background (proxy) variables, particularly household economic condition and employment, exert a strong and independent influence over fertility preferences and ever-use of contraception regardless of a woman's autonomy. In their relationship to reproductive behaviours, therefore, employment and economic status cannot be considered as proxies for women's autonomy in Eritrea. A complete explanation of the relationship between women's autonomy and reproductive preferences must recognize the effects of both the background and direct autonomy indicators. Interventions are needed to improve women's decision-making autonomy and strengthen their negotiating capacity on family planning if an increased desire to limit fertility is to be attained.

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3. The effect of community-based reproductive health communication interventions on contraceptive use among young married couples in Bihar, India

Authors: Daniel EE 1; Masilamani R 1; Rahman M 2
Institutions: 1 Pathfinder International/India, New Delhi, India; 2 Pathfinder International, Watertown, MA
Source: International Family Planning Perspectives, Dec 2008; 34(4): 189-97.


CONTEXT: Contraceptive use among young couples in India is low, and early childbearing and short birth intervals are common. The PRACHAR Project, an ongoing intervention in Bihar, seeks to increase contraceptive use for delaying and spacing births through communication interventions.

METHODS: Random samples of married women younger than 25 with no more than one child were surveyed in 2002-2003, before PRACHAR was implemented (N=1,995), and in 2004, 21-27 months after implementation (N=2,080). Contraceptive demand and use, and related attitudes and knowledge, were assessed in the two surveys in both intervention areas and comparison areas. Logistic regression was used to assess the effect of the interventions on these indicators.

RESULTS: Contraceptive use was very low (2-6%) at baseline in both comparison and intervention areas. Demand for contraception increased from 25% at baseline to 40% at follow-up in intervention areas, but remained virtually unchanged in comparison areas. At follow-up, contraceptive use had risen in both areas, but the adjusted odds of use in intervention areas were 3.8 times those in comparison areas. Women in intervention areas had elevated odds of knowing that fertility varies during the menstrual cycle, and of agreeing that early childbirth can be harmful and that contraceptive use is necessary and safe for delaying first births (odds ratios, 1.6-3.0).

CONCLUSION: Culturally appropriate, community-based communication programs that target youth and those who influence their decisions can create demand for contraception among young couples and lead to increased contraceptive use.

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4. The influence of wives' and husbands' education levels on contraceptive method choice in Nepal, 1996-2006

Author: Gubhaju B
Institution: Social Policy Research Centre, University of New South Wales, Sydney, Australia
Source: International Perspectives on Sexual and Reproductive Health, Dec 2009; 35(4): 176-85.


CONTEXT: The association between education level and fertility, contraceptive behavior and method choice has been extensively researched, but little is known about how the education differential between husbands and wives in Nepal may influence the choice of specific methods.

METHODS: Data collected from currently married, nonpregnant women aged 15-49 in the Nepal Demographic and Health Surveys of 1996, 2001 and 2006 were analyzed to identify shifts in the education levels of husbands and wives and the influence of those shifts on couples' current contraceptive method use over the past decade. Multinomial logistic regression models assessed associations between method choice and each partner's education level, the education differential between partners and a combined education measure.

RESULTS: Although the wife's education level was associated with the type of method used by the couple, the husband's education level had more influence on the use of male sterilization and condoms. For example, men with any secondary or higher education were more likely than those with none to rely on either of these methods (relative risk ratios, 1.6-2.1). Furthermore, couples in which the husband had at least six more years of education than the wife also showed increased reliance on male sterilization or condoms (1.6-1.8). Differences in the use of any method of family planning by education level have narrowed considerably in the past decade, although differentials remain in the use of some methods.

CONCLUSION: A better understanding of how wives' and husbands' relative educational attainment affects decisions on their contraceptive choices is needed, particularly when both education levels and contraceptive use are increasing.

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5. Achieving success with family planning in rural Afghanistan

Authors: Huber D a; Saeedi N b; Samadi AK c
Institutions: a Management Sciences for Health, 784 Memorial Drive, Cambridge, MA; b Early Recovery Team, Bureau for Crisis Prevention and Recovery, United Nations Development Programme, Kabul, Afghanistan; c STEP Health and Development Organization, Kabul, Afghanistan
Source: Bulletin of the World Health Organization, Mar 2010; 88(3): 227-31. [Epub before print; Open Access]


PROBLEM: Afghan women have one of the world's highest lifetime risks of maternal death. Years of conflict have devastated the country's health infrastructure. Total fertility was one of the world's highest, contraceptive use was low and there were no Afghan models of success for family planning.

APPROACH: We worked closely with communities, providing information about the safety and non-harmful side-effects of contraceptives and improving access to injectable contraceptives, pills and condoms. Regular interaction with community leaders, mullahs (religious leaders), clinicians, community health workers and couples led to culturally acceptable innovations. A positive view of birth spacing was created by the messages that contraceptive use is 300 times safer than pregnancy in Afghanistan and that the Quran (the holy book of Islam) promotes two years of breastfeeding. Community health workers initiated the use of injectable contraceptives for the first time.

LOCAL SETTING: The non-for-profit organization, Management Sciences for Health, Afghan nongovernmental organizations and the Ministry of Public Health implemented the Accelerating Contraceptive Use project in three rural areas with different ethnic populations.

RELEVANT CHANGES: The contraceptive prevalence rate increased by 24-27% in 8 months in the project areas. Men supported modern contraceptives once they understood contraceptive safety, effectiveness and non-harmful side-effects. Injectable contraceptives contributed most to increases in contraceptive use.

LESSONS LEARNT: Community health workers can rapidly increase contraceptive use in rural areas when given responsibility and guidance. Project innovations were adopted as best practices for national scale-up.

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6. Indonesian couples' pregnancy ambivalence and contraceptive use

Authors: Barden-O'Fallon JL 1; Speizer IS 2
Institutions: 1 MEASURE Evaluation Population and Reproductive Health, University of North Carolina, Chapel Hill, NC; 2 University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
Source: International Perspectives on Sexual and Reproductive Health, Mar 2010; 36(1): 36-43.


CONTEXT: Most studies on pregnancy ambivalence are based on data from women and depend on the women's perceptions to measure their partner's pregnancy intentions. Because these perceptions may not be accurate, data collected directly from men are needed to understand the role of couple dynamics in fertility behavior.

METHOD: Matched couple data from the 2002-2003 Indonesia Demographic and Health Survey were used to examine contraceptive use, fertility desires and attitudes about becoming pregnant in the next few weeks-whether it would be a big problem, a small problem or no problem. Concordance between partners on these issues was evaluated. Inconsistent fertility desires and responses to the problem question are used to define ambivalence within couples. Multivariate logistic regression analyses were used to assess whether couples' pregnancy ambivalence was associated with contraceptive use.

RESULTS: Seventy-one percent of husbands and 54% of wives reported that a pregnancy in the next few weeks would be "no problem"; couples' concordance on this question was 64% among contraceptive users and 61% among nonusers. In the multivariate analysis, couples who were discordant on the issue of a pregnancy in the near future had 26% lower odds of using contraceptives than couples in which both partners agreed a pregnancy would be a big or small problem. Contraceptive use was also less likely for couples in which one partner wanted to delay or stop childbearing and the other wanted more children or was undecided (odds ratio, 0.4).

CONCLUSIONS: Husbands and wives influence each other's fertility attitudes and family planning use. Both husbands' and wives' pregnancy attitudes should be taken into account at the time of screening and method selection.

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7. Family planning practice in a tertiary health institution in north-western Nigeria

Authors: Isah AY; Nwobodo EI
Institution: Department of Obstetrics & Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
Source: Nigerian Journal of Clinical Practice, Sep 2009; 12(3): 281-3.


BACKGROUND: Family planning in our environment had remained a delicate issue that is still reluctantly being accepted based on religious belief and the perception that it is synonymous with population control.

OBJECTIVE: This study was carried out with the objectives of identifying the characteristics of contraceptive acceptors in our family planning unit, their source(s) of information and methods of preference among others.

MATERIALS AND METHODS: The record cards of all clients who attended the family panning clinic between January 1st 1998 and December 31st 2002 as well as the theatre records of patients that had bilateral tubal ligation (BTL) during the study period were reviewed. Relevant information on biodata, reasons for family planning, methods of choice and reasons for discontinuation were extracted and analysed. Comparative percentage was used for the analysis.

RESULT: A total of 839 clients requested and were served with contraceptives during the study period with an acceptor rate of 167.8/annum.Over 75% of the acceptors were Muslims. The main reason for selecting family planning services was for child spacing (84.9%) with only 12% requiring the service to end the reproductive carrier. Antenatal/postnatal clinics were their main source(s) of information about family planning services.

CONCLUSION: The study revealed that the practice rate of family planning in this community is still low. Female education, use of religious/traditional leaders along with improved dissemination of information using the mass media may go a long way to increase contraceptive uptake.

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Male Role In Family Planning

8. Male perceptions on female sterilization: A community-based study in rural Central India

Authors: Char A 1; Saavala M 2; Kulmala T 1
Instutitions: 1 School of Public Health, University of Tampere, Finland; 2 The Family Federation of Finland, Helsinki, Finland
Source: International Perspectives on Sexual and Reproductive Health, Sep 2009; 35(3): 131-8.


CONTEXT: Use of modern contraceptive methods has increased fourfold in India since the 1970s, characterized by a predominance of female sterilization. There has been considerable investigation about women's choice of female sterilization, but little from the male perspective.

METHODS: Seven focus group discussions were conducted among 58 men currently married to women aged 15-45, followed by a cross-sectional survey among 793 men currently married to same-aged women. Bivariate analysis was used for the survey data, and content analysis was used for the qualitative data.

RESULTS: Men's primary source of reproductive health information was mass media, although they expressed interest in getting information through discussion with knowledgeable sources. Men understood family planning and contraception to be two separate issues: Men viewed "family planning" as synonymous with female sterilization, whereas they saw "contraception" as referring to spacing methods, knowledge of which was limited. Thirty-four percent of men reported that their wives had been sterilized; 79% of men who did not rely on any permanent method said they wanted their wives to be sterilized. In focus group discussions, most men reported themselves as their family's sole decision maker about reproductive health; however, only one-third of survey respondents did so.

CONCLUSION: Men are interested in acquiring family planning information, but lack knowledge about available information sources, which hampers their ability to make informed family planning choices. Family planning service providers and program planners need to be aware of males' knowledge and perceptions pertaining to family planning, and make appropriate modifications to communication strategies.

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9. The relationship of family size and composition to fertility desires, contraceptive adoption and method choice in South Asia

Authors: Jayaraman A; Mishra V; Arnold F
Institution: Macro International, Inc., Calverton, MD
Source: International Perspectives on Sexual and Reproductive Health, Mar 2009; 35(1): 29-38.


CONTEXT: Many countries in South Asia, including Nepal, India and Bangladesh, demonstrate a strong cultural preference for sons, which may influence fertility desires and contraceptive use.

METHODS: Demographic and Health Survey data from married, nonpregnant women aged 15-49 who had at least one child were used to examine the relationship of parity and number of sons to reproductive outcomes in Nepal, India and Bangladesh. Outcomes of interest were desire for another child, contraceptive use and type of contraceptive (modern vs. traditional, temporary vs. permanent). Odds ratios and relative risk ratios were calculated using binary and multinomial logistic regression.

RESULTS: In general, desire for another child decreased and contraceptive use increased as the number of children and number of sons increased. These associations were more prominent in Nepal and India than in Bangladesh. For example, compared with women who had three daughters and no sons, the odds of contraceptive use among women with two sons and one daughter were 4.8 in Nepal, 3.5 in India and 2.0 in Bangladesh. Within India, the associations of parity and number of sons with reproductive outcomes were generally stronger in northern states than in South India or West Bengal.

CONCLUSIONS: Son preference remains widespread in all three countries and has a major influence on reproductive behavior. Reducing such preference would require a change in social norms and attitudes of the people and an improvement of the status of women.

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10. Spousal communication, changes in partner attitude, and contraceptive use among the yorubas of southwest Nigeria

Authors: Ogunjuyigbe PO 1; Ojofeitimi EO 2; Liasu A 1
Institutions: 1 Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria; 2 Institute of Public Health, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
Source: Indian Journal of Community Medicine, Apr 2009; 34(2): 112-6. [PubMed Central]


OBJECTIVE & DESIGN: This paper highlights the relevance of spousal communication on males' attitude towards their partners' contraceptive use. This was a cross-sectional study.

MATERIALS AND METHODS: Data for the study were obtained from a survey carried out in three states, Oyo, Osun, and Ondo, mainly inhabited by the Yorubas.

RESULTS: The results show that men have a significant role to play in the adoption of contraception. About 37% of the respondents reported joint decision making on when to have another child, 40.8% on whether to stop having children, and 44% on what to do to stop childbearing. Communication between a husband and wife on reproductive matters was also recognized as a factor that may influence male participation in family planning.

CONCLUSION: This study has shown that the male partner may be highly motivated to obtain contraceptives. The results therefore suggest that male involvement in family planning should be encouraged through inter-spousal communication.

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