World Development Report 1984

counterparts to be practicing contraception. Gov- restrict their activities. Some methods increase the
ernment plays a central role in narrowing these risk of developing serious health problems; higher
gaps, especially between urban and rural areas risk of pelvic inflammatory disease among IUD
(see Table 7.2). In Colombia and Korea, which users and of cardiovascular disease among users of
have strong family planning programs, rural the pill have been reported. (These risks, however,
women who want no more children are as likely as are small compared with those associated with
urban women to be practicing contraception. In pregnancy and childbirth.)
Kenya, Nepal, and Pakistan, which have weaker * Social disapproval-the private nature of famprograms,
the contrast between rural and urban ily planning and the difficulty of discussing it with
areas is much greater. providers of services or even with spouses. Family
planning may violate personal beliefs, create mari-
Reasons for not using contraception tal disharmony, or be socially, culturally, or religiously
unacceptable.
Couples who wish to plan their families face cer- Surveys of contraceptive use in ten countries
tain costs-financial, psychological, medical, and asked married women not practicing contraception
- time-related costs. If these exceed the net costs of why they were not doing so. Unless they wanted
additional children, couples will not regulate their another child or were pregnant, their reasons
fertility, even if, ideally, they would prefer to post- included lack of knowledge of a source or method
pone or to prevent a pregnancy. To individuals, of contraception, medical side effects of methods,
the costs of contraception include: religious beliefs, opposition from husbands, and
* Information-the effort to find out where con- financial costs. In Nepal lack of knowledge of a
traceptive methods can be obtained and how they source was the main reason. In Honduras, Mexico,
are properly used. In Kenya 58 percent of married and Thailand half of the women who did not pracwomen
aged fifteen to forty-nine who are exposed tice contraception but were exposed to the risk of
to the risk of pregnancy do not know where they pregnancy either knew of no source of contracepcan
obtain a modern method of contraception; in tion or feared side effects. In Bangladesh, Barba-
Mexico the figure is 47 percent. dos, and Nepal as much as a quarter to a third of
* Travel and waiting time-the money and time all married women were not using contraception
needed to go to and from a shop or clinic and to for these reasons. Contraceptive prevalence clearly
obtain family planning services. Average waiting could be increased by better information and servtimes
are as high as three hours in hospitals and ices-directed to men as well as to women.
family planning clinics in El Salvador. Family plan- Discontinuation rates tell a similar story. Accordning
programs in Bangladesh, India, and Sri ing to surveys in thirty-three countries, as many as
Lanka compensate sterilization clients for their 30 percent of married women of childbearing age
transport costs and lost wages. have used contraception in the past but are no
* Purchase-the financial cost of either contra- longer doing so (see Table 7.3). When contracepceptive
supplies (condoms, pills, injections) or tion is being used to space births, some discontinuservices
(sterilization, IUD insertion and periodic ation is normal. But many who discontinue contracheckups,
menstrual regulation, and abortion). ceptive use do not want more children. As the
* Most public family planning programs provide second column of Table 7.3 shows, as many as 10
supplies and services free of charge or at highly percent of all married women are discontinuers
subsidized rates. Purchase costs from private sup- who want no more children and are at risk of getpliers
and practitioners may be substantially ting pregnant. In Barbados, Guyana, Jamaica,
higher. Korea, and Pakistan, the proportion exceeds one-
- * Side effects and health risks-the unpleasant third (column 3). Follow-up surveys of women
and sometimes medically serious symptoms that who have accepted contraception typically find
some women experience while practicing contra- that much discontinuaton is due to medical side
ception. Users of the pill may gain weight or feel effects. In a follow-up survey in the Philippines,
ill. The IUD may cause excessive menstrual bleed- for example, this reason was cited by 66 percent of
ing, persistent spotting, and painful cramps. In those who stopped using the pill and 43 percent of
addition, in some countries women are forbidden those who stopped using the IUD. Reducing disfor
religious or cultural reasons from cooking dur- continuation among women who want no more
ing their menstrual periods; spotting and heavier children could increase contraceptive use by at
menstrual flow caused by the IUD can further least one-fifth in eight countries (column 4).
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