Family Planning in Asia and the Pacific - International Council on ...

Of those who are “unwill<strong>in</strong>g” to use contraception, a fearof side effects is <strong>the</strong> predom<strong>in</strong>ant reason given <strong>in</strong> threecountries. In <strong>the</strong> o<strong>the</strong>r countries, some form of oppositionis <strong>the</strong> ma<strong>in</strong> reason. When fear of side effects is comb<strong>in</strong>edwith health concerns or “<strong>in</strong>terferes with <strong>the</strong> body’s normalprocesses”, issues relat<strong>in</strong>g to health <strong>and</strong> side effects accountfor <strong>the</strong> largest number of responses among women who donot <strong>in</strong>tend to use contraception. In Kiribati <strong>and</strong> Samoa,however, opposition to family plann<strong>in</strong>g is <strong>the</strong> predom<strong>in</strong>antresponse. In Samoa 70.2 per cent of women who do not<strong>in</strong>tend to use contraception <strong>in</strong> <strong>the</strong> future mentioned<strong>in</strong>dividual opposition to family plann<strong>in</strong>g as <strong>the</strong> reason.However, <strong>in</strong> no country did husb<strong>and</strong>’s opposition accountfor more than 5.5 per cent of <strong>the</strong> responses. Religiousopposition to family plann<strong>in</strong>g was significant only <strong>in</strong>Kiribati <strong>and</strong> Nauru, countries that have a large Catholicpopulation.Several prelim<strong>in</strong>ary conclusions may be drawn from <strong>the</strong>sedata: (a) lack of access to contraceptives does not appearto be <strong>the</strong> ma<strong>in</strong> cause of high unmet need, o<strong>the</strong>r than <strong>in</strong>Papua New Gu<strong>in</strong>ea, which is a somewhat special case.This is consistent with o<strong>the</strong>r f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong> DHS that showthat knowledge of contraceptive methods is relatively high<strong>and</strong> most people know where to obta<strong>in</strong> <strong>the</strong>m; (b) <strong>the</strong>pr<strong>in</strong>ciple cause of unmet need is not <strong>the</strong> unavailability ofcontraceptive methods but <strong>the</strong> unwill<strong>in</strong>gness of women touse <strong>the</strong>m; (c) <strong>the</strong> ma<strong>in</strong> reason that women are unwill<strong>in</strong>g touse contraception has to do with <strong>the</strong> methods <strong>the</strong>mselves<strong>and</strong> <strong>the</strong>ir impact (real or perceived) on women’s health or<strong>the</strong> physical or psychological discomfort that <strong>the</strong> methodsmight cause; (d) opposition to contraception by husb<strong>and</strong>s oro<strong>the</strong>r persons is a negligible factor but religious oppositionis significant <strong>in</strong> some countries; (e) opposition on <strong>the</strong> partof <strong>the</strong> respondent herself is very significant <strong>in</strong> Samoa <strong>and</strong>somewhat significant <strong>in</strong> Nauru, but not elsewhere. (InSamoa, <strong>the</strong>re is a possibility that <strong>the</strong> very high proportionof “respondent opposed” may be a result of poor <strong>in</strong>terviewmethods, particularly <strong>in</strong>sufficient prob<strong>in</strong>g).Programme implications of <strong>the</strong>f<strong>in</strong>d<strong>in</strong>gs of Demographic <strong>and</strong>Health SurveysOpposition to family plann<strong>in</strong>gThe implications of <strong>the</strong> DHS results discussed abovedepend on <strong>the</strong> country <strong>in</strong> question, as <strong>the</strong>re is considerablevariation between countries. The first po<strong>in</strong>t to be madeis that DHS results need to be supplemented by fur<strong>the</strong>rfocused social research. The f<strong>in</strong>d<strong>in</strong>g that 70 per cent ofwomen <strong>in</strong> Samoa who do not <strong>in</strong>tend to use contraception<strong>in</strong> <strong>the</strong> future mention that <strong>the</strong>y are “opposed” to familyplann<strong>in</strong>g is a clear example. Before plann<strong>in</strong>g <strong>in</strong>terventionsto address such opposition, it is important to determ<strong>in</strong>e ifthis is a valid result or ra<strong>the</strong>r a consequence of <strong>in</strong>terviewmethods. It is possible, for example, that <strong>in</strong>terviewersoverused this broad category <strong>and</strong> did not dist<strong>in</strong>guishbetween <strong>the</strong> various reasons why women could be opposed.In itself, “opposition” on <strong>the</strong> part of <strong>the</strong> respondent is notvery <strong>in</strong>formative. In Nauru, respondent opposition wasalso significant, but unlike <strong>in</strong> Samoa, religious oppositionwas also an important reason for not <strong>in</strong>tend<strong>in</strong>g to usecontraception. In Kiribati, religious opposition was also<strong>the</strong> primary reason for women be<strong>in</strong>g unwill<strong>in</strong>g to usecontraception – substantially overshadow<strong>in</strong>g health issuesor fear of side effects.Religious opposition to family plann<strong>in</strong>g is a difficult issueto address as all <strong>in</strong>dividuals have <strong>the</strong> right to practise<strong>the</strong>ir religion <strong>and</strong> follow its precepts. It is not <strong>the</strong> role offamily plann<strong>in</strong>g providers to change religious views. S<strong>in</strong>cemost religious opposition <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> comes from <strong>the</strong>Catholic Church, <strong>the</strong> issue to be <strong>in</strong>vestigated is whe<strong>the</strong>rrespondents understood that “natural” family plann<strong>in</strong>g isacceptable to <strong>the</strong> Church. The “ovulation” method is taughtby family plann<strong>in</strong>g nurses <strong>in</strong> most countries, even thoughit is understood that this method it has a high failure rate.Side effects <strong>and</strong> health concernsIt is clear that <strong>the</strong> primary issue that needs to be addressed<strong>in</strong> most countries where unmet need is high is <strong>the</strong>perceived health consequences of contraception, <strong>in</strong>clud<strong>in</strong>g<strong>the</strong> question of “side effects”. That some women experienceside effects, especially with hormonal methods <strong>and</strong> IUDs,is <strong>in</strong>disputable. Whe<strong>the</strong>r <strong>the</strong> women who cite fear of sideeffects have actually experienced <strong>the</strong>m <strong>the</strong>mselves or arerespond<strong>in</strong>g to generally held beliefs with<strong>in</strong> <strong>the</strong> community,however, cannot be determ<strong>in</strong>ed from DHS. Fur<strong>the</strong>r<strong>in</strong>vestigation, possibly us<strong>in</strong>g focus group methods, mightbe needed to clarify this question. In small communities,one or two bad experiences with a contraceptive are likelyto become well known throughout a community, rais<strong>in</strong>g<strong>the</strong> fear level even higher 22 . More generalized concernsmay well be based on <strong>in</strong>correct <strong>in</strong>formation, such as claimsthat a method could result <strong>in</strong> sterility. Studies are neededthat focus on what women <strong>and</strong> men actually know aboutvarious methods, <strong>in</strong>clud<strong>in</strong>g how <strong>the</strong>y work <strong>and</strong> what <strong>the</strong>irpotential health consequences might be. Only when <strong>the</strong>basis of women’s fears can be identified will it be possible todesign programmes to address <strong>the</strong>m, although forewarn<strong>in</strong>gwomen about <strong>the</strong> possibility of side effects can reduce <strong>the</strong>likelihood of discont<strong>in</strong>uation.Where unmet need is low due to family size preferences,<strong>the</strong> central question is whe<strong>the</strong>r it is <strong>the</strong> function of a91