Contraceptives Use Dynamics In

The Philippines

Determinants of Contraceptive Method Choice and

Discontinuation

Rose Angela R. Acosta Lilia G. Caballes

SLU BSN II B2 CLINICAL INSTRUCTOR

SUMMARY:

In the Philippines, the challenge of encouraging more couples to use contraceptives is still imperative.
However, this mission is no longer limited to the adoption of contraception, but also includes the selection
of appropriate methods that suit client needs and the maintenance of effective use over time. It is in this
light that an analysis of contraceptive use dynamics focusing on the determinants of method choice and
discontinuation is useful to better guide policy and program direction.

REACTION

INSIGHTS/RELEVANCE TO PATIENTS CASE/CARE:

This is relevant to my patient’s case because as my patient verbalizes that she’s using Daphne
before but it has an side effect to her, it gives her an headache so she decided to stop and they
started using natural method called withdrawal for 5 years but suddenly they made a mistake so
she got pregnant. So that she decided to use the pills.

RELEVANCE TO AREA OF ROTATION:

We are going to every houses getting a patient, most likely a post-partum mother. And after that we will
ask them if what kind of family planning that they refer and we conduct a health teaching about family
planning and contraceptives.

RELEVANCE TO NURSING EDUCATION AND PRACTICE

Nurse’s play a key role in instructing a women how to use contraception in family planning clinic
consultations. These on to one situations are encounters where women are taught how to use
contraceptive methods effectively. However, very little is known about the nature of these consultations.

LEARNING INSIGHT

We, student nurses must know how to appropriately use the contraceptive to be effective and before
giving or endorsing that to the patient we must first assess the mother of what she know about
contraceptive. We must also know if there is a side effect to the mother and explain it efficiently.
1 Introduction

The Philippines ranks as the fifteenth most populous country in the world and eighth in the Asian
region (DOH, 1996). Its population is expected to increase from 68.3 million in 1995 to 91.8 million by
2010, even if replacement fertility is attained by the year 2010 (NSO et al., 1999:32). For more than three
decades, the Philippine family planning program has been implementing strategies aimed at managing the
population in relation to the developmental needs of the country. The emphasis provision of family
planning information and services is based on a policy of noncoercion and respect for religious and moral
convictions. Emphasis is placed on the health benefits derived from practicing family planning. This
emphasis is achieved by providing accurate and timely information consistent with the fertility intentions
of couples and by broadening the range of available contraceptives appropriate for each stage of the
reproductive lifespan (ESCAP, 1992:16).

Greater attention is now being given to the concerns of current users and potential users. By increasing
contraceptive options, the family planning program can better accommodate the preferences of its clientele
(Shah, 1991:617). There is also a need to encourage users to maximize contraceptive efficacy through
continued use. Past research on contraceptive use has not focused extensively on why couples initially choose
and later discontinue particular contraceptive methods. One possible explanation for this lack of research may
be that policymakers have focused more on encouraging couples to accept any method of family planning.
However, rapid increases in contraceptive prevalence have heightened the awareness that method choice and
contraceptive discontinuation are important research and policy questions.

2 Family Planning Efforts in the Philippines: An Overview

Family planning was first introduced in the Philippines by the private sector in the early sixties. It
was only through the Population Act of 1971 that family planning was integrated into the government’s
development plans (Perez and Tabije, 1996). As can be seen in Table 1, substantial gains have been
achieved by the program, as is evident by the marked rise in contraceptive prevalence from 15.4 percent
of currently married women in 1968 to 46.5 percent in 1998 (NSO et al., 1999). However, the tripling of
contraceptive prevalence in the span of thirty years has not been sufficient to reduce fertility to
replacement level (TFR=2.1). The Philippine total fertility rate (TFR) is still well above replacement
level, falling to 3.7 in 1998 from 6.0 in 1970 (NSO et al., 1999). In general, the transition to low fertility
has been slow in the Philippines, particularly in comparison with neighboring Asian countries.

Table 1 Trends in Contraceptive Use, Philippines, 1968-1998

Modern Traditional
Survey methods methods Total

1968 National Demographic Survey 2.9 11.5 15.4

1973 National Demographic Survey 10.7 6.7 17.4
1978 Republic of the Philippines Fertility Survey 17.2 21.3 38.5
1983 National Demographic Survey 18.9 13.1 32.0
1988 National Demographic Survey 21.6 14.5 36.1
1993 National Demographic Survey 24.9 15.1 40.0
1996 Family Planning Survey1 30.2 17.9 48.1
1997 Family Planning Survey1 30.9 16.1 47.0
1998 National Demographic and Health Survey1 28.2 18.3 46.5

Sources: World Bank, 1991; NSO, 1996; NSO, 1997; NSO and Macro International Inc., 1994 (as cited in NSO, 1999)
1 Based on currently married women 15-49
1
The 1998 National Demographic and Health Survey (NDHS) confirms that knowledge of family planning
methods is high; 98 percent of all women know at least one family planning method. However, this
awareness is not reflected in the level of contraceptive use. More than half of all currently married
Filipino women were still not using any method of contraception in 1998. Among current users, 9.6
percent rely on traditional methods, while 36.9 percent use a modern method. Female sterilization is the
most widely used modern method (10.3 percent), followed closely by pills (9.9 percent)

Another programmatic issue of pressing concern in the Philippines is the high level of
contraceptive discontinuation among users. The 1998 NDHS data show that two in five users discontinue
use after the first year. Discontinuation is highest for condoms (60 percent), followed by injections (52
percent), withdrawal (46 percent), and pills (44 percent). As is evident from past surveys (NSO, and MI,
1994), side effects (health concerns), method failure, and the desire to become pregnant are commonly
cited by respondents as reasons for discontinuing the use of contraception.

The challenge of encouraging more couples to use contraceptives is still imperative. However,
this mission is no longer limited to the adoption of contraception, but also to the selection of appropriate
methods that suit client needs and the maintenance of effective use over time. It is in this light that an
analysis of contraceptive use dynamics focusing on the determinants of method choice and
discontinuation is useful to better guide policy and program directions.

Contraceptive Method Choice

This analysis uses information from the 1998 National Demographic and Health Survey. The
selection of variables to be included as possible determinants of contraceptive method choice is guided by
the conceptual scheme developed by Bulatao (1989). He views contraceptive method choice as largely
influenced by four dimensions: 1) contraceptive goals (spacing or limiting of children), 2) contraceptive
competence (the ability to use methods effectively), 3) contraceptive evaluation (assessment of ethical
and cultural influences affecting the use of contraception), and 4) contraceptive access (geographic,
economic, and other aspects of accessibility).

In this study, contraceptive goals include fertility intent, age at the time of the survey, number of
living children, and type of marital union. Contraceptive competence comprises the respondent’s level of
education, knowledge of the fertile period, and the frequency of spousal communication about family
planning. Contraceptive evaluation refers to a woman’s religious affiliation and region of residence.
Finally, contraceptive access is composed of urban-rural residence, work status, household wealth status,
exposure to family planning messages, visits by family planning fieldworkers in the past 12 months, visits
to a health facility in the past 12 months, residence in an LPP province, source of supply for last
contraceptive method, type of referral to source of supply, and travel time to source of supply. It should
be noted that the last three variables can only be used to assess the use of modern methods since this
information was only collected for current users.

Data analysis is limited to currently married women 15-49 years of age who were not pregnant at
the time of the survey. These women were able to choose which method of contraception to use.
Currently married women include those who are legally married and those living in consensual unions.

3.1 Differentials in Contraceptive Use

Method-specific patterns of contraceptive use are shown in Tables 2-5 in relation to measures of
contraceptive goals, competence, evaluation, and access. The results are summarized below.

3.1.1 Contraceptive Goals

 In the Philippines, women who do not want to have any more children (i.e., want to limit) are more
likely to use contraception than women who want to space their next child (see Table 2). However, much of
the difference between the two groups results from the greater use of natural and traditional methods by
women who want to limit. This finding suggests that many women who wish to cease childbearing are not
using methods that are well suited to their reproductive intentions and fertility regulation needs.

Young adults age 15-24 are less likely to use modern methods. Many younger women want to
begin childbearing once they marry, so lower levels of use (especially for permanent methods of fertility
regulation) are to be expected. However, older women are less likely to use pills and injectables
(hormonal spacing methods) and are more likely to use sterilization.

3.1.2 Contraceptive Competence

Table 2 shows that there is a positive association between modern method use and education.
Modern method use increases at higher levels of education. For the pill, IUD, and injectables, the highest
level of use occurs among women who have had the most schooling. The use of modern natural family
planning methods is also elevated among more educated women. A majority of nonusers have little or no
education (elementary or less).

3
 Discussion of family planning between husbands and wives appears to be positively related to
modern method use. For most methods, the use of contraception increases with the frequency of
discussion of family planning among couples. The one exception is female sterilization: Women who
never discussed family planning with their husband (22.4 percent of all respondents) are more likely
to use sterilization to limit childbearing. This finding is somewhat surprising given the
nonreversibility of the method.

Table 2 Percent distribution of currently married women by current use of specific contraceptive methods, according to selected background
characteristics, contraceptive goals, and competence, 1998

Modern methods
Background
characteristics, All Female Male Tradi- Using
contraceptive goals, modern Injec- Con- sterili- sterili- Natural tional no
and competence methods Pill IUD tables Dom zation zation methods methods method Total Number

Age of respondent
15-24 24.1 13.7 3.2 3.1 0.8 0.2 - 3.2 9.4 66.4 100.0 1,212
25-34 39.1 14.7 4.7 3.2 1.9 6.2 - 8.4 11.3 49.6 100.0 3,315
35-49 39.0 4.5 2.9 1.4 1.6 17.1 0.3 11.1 8.3 52.7 100.0 3,810

Parity
0-1 18.6 8.5 2.4 1.0 0.7 0.6 - 5.4 7.6 73.8 100.0 1,966
2-3 44.6 13.3 4.3 2.9 2.2 12.2 0.2 9.5 10.9 44.5 100.0 3,318
4+ 40.2 7.2 3.8 2.6 1.6 14.5 0.1 10.4 9.5 50.2 100.0 3,051

Type of union
Legal marriage 38.5 10.2 3.8 2.3 1.7 10.8 0.1 9.5 9.6 51.9 100.0 7,467
Consensual union 23.0 7.8 2.5 2.5 0.7 6.1 0.2 3.1 9.9 67.1 100.0 8,69
Education
Elementary or below 30.4 8.1 2.8 2.3 1.1 9.8 0.2 6.0 9.2 60.4 100.0 2,924
High school 38.9 11.7 4.5 2.7 1.5 9.8 0.1 8.6 11.3 49.8 100.0 3,050
College or higher 42.4 9.8 3.8 1.9 2.4 11.5 0.0 12.8 8.0 49.7 100.0 2,362

Discussed family
planning w/husband
Never 24.0 2.1 1.4 0.6 0.6 15.1 0.3 3.8 3.5 72.5 100.0 1,863
Once or twice 38.4 10.9 3.9 2.9 1.5 9.6 0.1 9.5 11.0 50.6 100.0 3,237
More often 42.8 13.5 4.8 2.8 2.2 8.2 0.1 11.2 11.9 45.2 100.0 3,216

Fertility intent
To space 25.6 11.8 3.3 2.2 1.2 - - 7.2 9.0 65.4 100.0 2,652
To limit 33.4 11.1 5.0 3.1 2.1 - - 12.2 12.2 54.4 100.0 4,286

Knowledge of cycle
Correct 42.8 10.5 3.0 2.5 2.3 10.4 - 14.1 8.3 48.8 100.0 1,320
Incorrect 35.8 9.8 3.8 2.3 1.5 10.3 0.2 7.9 9.9 54.4 100.0 7,010

Women who correctly identify when they are most likely to be at risk of conception
during their ovulatory cycle are more likely to use modern contraceptive methods, especially
natural methods. However, since 84.1 percent of all respondents could not identify when they are
most at risk during their cycle, the absolute number of women likely to be using natural methods
incorrectly is substantial and may be responsible for many unwanted pregnancies.

4 Contraceptive Discontinuation

The objective of this analysis is to provide more complete information on the nature and
dynamics of contraceptive use in the Philippines. For example, who are the users most susceptible to
discontinuing the use of contraceptives? What do women do after discontinuing the use of a method? Do
women switch to another method or terminate use of a method altogether?
 This analysis uses calendar data from the 1998 National Demographic and Health Survey
(NDHS). This portion of the individual NDHS questionnaire provides information pertaining to the
reproductive life of a woman covering the five-year period before the start of the survey (in this case,
1993-1998). It presents data on pregnancies, births, contraceptive use, contraceptive discontinuation,
marriage/union formation, and geographical mobility. The use of the calendar for retrospective
information is considered more reliable than other methods as it captures characteristics of respondents
over time (Goldman, et al., 1990, as cited in Choe and Zablan, 1991).

The unit of analysis is the segment of use among women age 15-49. Use segments refer to
uninterrupted periods of use and nonuse for a particular contraceptive method. However, segments that started
three months before the time of interview, as well as those that started before the beginning of the five-year
period, were excluded from the analysis since duration cannot be determined for these cases. The three-month
cutoff was made to account for the possibility that women, although using a method, might be pregnant
without knowing, thereby reducing the possibility of underestimating contraceptive discontinuation because of
method failure. Censored cases, or those segments that are still in effect at the end of the five-year period, were
considered to represent segments of longer duration (Perez and Tabije, 1996; Fathonah, 1996).

To identify the duration of use over time, contraceptive use segments (rather than individual
women) are used as the unit of analysis. This procedure also provides information on the transition from
one method to another. Moreover, as there is a wide array of contraceptive methods for women to choose
from, analysis based on segments of use is not confined to only one or two methods.

The Dynpak software package developed by Macro International Inc. was used in matching the
calendar data with respondents’ background characteristics. This package also contains relevant analysis
tools for determining data quality, discontinuation, switching behavior, and failure rates. In this analysis,
Dynpak was employed to generate the probability of discontinuing contraceptive use and switching
between methods over the period of one year (12 months). A total of 13,428 segments of use and nonuse
were generated by Dynpak. Of these, 5,284 were segments of use for any method. Forty-six percent of
these segments were censored, meaning that the method was still being used at the time of the survey,
while 54 percent of the segments pertained to methods that were discontinued at some point during the
five-year period before the survey.
4.1 Differentials in Contraceptive Discontinuation Rates

As pointed out earlier, two out of five women (40 percent) who use any method of contraception stop
using the method after a year (NSO et al., 1999). This rate is higher than the 1993 figure of 34 percent (Perez
and Tabije, 1996). Across methods, the rate varies, with condoms having the highest discontinuation rate,
followed by injectables, withdrawal, the pill, the calendar/rhythm method, and IUDs (Figure 2). Noteworthy is
the low discontinuation rate observed for IUDs, a method deemed more effective in preventing pregnancy.

Figure 2 Twelve-months Contraceptive

Discontinuation Rates (%)

60

49

44 45

35

14

Pill IUD Injectables Condom Calendar/Rhythm Withdrawal

The median duration of use by method shows that IUDs have the longest mean duration of use
(Figure 3). Half of all IUD users have already used the method for 36 months, followed by periodic
abstinence with a median duration of 20 months. Pill use averages 15 months, while injectables are most
often used for a year, or 4 cycles of use. The sporadic nature of condom use most likely partly explains its
relatively short median duration of six months.

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 Contraceptive Use Dynamics In
The Philippines: Determinants Of
Contraceptive Method Choice And
Discontinuation

Elma P. Laguna
Anna Liza C. Po
Aurora E. Perez

Population Institute
University of the Philippines
Quezon City, Philippines