Journal of

Original Article Preventive Medicine

J Prev Med Public Health 2019;52:258-264 • https://doi.org/10.3961/jpmph.18.198 & Public Health
pISSN 1975-8375  eISSN 2233-4521

Perceptions of Contraception and Patterns of Switching

Contraceptive Methods Among Family-planning
Acceptors in West Nusa Tenggara, Indonesia
Yuli Amran1,2, Narila Mutia Nasir2, Dini Dachlia3, Fitra Yelda3, Budi Utomo4, Iwan Ariawan4, Rita Damayanti5
1
Public Health Science Program Studies, Faculty of Public Health, University of Indonesia, Depok, Indonesia; 2Faculty of Health Sciences, Syarif
Hidayatullah State Islamic University, Jakarta, Indonesia; 3Center for Health Research, University of Indonesia, Depok, Indonesia; 4Department of
Biostatistics and Population Studies, Faculty of Public Health, University of Indonesia, Depok, Indonesia; 5Department of Health Education and
Behavioral Science, Faculty of Public Health, University of Indonesia, Depok, Indonesia

Objectives: The perceptions of family-planning (FP) acceptors regarding contraception influence the reasons for which they choose
to switch their method of contraception. The objective of this study was to analyze the perceptions of contraception and rationales
for switching contraceptive methods among female FP acceptors in West Nusa Tenggara, Indonesia.
Methods: This study involved the analysis of secondary data from the Improve Contraceptive Method Mix study, which was conduct-
ed in 2013 by the Center for Health Research, University of Indonesia. The design of the study was cross-sectional. We performed 3
stages of sampling using the cluster technique and selected 4819 women who were FP acceptors in West Nusa Tenggara Province, In-
donesia as the subjects of this study. The data were analyzed using multiple logistic regression.
Results: The predominant pattern of switching contraceptive methods was switching from one non-long-term method of contracep-
tion to another. Only 31.0% of the acceptors reported a rational pattern of switching contraceptive methods given their age, number
of children, and FP motivations. Perceptions of the side effects of contraceptive methods, the ease of contraceptive use, and the cost
of the contraceptives were significantly associated (at the level of α=0.05) with rational patterns of switching contraceptive methods.
Conclusions: Perceptions among FP-accepting women were found to play an important role in their patterns of switching contracep-
tive methods. Hence, fostering a better understanding of contraception through high-quality counseling is needed to improve per-
ceptions and thereby to encourage rational, effective, and efficient contraceptive use.

Key words: Perception, Contraception, Family planning, Switching, Indonesia

INTRODUCTION
Received: August 23, 2018 Accepted: July 4, 2019
Family-planning (FP) programs are intended to regulate fer-
Corresponding author: Yuli Amran, PhD
Public Health Science Program Studies, Faculty of Public Health, tility to improve maternal and child health. They can decrease
University of Indonesia, Depok 16424, Indonesia maternal, infant, and child mortality. Globally, the contracep-
E-mail: yuliamran80@gmail.com tive prevalence rate (CPR), an indicator for FP programs, has
This is an Open Access article distributed under the terms of the Creative Commons increased significantly from 35% in 1970 to 63% in 2017. How-
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
ever, FP programs continue to face challenges in developing
nc/4.0/) which permits unrestricted non-commercial use, distribution, and repro-
duction in any medium, provided the original work is properly cited. countries, including Indonesia. One of these challenges is the

258 Copyright © 2019 The Korean Society for Preventive Medicine

 Contraception and Switching Methods

lack of variety of available methods of contraception. In gen- ers may adopt a certain method of contraception. For exam-
eral, only one or two methods are commonly used [1]. Al- ple, the result of Indonesia Demographic and Health Survey
though Indonesia provides universal access to various meth- (2012) show the percentages of choice of contraceptive meth-
ods of FP that are safe and reliable, following the recommen- od and the source of information [3].
dations of the International Conference on Population Devel- Choices to switch contraceptive methods for reasons be-
opment in Cairo [2], the use of contraception continues to be yond rational considerations are influenced by FP acceptors’
dominated by injections (32.0%) and pills (13.6%), which are perceptions of specific methods, including perceptions of side
not long-term methods. Only 10.6% of the relevant popula- effects in comparison with those of their previous contracep-
tion uses long-term contraception in Indonesia [3]. tive method [12], the convenience of the particular method of
The selection of a contraceptive method is important for FP contraception [13], and perceptions relating to how it is used
acceptors. Because the objective of contraceptive use is main- [14]. Concerns have been raised about methods of contracep-
ly to space out or limit pregnancies, FP acceptors should tion in the province of West Nusa Tenggara in Indonesia. The
choose effective methods that prevent unwanted pregnan- CPR of West Nusa Tenggara is lower than the national aver-
cies. Therefore, individuals should consider their choices care- age. Furthermore, the percentage of unmet need in this prov-
fully when switching from one method of contraception to ince is 14%, which is higher than the national level [3]. The
another. Many previous studies have investigated switches in objective of this study was to analyze perceptions of contra-
contraceptive methods, emphasizing the patterns of and rea- ception among FP-accepting women in West Nusa Tenggara,
sons for switching [4-7]. Indonesia and their rationales for switching contraceptive
Previously reported data indicate that many Indonesian FP methods.
acceptors do not show rational patterns of switching methods
of contraception. A study showed that older women prefer METHODS
non-long-term methods of contraception to long-term ones
[8]. The Indonesian Basic Health Research study revealed that This study used baseline data from the Improving Contra-
49.4% of women with 3 or more children tended to use non- ception Method Mix (ICMM) study conducted in 2013. This
long-term contraception [9]. High levels of discipline and con- was a collaborative study between the Center for Communica-
trol are needed when utilizing non-long-term contraceptive tion Program of Johns Hopkins University, the Cipta Cara Padu
methods to avoid unwanted pregnancies. Of women who Foundation, and the Center for Health Research of the Univer-
used a non-long-term contraceptive method for 1-3 months, sity of Indonesia. The ICMM study included 7500 married
20-40% discontinued contraceptive use, which may result in women of reproductive age (15-49 years old) in West Nusa
unintended pregnancy [10]. Tenggara by using a 3-stage cluster sampling technique. The
Thus, it is important that women make rational choices study design was cross-sectional. The inclusion criteria for the
when switching contraceptive methods in light of changes in respondents of our study were living in West Nusa Tenggara,
their age, number of children, and health conditions. Such being married, and having ever used and using contraception.
changes may affect which methods of contraception are ideal. Thus, we analyzed data from 4819 women who were FP ac-
For example, the first contraceptive method used by a woman ceptors. The data were collected through face-to-face inter-
≤35 years old might be a short-term method because she views with a questionnaire.
may want to have more children. Then, after 35, it would be The dependent variable of this study was the rationality of
recommended for her to switch to a long-term or permanent respondents’ pattern of switching contraceptive methods. The
method that is more effective at preventing pregnancy [11]. criteria used to define a rational pattern of switching contra-
Women older than 35 are at a higher risk in pregnancy and ceptive methods were developed on the basis of the patterns
delivery; therefore, long-term or permanent methods of con- of rational use of FP presented by the National Population and
traception may be preferable. Family Planning Board of Indonesia. Rationality in switching
In Indonesia, no studies have yet investigated FP acceptors’ contraceptive methods means that the method of contracep-
rationales for switching contraceptive methods, although tion is changed in accordance with a woman’s age, number of
some studies have explored the reasons why first-time FP us- children, and FP motivation [11]. The independent variables

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were perceptions of contraceptive methods, including percep- RESULTS

tions of side effects, cost, ease of use, and accessibility. Individ-
ual characteristics and FP provider characteristics were ana- Of the 4819 women of reproductive age, 2196 were FP ac-
lyzed as confounding variables. ceptors over 35 years of age, of whom 80.9% expressed the
This study analyzed data using univariate and bivariate motivation to space their pregnancies (Table 1). Meanwhile,
analysis. These statistical analyses were followed by multiple among the 3232 FP acceptors who had 2 or more children,
logistic regression analyses to confirm the influence of factors 83.4% expressed the motivation to space their pregnancies.
related to rational patterns of switching methods of contra- As also shown in Table 1, regardless of age and number of
ception. children, among women with the FP motivation of spacing
We controlled for individual characteristics and FP provider their pregnancies or limiting the number of children, the pre-
characteristics in order to focus on the effects of perceptions dominant tendency was to switch from a non-long-term con-
of the side effects, cost, ease of use, and accessibility of contra- traceptive method to another non-long-term contraceptive
ceptives on the likelihood of having a rational pattern of switch- method. In other words, differences in women’s circumstances
ing contraceptive methods. The first step in the multivariate led to no fundamental difference in the pattern of switching
analyses was to include all independent variables and to ob- contraceptive methods. Among women who were FP accep-
tain odds ratios (ORs) for the main independent variables (per- tors, only 31.0% reported a rational pattern of switching con-
ception-related variables). The second step was to control the traceptive methods.
confounding variables. We excluded the confounders one by Table 2 presents the distribution of women who were FP ac-
one, and then we observed the changes in the ORs of the per- ceptors, based on their perceptions of their methods of con-
ception-related variables compared with their original values. traception. Women who perceived that their contraceptive
By controlling the confounding variables, we obtained adjust- method had no side effects tended to have a rational pattern
ed odds ratios (aORs) for the perception-related variables. The of switching contraceptive methods (33.2%), unlike those who
analyses concluded if individual characteristics and family reported that their method of contraception had side effects
planning provider were not the confounder variables. (18.8%). Women who reported that contraceptives were not
easy to use were more likely to show a rational pattern of
Ethics Statement switching contraceptive methods than those who stated that
This study was approved by the Ethical Review Committee contraceptive use was easy. In addition, women who reported
of the Faculty of Public Health, University of Indonesia (329/ that the cost of their method of contraception was moderate
UN2.F.10/PPM.00.02/2016). tended to have a rational pattern of switching contraceptive
methods.

Table 1. Characteristics, FP motivations, and patterns of switching contraceptive methods among female FP acceptors in West
Nusa Tenggara, Indonesia, 2013
Switching pattern, %
Characteristics Motivation, n (%)
N→L L→L L→N N→N
Age (y)
≤35 Spacing pregnancies 2460 (93.8) 5.81 6.71 3.01 84.61
Limiting number of children 163 (6.2) 19.01 11.71 5.5 63.8
>35 Spacing pregnancies 1777 (80.9) 7.11 9.31 10.7 72.9
Limiting number of children 419 (19.1) 18.91 20.31 8.1 52.7
No. of children (n)
<2 Spacing pregnancies 1542 (97.2) 2.61 2.81 1.61 87.91
Limiting number of children 45 (2.8) 8.91 11.11 4.4 75.6
≥2 Spacing pregnancies 2695 (83.4) 8.51 7.81 8.8 75.0
Limiting number of children 537 (16.6) 19.71 18.41 7.6 54.2
FP, family-planning; N, non-long-term contraceptive method; L, long-term contraceptive method.
1
Refers to a rational pattern of switching contraceptive methods.

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Table 2. Patterns of switching contraceptive methods accord- Table 3. Patterns of switching contraceptive methods ac-
ing to perceptions of contraception among female family- cording to knowledge level, individual characteristics, and
planning acceptors in West Nusa Tenggara, Indonesia, 2013 family-planning (FP) provider characteristics among female
Pattern of switching FP acceptors in West Nusa Tenggara, Indonesia, 2013
Total contraceptive methods, %
Independent variable Pattern of switching
(n=4819) Total contraceptive methods, %
Rational Irrational Variables
(n=4819)
Perception of the side effects of contraceptives Rational Irrational
Do not exist 4265 33.2 66.8 Individual characteristics
Exist 554 18.8 81.2 Knowledge level
Perception of the cost of contraceptives High 1932 29.6 70.4
Expensive 1098 30.0 70.0 Low 2887 32.9 67.1
Moderate 2082 32.9 67.1 Education
Free 1639 31.1 68.9 High 231 45.5 54.5
Perception of ease of contraceptive use Middle 884 39.4 60.6
Low 3704 28.9 71.1
Easy 4178 30.9 69.1
Socioeconomic status
Not easy 641 36.3 63.7
Quintile 5 (richest) 455 24.0 76.0
Perception of the accessibility of contraceptives
Quintile 4 682 27.1 72.9
Easy 4311 31.4 68.6
Quintile 3 1120 31.1 68.9
Not easy 508 33.1 66.1
Quintile 2 1128 32.4 67.6
Quintile 1 (poorest) 1434 35.9 64.1
Furthermore, Table 3 shows that rational patterns of switch- Decision-making
Husband and wife 2091 32.6 67.4
ing contraceptive methods were more common among wom-
Wife only 2728 30.8 69.2
en who had a higher education (45.5%), made decisions with FP provider
their husbands (32.6%), and received information on contra- Provider type
ception from an FP provider (32.4%). Government 1692 31.0 69.0
Multiple logistic regression analyses were performed to de- Private 1651 31.6 68.4
termine the relationship between perceptions of contracep- Other 1476 32.2 67.8
tion and the likelihood of having a rational pattern of switch- Information from provider
Yes 2320 32.4 67.6
ing contraceptive methods. When individual characteristics
No 2490 30.8 69.2
and FP provider variables were controlled, perceptions of the
Recommendation
side effects, cost, and ease of use of contraceptives were sig- Midwife 1448 31.0 69.0
nificantly associated (α =0.05) with a rational pattern of Doctor 141 31.2 68.8
switching contraceptive methods. Other 3230 31.9 68.1
Compared to women who perceived the cost of contracep-
tives to be free, those who perceived that the cost of contra- easy were 1.33 times (95% CI, 1.11 to 1.58) more likely to have
ceptives from a private provider was high were 1.65 times a rational pattern of switching contraceptive methods than
more likely (95% confidence interval [CI], 1.14 to 2.39) to have those who perceived contraceptive use as difficult. Additional-
a rational pattern of switching contraceptive methods. Simi- ly, perceptions of the side effects of the contraceptive method
larly, women who perceived the cost of contraceptives from a had a significant impact on the likelihood of women to report
private provider to be moderate were 1.72 times more likely a rational method of switching contraceptive methods (aOR,
(95% CI, 1.29 to 2.30) to report a rational pattern of switching 1.62; 95% CI, 1.43 to1.83) (Table 4).
contraceptive methods. Meanwhile, women who perceived
that the cost of contraceptives from a government provider DISCUSSION
was moderate were 0.76 times less likely (95% CI, 0.62 to 0.95)
to have a rational pattern of switching contraceptive methods. The results of this study indicate that moving from one non-
In addition, women who perceived contraceptive use to be long-term method of contraception to another non-long-term

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Table 4. Associations between perceptions of contraceptive of children, and FP motivation. Of the 4 perception-related
methods and the likelihood of having a rational pattern of variables measured in this study, perceptions of the side ef-
switching contraceptive methods, controlling for individual fects of contraception were the most influential factor in
characteristics and FP provider characteristics, among female
women switching contraceptive methods. Mansour [13]’s
FP acceptors in West Nusa Tenggara, Indonesia, 2013
study showed that a minimum impact on health and wealth
Independent variable aOR (95% CI)1
was key for the selection of a contraceptive method. Thus, im-
Perception of the side effects of contraceptives
proving FP acceptors’ understanding of the side effects of vari-
Do not exist 1.62 (1.43, 1.83)2
ous methods of contraception is needed to help them consid-
Exist (reference) 1.00 (reference)
Perception of cost of contraceptives er which method is most appropriate for them and to enable
Expensive from government provider 0.97 (0.73, 1.30) them to rationally switch contraceptive methods.
Expensive from private provider 1.65 (1.14, 2.39)2 This study also found that perceptions of the cost of contra-
Expensive from other provider 1.10 (0.78, 1.56) ceptives also influenced the pattern of switching contracep-
Moderate from government provider 0.76 (0.62, 0.95)2 tive methods among FP acceptors. They might have had the
Moderate from private provider 1.72 (1.29, 2.30)2 perception that private providers offer high-quality services
Moderate from other provider 1.28 (1.00, 1.65)2 and can provide contraceptive methods appropriate for their
Free (reference) 1.00 (reference) need with fewer side effects. Therefore, FP acceptors preferred
Perception of ease of contraceptive use
to obtain contraception from a private provider, although do-
Easy 1.33 (1.11, 1.58)2
ing so is a more expensive option than obtaining contracep-
Not easy (reference) 1.00 (reference)
tion from a government provider. Our study is supported by
Perception of the accessibility of contraceptives
Easy 1.20 (0.98, 1.48)
the findings of Korachais et al. [17], who concluded that the
Not easy (reference) 1.00 (reference) demand for contraception was not cost-sensitive among users
FP, family-planning; aOR, adjusted odds ratio; CI, confidence interval.
in low-income and middle-income countries. The present
1
Controlling for individual characteristics and FP provider characteristics. study also found that the likelihood of having a rational pat-
2
α=0.05.
tern of switching contraceptive methods was higher among
method was the predominant pattern of switching contracep- women who had specific perceptions about the cost of con-
tive methods. This result is similar to that obtained by a study traceptives obtained from private providers.
in southeastern Ethiopia [15], which found that 29.4% of par- This study also analyzed the perceptions of contraceptive
ticipants had switched their contraceptive method, of whom use. Women tend to switch to methods of contraception that
49.1% changed from pills to injections. In the USA, it was also are easy to use [4,13,14]. However, methods of contraception
found that 42.6% of married women had switched their con- that are easy to use may be not effective for fertility reduction.
traceptive method from pills to condoms [16]. In fact, it appears Our study found that FP acceptors believed that non-long-
that not all FP acceptors are willing to switch. Women older term contraceptive methods, such as injections and pills, were
than 35 and those who have 2 or more children have motiva- easy to use. Parajuli et al. [14] found a similar result, conclud-
tions to limit the number of their children, meaning that high- ing that oral contraceptive pills were felt to be easier to use.
effectiveness contraceptives are recommended for them. There- Contraceptive methods perceived as not easy to use included
fore, a long-term method of contraception is an appropriate those requiring an invasive intervention or surgery, such as in-
choice for such women [11]. However, in reality, women prefer trauterine devices, implants, and sterilization, which prompted
to choose other non-long-term methods of contraception in- fear among FP acceptors. However, we found that FP accep-
stead of long-term ones. We found that only one-third of FP- tors who perceived that their method of contraception was
accepting women in West Nusa Tenggara, Indonesia had a ra- difficult to use nevertheless were more likely to have a rational
tional pattern of switching their contraceptive method relative pattern of switching contraceptive methods. This may have
to their age, number of children, and FP motivation. been because women understood which method of contra-
Our study indicated that perceptions of the side effects of ception was most appropriate for their present condition. FP
methods of contraception were significantly associated with acceptors with a solid understanding of contraceptives tend
switching contraceptive methods, according to age, number to be loyal to their selected method [18]. More information is

262
 Contraception and Switching Methods

needed on FP acceptors’ rationales for selecting a method of ORCID

contraception, and knowledge about how contraceptive
methods are used is needed to help reduce fear regarding cer- Yuli Amran  https://orcid.org/0000-0001-7907-6646
tain contraceptive methods. Narila Mutia Nasir  https://orcid.org/0000-0001-6116-5835
In conclusion, our study found a high prevalence of irratio- Dini Dachlia  https://orcid.org/0000-0001-6000-8467
nal patterns of switching contraceptive methods. The pre- Fitra Yelda  https://orcid.org/0000-0002-9545-4931
dominant pattern among women who were FP acceptors was Budi Utomo  https://orcid.org/0000-0002-8733-5975
to switch from one non-long-term contraceptive method to Iwan Ariawan  https://orcid.org/0000-0001-8414-8173
another. This may have been because the majority of women Rita Damayanti  https://orcid.org/0000-0002-4710-3213
had the motivation to space out their pregnancies, not to limit
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