Sri Lanka current use of contraception : patterns and determinants

PHN Technical Notes RES 3 SI~I LANKA CURRENT USE OF -CONTRACEPTION: PATTERNS AND DETERMINANTS Sulekha Patel October 1982 * This paper is one of a series issued by the Population, * * Health and Nutrition Department for the information and * * guidance of Bank staff working in these sectors. The * * views and opinions expressed in this paper do not neces- * * sarily reflect those of the Bank. * ***********************************************  RES 3 A B S T R A C T This paper uses data from the World Bank and UNFPA sponsored survey on the Determinants of Fertility Decline in Sri Lanka. The multi- variate analysis shows that whereas the traditionally strong influences on fertility, and hence contraceptive use, such as education, age and labor force participation still exist among the older women, changes in the nature of delivery of family planning services are making these socio-economic factors less salient among younger women, as well as among sub-groups of older women.  TABLE OF CONTENTS Page No. Introduction ..................................................... 1 The National Family Planning Program .............................. 4 Current Use of Contraception ..................................... 8 Multivariate Analyses ........................................... 19 Conclusion ...................................................... 28 Appendix A Knowledge and Ever Use of Contraception ..................... 30 Appendix B Multivariate Analysis of Type of Contraceptive -Method Used ......................... .@c .......... 37 References ............................................. ...... . .... 46  List of Tables Page No. Table 1 Re-interviewed WFS Respondents and New Respondents by Socio-economic and Demographic Characteristics ........................... ..3 Table 2 Percent Age Distribution of WFS and New Respondents, Sri Lanka .............................. 3 Table 3 New Acceptors of Family Planning, Sri Lanka ............. 5 Table 4 Demographic Characteristics of New Acceptors, 1976-1979. ................................... 6 Table 5 Proportion of Currently Married Women who are Sterilized, by Age of Respondent .............. 9 Table 6 Percent of Women currently Using a Method of Contraception, by Type of Method Used ............... 10 Table 7 Percent of Women Currently Using a Method of Contraception, by Age of Respondents........... 12 Table 8 Percent of Women Currently Using a Method of Contraception, by Parity of Respondents ............. 12 Table 9 Percent of Women Currently Using a Method of Contraception, by Family Formation Status of Respondents .............................. 13 Table 10 Percent of Women Currently Using a Method of Contraception by Religion of Respondent ............................................. 13 Table 11 Percent of Women Currently Using a Method of Contraception by Are of Residence of Respondent .......................................... 14 Table 12 Percent of Women Currently Using a Method of Contraception by Education of Respondent .............. 14 Table 13 Percent of Women Currently Using a Method of Contraception by Household Expenditure of Respondent.. ................................ 16  Page No. Table 14 Percent of Women Currently Using a Method of Contraception by Respondent's Employment Status ............................................... 16 Table 15 Percent of Women of Respondents Currently Using a Method of Contraception by Education of Husband ............................................... 18 Table 16 Description of Variables included in the Analyses .............................................. 20 Table 17a Standardised and Metric Canonical Discriminate Function Coefficients, WFS Respondents ..................... 22 Table 17b Standardised and Metric Canonical Discriminate Function Coefficients, New Respondents ................. 23 Table 18 Eigen Vector Summary and Canonical Correlation for the Derived Function Differentiating between Users and Non-Users ............................. 27 Table 19 Distribution of Observed-and Predicted Group Membership of Users and Non-Users ....................... 29 Table A.1 Percent Distribution of Women by Number of Family Planning Methods Known before Probing, All Respondents .............................. 31 Table A.2 Percent Distribution of Ever-Married Women by Methods Known and Age, All Respondents ............... 32 Table A.3 Percent Distribution of Ever-Married Women by Method Known and Education, All Respondents .......................................... 32 Table A.4 Percent Distribution of Ever-Married Women by Method Known and Parity, Al-l Respondents ............ 34 Table A.5 Distribution of Ever-Users by Methods and Age, All Respondents .......................... 34 Table A.6 Distribution of Ever-Users by Methods and Education, All Respondents ............................ 36 Table A.7 Distribution of Ever-Users by Methods and Parity, All Respondents ............................... 36  Page No. Table B.1 Description of Variables Included in the Analysis ........38 Table B.2 Descriptive Statistics (means) of Selected *Variables Included in the Analysis .......................39 Table B.3a Standardized and Metric Canonical Descriminant Function Coefficients, WFS Respondents ................... 40 Table B..3ib Standardized and Metric CanorLical Descriminant EFunction Coefficients, New Respondents .............. 41 Table B.4 Eigen Vector Summary and Canonical Correlation for the Derived Function Differentiating Between Users and Non-users .............................. 44 Table B.5 Distribution of Observed and Predicted Group Membership of Users and Non-users ................... 45 01  CURRENT USE OF CONTRACEPTION: PATTERNS AND DETERMINANTS I. Introduction 1.01 The central concern of this chapter is to examine the patterns of contraceptive usage in Sri Lanka. The focus of the analysis is on the currerLt use of conventional methods of contraceptionl/, a measure that is appropriate for describing the contraceptive practice prevailing in a population at any given time. Ever-use of contraception, although important in its own right, lacks some of the characteristics of good measurement associated with current use. First, it does not reflect a woman's current status; second, and more fundamentally, it does not measure exclusively the probability of use by women who feel they need contraception2/. For comparative purposes, however, data on contraceptive knowledge anid ever-use are also analyzed and the results are presented in Appendix A. 1.02 Information on current use was obtained by routing the responses of currently married women, exposed to the risk of pregnancy (non-sterilized, fecund women) through the following questions: a. -Are you or your husband using a method to keep you from getting pregnant? If the response was affirmative, they were further asked: b. What method are you using? 1.03 The respondents in the study sample can be categorized into two subgroups. The first group consists of women who had participated in the World Fertility Survey conducted in 1975 and were declared eligible for the 1/ Use of sterilization for contraceptive purposes is analyzed separately. 2/ Ryder, Norman and Charles Westoff, Reproduction in the United States, 1965. Princeton University Press, Princeton, New Jersey, 1971, p. 1146  -2- present survey by meeting the age criteria. The second group is constituted of women who became eligible for interview either (1) by meeting the age and marital status criteria in the interim period; or (2) by change of residence 4 to units that were targeted for interview in the World Fertility Survey. 1.04 The two sets of respondents differ systematically from each other in their socio-economic and demographic characteristics, as well as in their orientation toward family size (Table 1). The newer respondents are younger, (see also Table 2), married at older ages, desire smaller families, and are more educated than their reinterviewed WFS counterparts. However, fewer of them are currently in the labor force, and fewer have ever worked, either before or after marriage. In view of these differences it is not unreasonable to assume that the two groups of respondents are likely to differ in their contraceptive behavior also. It can further be assumed that the contraceptive behavior of the new respondents is indicative of the more recent pattern of contraceptive usage. The two groups are therefore treated separately in the analysis and, for the sake of convenience, are hereafter referred to as the WFS respondents and the new respondents (NR). 1.05 The next section briefly examines the Family Planning Program. Section III discusses the differentials in current use of contraception by socio-economic and demographic variables identified by other studies as being relevant for t'he analysis of contraceptive use. Finally, the relative importance of factors that differentiate between users and non-users of conventional methods of contraception are identified within a multivariate framework.  -3- Table 1. Re-interviewed WFS Respondents and New Respondents by Socio-Economic and Demographic Characteristics Respondents WFS NR Mean Age (years) 34.4 27.9 Mean Age at marriage (years) 19.8 21.2 Desired family size (mean) 3.9 3.0 Children ever born (mean) 4.2 2.3 Children dead (mean) 0.4 0.2 Wife's education (years) 5.1 5.6 Husband's education (years) 5.8 6.7 Average household expenditures (Rs) 504.4 526.7 *% Currently in labor force 25.9 22.4 % Ever Worked 41.0 40e.1 Table 2: Percent Age Distribution of the WFS andl New Respondents, Sri Lanka Age Respondents Group WFS New 15-19 0.2 7.0 20-24 5.2 29.9 25-29 20.5 28.1 30-34 25.1 18.8 35-39 25.6 8.7 40-44 16.1 5.7 45-49 7.4 1.8 Total 100.0 100.0 (N) (1765) (789)  -4- II. The National Family Planning Program 2.01 Family planning was initially made available in Sri Lanka by the Family Planning Association (FPA) as early as 1953 for protecting the health of mothers and children. In 1965, by a Cabinet decision the Government of Sri Lanka (GOSL) accepted family planning as an integral part of the Maternal and Child Health Services, and the Family Planning Bureau, now known as the Family Health Bureau was established within the Ministry of Health (now the Ministy of Family Health) with the responsibility of implementing family planning activities. The FPA continues to function, but mostly in research and promotional activities, directing its efforts to areas and groups outside the scope of the official program. 2.02 Table 3 illustrates the pattern of family planning acceptance in Sri Lanka during the period 1968-1980. There was an increase in the number of acceptors from 1968 to 1975 and substantial increases in female sterilization during 1972-1974, a period distinguished by heightened family planning activity on the one hand, and by the lack of any policy movement towards anti-natal legislation on the other. This was followed by a decline in total acceptors in 1976-77. Thereafter, an increase was again observed, and in 1980 there were 153,553 new acceptors of family planning. Roughly this means that in 1980 approximately 42 out of every 1000 women of reproductive age were new acceptors of family planning, an Increase of 8 new acceptors per 1000 since 1975.3/ 2.03 Table 4 gives information on the demographic characteristics of new acceptors. Among acceptors of sterilization, there is a decrease in both 3/ Computed using acceptor statistics from Table 3 and estimates of women in reproductive ages.  -5- Table 3. New Acceptors of Family Planning, Sri Lanka Sterilization Year Male Female Total Orals IUD Condom Total 1968 - - 1,011 16,014 20,615 4,3z75 43,964 1969 - - 2,947 25,284 19,537 5,207 54,534 1970 - - 4,971 26,889' 15,799 6,416 55,279 1971 245 4,090 4,335 25,828 11,446 6,945 49,323 1972 498 9,078 9,576 32,300 18,599 9,290 71,043 1973 1,850 18,398 20,248 34,214 27,528 12,963 95,931 1974 7,292 34,942 42,234 35,924 29,693 NA 107,851 1975 6,034 33,130 39,164 37,720 32,755 NA 109,639 1976 2,924 32,664 35,588 25,597 27,030 NA 88,215 1977 1,302 17,752 19,055 27,514 21,321 NA 67,890 1978 2,325 19,624 21,949 31,146 23,085 NA 76,180 1979 5,586 27,740 33,326 29,022 18,878 NA 85,804 198Oa/ 45,967 55.,215 j 101,182 26,867 17,055 NA | 153,553 a/ Provisional totals. Source: Reports on New Acceptors of Family Planning, Evaluation Unit, Family Health Bureau, Sri Lanka.  -6- Table 4: Demographic Characteristics of New Acceptors, 1976-1979 Vasectomy Tubectomy IUD Pill 1976 Mean Age of Mother 32.3 31.5 27.0 27.5 Mean Parity 3.8 4.8 2.8 2.8 1977 Mean Age of Mother 30.5 31.2 27.0 27.5 Mean Parity 3.5 4.5 2.6 2.7 1978 Mean Age of Mother 30.0 31.1 27.4 27.4 Mean Parity 3.5 4.5 2.7 2.7 1979 Mean Age of Mother N.A. 31.1 27.0 N.A. Mean. Parity 3.5 4.4 N.A. N.A. N.A. - Not Available. Source: Service Statistics, 1976-1979  -7- the age and the parity at which sterilization is performed. The increase in the number of vasectomy acceptors in 1980, if maintained appears to bode well for the future of fertility decline in Sri Lanka, since the wives of vasectomy acceptors are at lower parities than women who themselves get sterilized. The pill and the IUD are favoured by younger women at lower parities, mainly for spacing purposes. 2.04 Much of this upsurge in contraceptive acceptance since 1978 can be attributed to initiatives in family planning that were implemented by the GOSL with a view to controlling population growth. Bonuses in excess of daily wages lost and out of pocket expenses incurred, as well as extra leave days were granted to any employed person voluntarily undergoing sterilization The success of the scheme, which has been in operation since May 1979 is reflected in the number of sterilization acceptors, both male and female, in 1980. It is the hope of the GOSL to extend a similar system of sterilization bonuses to the unemployed.4/ Another move that is hoped will prove beneficial to the family planning program is that program administration and direction are decentralized, and have become the responsibility of the 24 districts. Such organisational decentralization is expected to ensure that motivation, provision of services and referral in each district is responsive to local conditions.5/ 2.05 In recent years, attention has been focused on analysing the impact of the national faipily planning program on the decline in the crude 4/ Many public and private corporations, including the tea industry, which is Sri Lanka's largest single employer, already pay sterilization bonuses which are set to compete with generous maternity benefits. 5/ "UNFPA Assists Sri Lanka in its Drive to Lower Birth Rates", in Population, UNFPA Newsletter, Vol. 6, No. 1, January 1980.  -8- birth rate. It is generally agreed that up to 1970 the majority of the decline is attributable to an increase in the age at marriage.6/ Since 1970 however, the effect of declining marital fertility has increased and, more recently, even matched the effect of increasing age at marriage.7/ Although there is no direct evidence, the coincidence in the timing of the shift in the relative importance of the two factors8/ in contributing to fertility decline and the increased emphasis accorded to the family planning program in general, and the promotion of services in particu'lar suggest a causal connection. III. Current Use of Contraception 3.01 Among the women interviewed for the Survey, sterilization is not only the most popu':arly known, but also the most frequently used method of contraception. Of all (4360) currently married women 12-49 years of age, 14.3 percent or 624 women were protected against future pregnancies because either they, or their husbands, were sterilized. Table 5 shows that the proportion of women sterilized increases with age up to age group 35-39 years; thereafter, the proportion sterilized declines steadily. This variation in the prevalence of surgical sterilization by age is not unusual for a terminal method of birth control. Use of sterilization is low at 6/ Fernando, D.F.S. "Fertility Trends in Sri Lanka and Future Prospects". Journal of Biosocial Science 8, January 1976, Cambridge, England. 7/ Alam, Iqbal and Cleland, John. "Illustrative Analysis: Recent Fertility Trends in Sri Lanka". World Fertility Survey Scientific Report No. 25, November, 1981. 8/ Age structure is the third factor that affects the crude 'birth rate. In developing countries however, the age structure is generally conducive to a higher fertility because of past high fertility and improving health conditions which ensure a large proportion of the female population surviving to reproductive ages.  -9- younger ages because these women are still in the process of family formation; use is low among older women:-either because of biological reasons (they have become sub-fecund or biologically sterile), or because they are less aware of and receptive to innovation than their younger counterparts. Table 5. Proportion of Currently Married Women Who are Sterilized by Age of Respondent Age Group Percent Sterilized a/ 15-19 20-24 1.4 25-29 6.3 30-34 20.4 35-39 22.3 40-44 21.0 45-49 12.6 Total 14.3 (N) (624) a/ Based on 4,360 currently married women in.the sample. 3.02 Of the remaining 3736 currently married women, 2762 women at risk of pregnancy are the focus of this analysis; 974 currently married women were declared ineligible because they reported fecundity impairments or considered themselves physically unable to have more children. Among those at risk, 35.1 percent of the WFS respondents and 30.2 percent of the new respondents were using a conventional method of family planning.at the time of the survey (Table 6). 3.03 Overall, the proportion of women at risk using the more efficient conventional methods, namely the pill, IUD, or condom, is low, both for the WFS and the new respondents. Only 12 percent of all WFS respondents,  - 10 - Table 6. Proportion Currently Using A Method of Contraception, by Type of Method Used Respondents Method Used All WFS New Pill 4.0 4.1 4.6 IUD 5.1 6.2 3.9 Condom 1.6 1.8 1.3 Subtotal 10.7 12.1 9.8 Douche 3.7 3.8 4.2 Withdrawal 9.9 10.9 9.5 Rhythm 5.0 5.9 4.4 Abstinence 2.2 2.4 2.3 Subtotal 20.8 23.0 20.4 Percent Using 31.5 35.1 30.2 Percent Not Using 68.5 64.9 69.8 TOTAL 100.0 100.0 100.0 (N) (2,762) (1,765)/a (789)/a /a Do not add up to 2,762 because 208 eligible respondents were not classified as either WFS or new respondents. comprising 34 percent of all current users, were employing an efficient method of birth control. The proportion among new respondents is even lower: approximately 10 percent, comprising 32 percent of current users. 3.04 Withdrawal is the most popular among the conventional methods, used by 10.9 and 9.5 percent of the&WFS and new respondents respectively. The next in popularity is the IUD for WFS respondents and the pill for new respondents. The condom, used by 1.8 and 1.3 percent respectively of the WFS and new respondents, is the least popular method. 3.05 Tables 7 through 15 give details on current use of contraception by selected socio-economic and demographic characteristics. The relation-  ships between use of contraception with age and parity (Tables 7 and 8) take a typical inverted U shape, with relatively lower proportions of women in younger and older ages, and at lower and higher parities using a method of family planning. The pattern is not pronounced among the new respondents who are younger, and therefore concentrated at low parities. The fact that a higher proportion of the new respondents compared to the WFS respondents in the 20-24 year age group and among women of low parity are current users suggests a significant emphasis on child spacing on the part of these new respondents. However, when we examine the respondents on the basis of their family formation status (Table 9) more WFS than new respondents who have cur- rent parities less than desired parities are using a method of contraception, thus indicating an interest in child spacing on the part of WFS respondents also. Among the respondents who had attained their desired family size, slightly more new respondents (41 percent) than WFS respondents (39 percent) were currently using a birth control technique. 3.06 Current use of contraception by religious denomination (Table 10) has the same distribution among both the WFS and the new respondents. Buddhists have the highest proportion using a method (46 and 39 percent respectively of the WFS and new respondents), followed by Christians (43 and 29 percent respectively). Use of family planning is lowest among the Hindus (18 and 16 per cent respectively). Rural-urban differentials (Table 11) are in the expected direction among both sets of respondents. Use of contracep- tion is most frequent-in urban areas and least frequent among women on the Estates.  - 12 Table 7. Percent of Women Currently Using a Method of Contraception, by Age Respondents Age Group All WFS New 15-19 10.3 - (18.2) 20-24 24.3 21.7 28.2 25-29 30.8 34.9 28.8 30-34 - 36.1 38.7 35.1 35-39 36.6 37.9 38.2 40-44 35.1 36.4 (33.3) 45-49 25.5 25.4 (35.7) Total 31.7 35.4 30.3 (N) (872) (623) (238) Note: ( ) indicates fewer than 20 respondents. Table 8. Percent of Women Currently Using a Method of Contraception by Parity Respondent Parity All WFS New 0 4.9 - (4.0) 1 24.7 24.6 24.8 2 36.0 35.6 36.5 3 38.8 38.4 40.2 4 40.8 41.9 (33.3) 5 41.5 42.0 (38.7) 6 35.8 35.0 (42.1) 7 28.0 29.4 (15.4) 8 28.7 31.7 (8.3) 9 18.8 19.6 (33.3) Total 31.7 35.4 30.3 (N) (872) (623) (238) Note: ( ) indicates fewer than 20 respondents.  - 13