Barriers to Modern Contraceptive Use by Female Workers in Indonesia’s Urban Areas
Article information
Abstract
Background
Female workers in Indonesia are vulnerable, because they must work to earn a living while still being responsible for domestic problems. This study analyzes the barriers to the use of modern contraceptives by female workers in Indonesia’s urban areas.
Methods
This cross-sectional survey looked at 21,696 female workers. We used modern contraceptive use as a dependent variable, and age, education, wealth, known modern contraceptives, number of live births, ideal number of children, and insurance ownership as independent variables. In the final test, we employed binary logistic regression.
Results
The results showed that women at all age categories were more likely than those aged 15–19 years not to use modern contraceptives, except those aged 35–39 years, who showed no difference. All other marital types were more likely to use modern contraceptives than married individuals. Rich female workers were 1.139 times more likely than poor workers not to use modern contraceptives (adjusted odds ratio [AOR], 1.139; 95% confidence interval [CI], 1.026–1.264). Female workers who did not know about modern contraceptives were 4.549 times more likely than those who did not to use modern contraceptives (AOR, 4.549; 95% CI, 1.037–19.953). Female workers with more than two children were 9.996 times more likely than those with two or fewer children not to use modern contraceptives (AOR, 9.996; 95% CI, 9.1890–10.875).
Conclusion
This study identified five factors associated with the non-use of modern contraceptives by female workers in Indonesia’s urban areas: young, unmarried, rich, did not know about modern contraceptives, and had more than two children.
INTRODUCTION
Modern contraceptive methods are medical treatments that purposefully prevent sexual activity from resulting in offspring [1]. They include hormonal techniques such as the pill, patch, and ring, as well as injections, condoms (for men and women), intrauterine devices (IUDs), contraceptive implants, and sterilization [2]. Most modern contraceptives have been developed to meet high safety and effectiveness requirements, yet current contraceptive techniques can vary in effectiveness depending on how correctly they are used. A systematic assessment of counseling techniques for modern contraceptive methods found that interventions targeting women starting a process tended to result in continued contraception. The best results were for unintended pregnancy per 100 women per year, shown particularly by sterilization, IUDs, and contraceptive implants. Almost as effective, resulting in between six and 12 pregnancies per 100 women per year, are methods like injectable contraceptives and hormonal methods such as the pill, patch, and ring [3]. The percentage of women of reproductive age whose demand for family planning is covered by modern contraceptive techniques has gradually increased over the past few decades from 73.6% in 2000 to 76.8% in 2020 [4]. Traditional contraception methods such as periodic abstinence or the rhythm method (of any kind), withdrawal, and lactational amenorrhea are often considered less effective than modern ones [2]. Compared to the failure rate of less than 1% for some modern approaches, conventional methods have a more significant failure rate. Nevertheless, traditional techniques are still widely employed in some contexts, especially in low- and middle-income nations, where access to modern methods may be constrained [5].
A search of the three Indonesian Demographic and Health Surveys (IDHSs) showed a change in the trend of contraceptive use in Indonesia. The use of modern contraceptive methods among married women increased from the 2002/03 IDHS (57%) to the 2012 IDHS (58%) but decreased slightly in the 2017 IDHS (57%) and reached 55.36% in 2022 [6]. Meanwhile, traditional contraceptive methods continued to grow from the 2002/03 IDHS (4%) to the 2017 IDHS (6%) [7]. The percentage of married women using modern contraceptives increases with age, from 44% for those aged 15–19 years to 64% among those aged 35–39 years, but was 61% among those aged 40–44 years and 45–49 years [7]. Most married women in Indonesia (29%) prefer injections.
Compared to other nations in the region, Indonesia shows a comparatively low rate of employment of modern contraceptive methods [8]. A 2019 study found that Indonesia had a modern contraceptive utilization rate of approximately 55%, while Vietnam and Thailand, two neighbors, had utilization rates of 69% and 76%, respectively. Current birth control decreased from 58% in 2012 to 57% in 2017 and 55% in 2019. In Indonesia, regional discrepancies in the use of modern contraceptives have also been observed, which have persisted for decades despite ongoing government funding and measures aimed at reducing these disparities [8].
According to a study that examined worldwide microdata, women are more likely than men to be employed in vulnerable positions [9]. One study found that married women in Indonesia frequently serve as both family caregivers and earners [10]. They face the challenge of marginalization in the labor market, resulting in lower wages for all types of work and fewer employment opportunities than men. Working women are considered secondary breadwinners, a role complementary to their domestic roles, because of their low awareness of gender equality [11]. Women are also more vulnerable when making health-related decisions. Although every woman has the right to actively decide how her health is cared for, more than two-fifths of women do not participate in these decisions, which are mainly made by their husbands [12].
Socioeconomic and demographic variables have a more significant effect on the usage of contraception in Indonesia, with such factors as maternal age of 30–34 years, urban residency, family wealth status in the fourth quintile, secondary education, employment among women, residence in Java/Bali, and having more than two living children being reported [13]. Women in Indonesia’s rural areas who are of reproductive age and moderate socioeconomic position are more likely to utilize contraceptives, according to a study done in 2021. The survey also revealed that women of reproductive age in rural Indonesia face barriers to contraceptive use, including older age, lack of education, no husband or partner, poverty, and having already had one child [14]. Women of reproductive age in Indonesia were significantly more likely to use modern contraceptives when they had high levels of autonomy in their family planning decisions, free national or district health insurance, and a higher proportion of women in their neighborhoods who were seen by community health workers [8]. Factors such as education, family economic status, religion, knowledge of modern contraception, age at first marriage, perception of the ideal number of children, number of children born alive, and place of residence are associated with the need for and predisposition to the use of modern contraceptives [15]. Therefore, this study analyzed the barriers to the use of modern contraceptives among female workers in Indonesia’s urban areas.
METHODS
1. Data Source and Study Design
This cross-sectional analysis relied on the 2019 Government Performance and Accountability Survey (GPAS), conducted from July to September 2019 in collaboration with the National Population and Family Planning Board and the Central Agency of Statistics. The poll used secondary data from the GPAS and featured both a representative province and a national sample. This study’s target demographics comprised households, women aged 15 to 49 years who might bear children, families, and unmarried adolescent girls aged 10 to 24 years. For the enumeration region, the study employed a clustering method, where a cluster was defined as a collection of census blocks (one or more) close to one another and located along a road.
2. Sample Selection
The goal of the 2019 GPAS was to generate parameters at both the provincial and federal levels. The 2019 GPAS sample comprised 67,725 households scattered across 34 provinces, 514 districts/cities, 82,030 villages, and 1,935 clusters. Previous long-term national plans and GPAS surveys covered respondents aged 15–49 years who could have children; in 2019, the youth module (unmarried) had a younger age range of 10–24 years.
The survey adopted a phased sampling procedure. In the first step, using probability proportionate-to-size (PPS) sampling, villages were chosen based on the number of households on each village’s list (or in the sample frame of all villages). A random sample of villages from both urban and rural areas was chosen within a district or city. In the second stage, PPS sampling was used to select one cluster from each desired village based on the number of households in the cluster. In the third stage, 35 households were selected using a systematic random selection based on the results of the household listings completed by the enumerators in the targeted cluster using smartphone applications.
The sample of women aged 15–49 years comprised all women in the 35 selected households in each cluster. This study had a 99.7% response rate and included 21,696 female workers in urban areas out of 59,825 female participants. The exclusion criteria were pregnant women, those who had already attained menopause, and having a history of hysterectomy.
3. Setting
We studied female workers in a national setting in urban areas in Indonesia.
4. Dependent Variable
The dependent variable was modern contraception use. In this study, the use of eight current contraceptive methods was elicited (male sterilization, female sterilization, contraceptive injection, contraceptive tablets, implants, condoms, intrauterine contraceptive device [IUD], and the lactational amenorrhea method) [15]. Modern contraceptive use comprised two options: “yes” (code=0) or “no” (code=1).
5. Independent Variables
Seven independent variables were used in this study: age group, education, wealth, known modern contraceptives, number of live-born children, ideal number of children, and health insurance ownership. The survey split ages into the groups 15–19 years, 20–24 years, 25–29 years, 30–34 years, 35–39 years, 40–44 years, and 45–49 years. Furthermore, we employed four educational levels: no formal education, primary, secondary, and higher education.
The 2019 GPAS uses the wealth index methodology to determine wealth status, in which the weighted average of a household’s overall spending was calculated. The survey built the wealth index using actual data on household spending on health insurance, food, lodging, and other essentials. Furthermore, the 2017 GPAS categorized wealth into three categories: poor, middle class, and wealthy.
Meanwhile, the study divided known modern contraceptives into “no” and “yes.” This study defines the number of live-born children as those who were alive at the time of the survey and born to the women. Meanwhile, the study described the ideal number of children as the number of children a woman or man would have if they could go back in time and pick exactly how many children they wanted. We divided the number of live-born children and the ideal number into the groups two or fewer and more than two children. Moreover, we split health insurance ownership into “no” and “yes.”
6. Data Analysis
Initially, the chi-square test was used to perform a bivariate study. A collinearity test was used in the second stage of the inquiry to ensure that there was no significant link between the independent variables. The final step employed a binary logistic regression test (entry procedure). This study provides adjusted odds ratios (AORs) with 95% confidence intervals (CI). The statistical analyses were performed using IBM SPSS ver. 26.0 (IBM Corp., Armonk, NY, USA).
7. Ethical Approval
This study was approved by the Family Planning and Reproductive Health Committee of Research Ethics (approval no., 454/LB.02/H4/2019). During the study, we removed the identities of all respondents from the dataset.
RESULTS
The results showed that the average contraceptive use among female workers in Indonesia’s urban areas was 45.4% nationally. Table 1 provides a statistical description of modern contraceptive use among female workers in Indonesia’s rural areas. By age group, those aged 15–19 years showed the highest proportion of female workers who did not use modern contraceptives. Regarding marital status, female workers who had never married had the highest proportion that did not use modern contraceptives.
Descriptive statistics of modern contraceptive use among female workers in Indonesia’s urban areas (n=21,696)
Table 1 further indicates that those with higher education have a higher proportion of modern contraceptive use than those with other levels of education. Moreover, rich female workers have a higher proportion than the others of not using modern contraceptives. Female workers who were unaware of modern contraceptives comprised the highest proportion of those who did not use modern contraceptives. Regarding the number of live-born children, female workers with more than two children had the highest proportion of those not using modern contraceptives.
Table 1 shows that according to the ideal number of children, female workers with two or fewer children have a slightly higher proportion of not using modern contraceptives than those with more than two children. Furthermore, based on health insurance ownership, uninsured women had a higher proportion of not using modern contraceptives than the insured.
The collinearity test results showed no evidence of a link between the independent variables. Furthermore, the variance inflation factor value for each variable was less than 10, indicating no multicollinearity in the regression model.
Table 2 displays the results of binary logistic regression for age-related use of modern contraceptives among female workers in urban areas in Indonesia. All age categories were more likely than those aged 15–19 years not to use modern contraceptives, except those aged 35–39 years, who showed no difference from those aged 15–19 years. Moreover, based on marital status, all types were more likely not to use modern contraceptives than married individuals were.
Results of binary logistic regression (n=21,696)
Table 2 shows that education level was not related to contraceptive use among female workers in urban areas in Indonesia. Meanwhile, rich female workers were 1.139 times more likely than poor workers not to use modern contraceptives (AOR, 1.139; 95% CI, 1.026–1.264). Furthermore, female workers who did not know about modern contraceptives were 4.549 times more likely not to use modern contraceptives than those who did (AOR, 4.549; 95% CI, 1.037–19.953).
Based on the number of live-born children, female workers with more than two children were 9.996 times more likely to not use modern contraceptives than those with two or fewer children (AOR, 9.996; 95% CI, 9.1890–10.875). Moreover, no significant relationship was found between health insurance ownership and modern contraceptive use.
DISCUSSION
The results clarify the age-related use of modern contraceptives among female workers in urban areas in Indonesia. All other age categories were more likely than those aged 15–19 years to not use modern contraceptives, except those aged 35–39 years, who showed no difference. This indicates that young women (15–19 years old) are more likely to use modern contraceptive techniques than older women (>40 years old). This is likely because older women feel more experienced and are more likely to avoid pregnancy than younger women, who may have little or no experience. Another possibility is that older women may prefer and be comfortable with traditional methods that have been used for generations [5,16].
By marital status, all other women were more likely not to use modern contraceptives than married individuals, or alternately that married women were more likely to use modern contraceptives than women with other relationship statuses. This finding is consistent with that of a previous study that found that marital status is associated with the adoption of modern contraceptive techniques and parity [17]. Marital status and parity, including modern contraceptive methods, have become essential personal variables affecting women’s reproductive health. Premarital sexual encounters are regarded as unfavorable in Indonesia; hence, contraceptive services are unavailable for unmarried couples. There is thus a challenge of making such reproductive health services more easily available to unmarried women as well [18].
This study indicated that educational level was not related to contraceptive use among female workers in urban areas in Indonesia. The knowledge of contraceptive methods is not obtained solely from formal education. The availability of midwives at the village level in Indonesia is likely to be a significant source of information for women at the lowest level [19]. This contradicts previous research, which found that women’s educational level influences their use of modern contraceptives, such that women with a higher level of education are more likely to use modern contraceptives than those with lower education [20]. Wealth and reputation tend to increase as educational levels increase, as does the desire to limit children through modern contraception [20]. Education increases one’s ability to obtain wealth and prestige; this clashes with childbearing decisions because in modern society, children are the source of consumption rather than resource creators [20]. Women with higher education typically want to delay marriage while working and continuing their education [21]. In addition, more educated and professionally talented women selected traditional contraceptive methods, especially Muslim women, a significant proportion of whom favored conventional contraceptive methods over modern ones [22].
Meanwhile, rich female workers were more likely not to use modern contraceptives than poor workers. This may be attributed to the fear of potential side effects or health problems experienced by wealthy women. A similar study in India revealed that the fear of side effects was a barrier to modern contraceptive methods among women in the highest wealth quintile [23]. In addition, a study among women living in urban areas of Kenya with higher socioeconomic status and better access to family planning services found that fear of side effects was the main perceived barrier to modern contraceptives [24]. The most common side effects reported by the respondents were weight gain, excessive bleeding, and decreased sexual desire [24]. This finding suggests the importance of education on misconceptions related to the side effects of contraceptive methods, which health professionals should provide during family planning counseling sessions.
Female workers who did not know about modern contraceptives were likelier not to use modern contraceptives than those who did. Recent studies in African countries have reported similar findings, concluding that modern contraceptive use is limited due to a lack of knowledge [25]. This could be because women with a better understanding of contraception are more aware of contraceptive methods and their benefits, including the forms most appropriate for their needs. Furthermore, a study in Sub-Saharan Africa highlighted the significant role of mass media exposure in addressing knowledge inequalities regarding contraceptive methods. Specifically, the promotion of contraception uses through radio, television, and newspapers encouraged women to use modern contraception methods [25]. This finding emphasizes the need for mass media campaigns to promote the use of modern contraceptives.
Based on the number of liveborn children, female workers with more than two children were more likely not to use modern contraceptives than those with two or fewer children. However, previous studies have reported contradictory findings, indicating that women with many living children were more likely to use modern contraceptives. This finding has been confirmed in a previous study [26]. Furthermore, although this study found that women in the labor force tended to have decision-making power in modern contraceptive use, sociocultural norms in a patriarchal society such as Indonesia allow husbands to take the lead and make decisions even on family planning [25]. Men’s opposition to contraception is a significant barrier to the use of modern contraceptive methods [27]. The disparity in the findings can be attributed to the fact that, as members of the largest Muslim population, married Indonesian women perceive that the use of modern contraceptives is against their religious beliefs [8].
Consequently, women preferred traditional contraceptive methods, such as withdrawal and periodic abstinence, which are permitted by their religion [28]. Further research is needed to examine the influence of religious and traditional beliefs on modern contraceptive use. Additionally, this finding suggests that family planning interventions should target and involve husbands rather than only targeting women.
1. Strengths and Limitations
The use of big data at the national level is one of the strengths of this study. Because the author’s analysis was quantitative, we could not investigate the causes of modern contraceptive use reported in previous studies, such as recent sexual activity, male involvement, values concerning the family and children, and religious beliefs [29]. Moreover, this study was designed cross-sectionally, so it can only describe relationships or associations and cannot indicate causality among the factors identified.
2. Conclusions
This study identified five factors associated with the non-use of modern contraceptives among female workers in Indonesia’s urban areas: young, unmarried, rich, did not know about modern contraceptives, and had more than two children.
The results of this study indicate that the government needs to implement policies with focused targets to increase the use of modern contraceptives. This targeted policy is important in relation to the steps formulated for strategies to deal with local barriers, such as the use of contraceptives among the unmarried.
Notes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
Acknowledgements
The author would like to thank the National Population and Family Planning Board, which has agreed to allow the author analyzed the 2019 GPAS data in this article.