Contraception use and probability of continuation: community-based survey of women in southern Jordan

Publication date: 2005

Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 545 Contraception use and probability of continuation: community-based survey of women in southern Jordan R.M. Youssef1 1Department of Community Medicine, Faculty of Medicine, Mu’tah University, Mu’tah, Jordan (Correspondence to R.M. Youssef: randayoussef@link.net). ABSTRACT A community-based survey was conducted in October 2003 to investigate the determinants of contraception use and probability of 2 years continuation among ever married women of reproductive age in Karak, south Jordan. Of the 1109 participants, 61% were ever users of contraceptives in 1389 segments, median duration 24.0 months. The cumulative proportion of continuation was 92% at 6 months, 65% at 12 months and 42% at 24 months. Older age, longer duration of marriage, large number of surviving children and use of the intrauterine device independently predicted a longer duration of contraception use. Pregnancy planning (74%) was the most frequently stated reason for discontinuation. Family planning programmes should focus on reducing discontinuation and recommending methods with a higher probability of continua- tion. Utilisation de la contraception et probabilité de sa poursuite : enquête communautaire dans le sud de la Jordanie RÉSUMÉ Une enquête communautaire a été réalisée en octobre 2003 pour identifier les déterminants de l’utilisation de la contraception et la probabilité de sa poursuite pendant 2 ans chez des femmes en âge de procréer déjà mariées à Karak dans le sud de la Jordanie. Sur les 1109 participantes, 61 % avaient déjà utilisé des contraceptifs dans 1389 segments, la durée médiane étant de 24,0 mois. La proportion cumulative de la poursuite de la contraception était de 92 % à 6 mois, de 65 % 133 à 12 mois et de 42 % à 24 mois. L’âge plus avancé, la plus longue durée du mariage, le nombre important d’enfants survivants et l’utilisation d’un dispositif intra-utérin prédisaient de façon indépendante une plus longue durée d’utilisation de la contracep- tion. La planification d’une grossesse (74 %) était la raison la plus fréquemment citée pour l’arrêt de la contraception. Les programmes de planification familiale devraient chercher à réduire l’abandon et recom- mander des méthodes ayant une plus forte probabilité de poursuite. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM545 546 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 Introduction Since the United Nations International Con- ference on Population and Development, held 5–13 September 1994 in Cairo, Egypt, Jordan’s record in advancing the reproduc- tive health agenda has been mixed, yet fam- ily planning has been recognized as a top priority and has been identified as a key ele- ment in reducing fertility for all age groups and in many developing countries [1–3]. Moreover, family planning is one of the 6 interventions recommended by the World Health Organization to achieve safe moth- erhood with subsequent reduction of ma- ternal and neonatal morbidity and mortality [4]. In Jordan, the provision of family plan- ning services by the government sectors started in 1980, and since then use of con- traception has become widespread. A steady increase in contraception use was observed among Jordanian women: the prevalence of use rose from 40% in 1990 to 53% in 1997, reaching 56% in 2002 [5]. In all population surveys, the proportion of women currently practising contraception is a routine component of monitoring and evaluation of family planning services. On a national level, however, few studies have included information on the ability or will- ingness of clients to persist with contracep- tion [6]. Grady et al. pointed to the high rate of discontinuation of contraception as a major problem facing family planning pro- grammes [7]. In Jordan, the most recent population and family health survey [5] re- vealed that 42% of women who are ex- posed to the risk of conception discontinue the method within 1 year of initial accep- tance. The rate for continuation of contra- ception is one of the major indicators of the quality of use and programme success [8]. The purpose of this study is to deter- mine the rate of continuation of contracep- tion and reasons for discontinuation as well as to identify the variation in continuation for different methods and different client types. This information is essential for pro- gramme managers to provide quality ser- vice and to ensure the success of family planning programmes. Methods A community-based survey was conducted in Al-Karak governorate in the southern re- gion of Jordan in October 2003. Adminis- tratively, Al-Karak governorate is divided into 7 districts, each of which has a num- ber of villages. This study is part of a more extensive survey of the duration and determinants of interbirth interval and contraceptive use. The target population for the current sur- vey was ever married women of reproduc- tive age (15–49 years). Eligibility criteria for inclusion were being ever married and having at least 1 child as women are not likely to opt for contraception before the birth of the first child. A total of 1109 women were enrolled in the study using the multistage sampling technique. Estimation of sample size and sampling procedure are given elsewhere [9] based on methods described by Lwan- ga et al. [10] and taking into account con- traceptive use in the region [5]. Participants were interviewed in their own homes using a pre-tested question- naire to collect relevant information. The questionnaire included questions on: • sociodemographic data, including cou- ple’s age, level of education, husband’s occupation, woman’s working status and current marital status; • reproductive history, including age at marriage; number of pregnancies, deliv- eries and miscarriages; history of child 04 Contraception use fc.pmd 2/1/2006, 1:01 PM546 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 547 death; number and sex of surviving children, woman’s ideal preference re- garding number of children; • use of modern contraceptive methods, both current and ever use; inquiry was made into the use of modern contracep- tion following each pregnancy (which represents a segment of contraception use), type of method used, duration of use and reason for discontinuation. In view of the lack of any register for contraception use, the dates of commence- ment and termination of contraception use were based on women’s recall. To ensure the accuracy of the reported duration of contraception use, the date of childbirth was obtained from the family register. The starting date was estimated by asking the women, “How many months after the birth of this child did you opt for contracep- tion?” The date of termination was estimat- ed by asking, “How many months did it take to conceive following discontinuation of contraception?” The dates were record- ed in years and months from which the du- ration of use was calculated. Switching to another contraceptive method was encoun- tered in a few segments and was consid- ered a new segment of use. Data processing and analysis were per- formed using SPSS, version 10. Two data files were created. The first represented the unit of inquiry, namely women interviewed while the second represented the “seg- ments” of contraception use reported by ever users. A segment is considered closed by the discontinuation of the method while if contraception is maintained, the segment is considered open and the observation is then censored. Data were presented using the mean, standard deviation and corre- sponding 95% CI of the mean. The univari- ate logistic regression analysis was applied for computing the odds ratio and the 95% CI. Analysis of the mean duration of con- traception use, the determinants of use and the probability of continuation was per- formed using life table, Kaplan–Meier sur- vival estimates and univariate and multivari- ate Cox regression analyses, which are suitable for censored observation. Signifi- cance was considered at the 5% level. Results A total of 1109 ever married women of re- productive age were enrolled in the study. Mean age was 32.4 years [standard devia- tion (SD) 7.1], minimum 18 years and maximum 49 years. The majority of wom- en (78.9%) and their husbands (79.7%) had completed ≥ 9 years of education. Just over a quarter of the women had been em- ployed for variable periods of time during their years of marriage and 21.0% were currently working. More than a third of the husbands were employed by the army and 27.6% were either professionals or semi- professionals (Table 1). The majority of women (98.3%) were in a marital union at the time of the survey. Mean age at marriage was 21.4 years (SD 3.9; median 21 years). The number of chil- dren ranged from 1 to 13, with a mean of 3.9 (SD 2.4) children per woman. Nearly half the women (48.0%) stated an ideal preference of 4 for number of children. Women who stated an ideal preference of > 4 children constituted 39.9% of the sam- ple and 12.1% had an ideal preference for 2 or 3 children. Only 19.8% of women had the number of children that matched their ideal preference. Just over half the women (57.7%) had not reached their ideal prefer- ence, while 22.5% had exceeded their ideal preference. Women who exceeded their ideal preference were significantly older, 38.9 years (SD 5.9; 95% CI: 38.2–39.7) compared to 34.6 years for those who had 04 Contraception use fc.pmd 2/1/2006, 1:01 PM547 548 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 the number of children matching their ideal preference (SD 6.0; 95% CI: 33.8–5.4) and 29.2 years (SD 5.7; 95% CI: 28.7–29.6) for those who had fewer children than their ideal preference. Moreover, women who exceeded their ideal preference for number of children had been married for a signifi- cantly longer duration, 19.3 years (SD 6.1; 95% CI: 18.5, 20.0), than those who had their ideal number of children, 13.3 years (SD 5.8; 95% CI: 12.6–14.1), or had fewer than their ideal number, 7.1 years (SD 5.0; 95% CI: 6.7–7.5). Excluding women who were pregnant and those who were no longer in a marital union, 40.8% of the women in the survey were current users of modern contracep- tives. However, 61.3% reported ever use in 1 or more segments. For both ever users and current users, the intrauterine device (IUD) was the commonest method of con- traception, followed by pills and condoms. Only 9 women opted for tubal ligation (Ta- ble 2). Table 3 shows contraception use in rela- tion to couple’s characteristics. The pro- portion of ever users of modern contracep- tion increased significantly with the increase in the level of education of the women (chi-squared for linear trend = 7.967; P = 0.00476) and their husbands (chi-squared for linear trend = 8.863; P = 0.00291). Couples who had 9 or more years of education each were nearly 2 times as likely to report ever use of modern con- traceptive methods compared to those who did not receive any formal education. Wom- en who reported ever use of modern con- traceptives were significantly older, mar- ried for a significantly longer duration and had a significantly greater number of chil- dren compared to never users. In contrast, ever use of modern contraceptives was not significantly associated with women’s working status or husband’s occupation. The study of contraception use extend- ed to include the duration of use and the probability of 2-years continuation. Among ever users, reversible modern contracep- tives were used in 1389 segments for a Table 1 Characteristics of the survey participants Characteristic No. % (n = 1109) Woman’s educational attainment No formal education 103 9.3 Primary (6 years) 131 11.8 Preparatory (9 years) 292 26.3 Secondary (12 years) 262 23.6 University or higher (> 12 years) 321 28.9 Husband’s educational attainment No formal education 64 5.8 Primary (6 years) 161 14.5 Preparatory (9 years) 354 31.9 Secondary (12 years) 318 28.7 University or higher (> 12 years) 212 19.1 Husband’s occupationa (n = 1104) Professional & semi- professional 305 27.6 Skilled & semiskilled 106 9.6 Militaryb 404 36.6 Manual 108 9.8 Otherc 181 16.4 Woman’s work status Worked before marriage 275 24.8 Worked during marriage 300 27.0 Currently working 233 21.0 Woman’s marital status Married 1091 98.3 Widowed 13 1.2 Divorced or separated 5 0.5 aExcluding those who have never been employed. bMilitary represents those who did not have any formal education or received some school education and are employed by the army. cIncludes traders, drivers, farmers and shepherds. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM548 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 549 mean duration of 40.4 months [standard er- ror (SE) = 1.6; 95% CI: 37.2–43.6] and a median of 24 months (SE = 0.2; 95% CI: 23.6–24.4). The cumulative proportion of women who continued contraception use at 6 months was 92.4%, falling to 64.9% at 12 months and 42.5% at 24 months. Analysis of the segments of use of re- versible modern contraceptive methods in relation to women’s characteristics at the beginning of the segment of use is displayed in table 4. The shortest duration of contra- ception use, for a mean of 25.1 months, was for segments starting before the age of 25 years and within the first 5 years of mar- riage (mean 24.8 months). In contrast, seg- ments of use starting after the age of 35 years and for ≥ 15 years of marriage ex- tended for around 87 months. The risk of discontinuation of contraception decreased significantly with the increase in women’s age and duration of marriage at the begin- ning of the segment of use, as indicated by the hazard ratio. A statistically significant difference was observed in the cumulative proportion of continuation of contraception in relation to women’s age and duration of marriage. For segments starting after the age of 35 years, the cumulative proportion of continuation was 80.5% at 12 months and 73.5% at 24 months. For those starting before age 25 years, the cumulative proportion of contin- uation decreased to 55.4% at 12 months and 29.1% at 24 months. Similarly, the cu- mulative proportion of continuation was 79.7% at 12 months and 70.1% at 24 months for segments starting after 15 years of marriage, whereas it was 52.3% at 12 months and 27.3% at 24 months for seg- ments starting within the first 5 years of marriage (Table 5). Mean duration of contraception use was the shortest, 20.2 months, for segments in which the woman had only 1 child, and peaked at 57.3 months for segments in which the woman had 4 or more surviving children. The likelihood of discontinuation of contraception decreased significantly when there were 2 surviving children (haz- ard ratio = 0.69) or 3 (hazard ratio = 0.56) and was lowest in segments where the number of surviving children was ≥ 4 (haz- ard ratio = 0.39). Sex composition of sur- viving children was significantly associated with the duration of contraception use. Segments starting with both boys and girls Table 2 Use of modern contraceptive methods Use of modern No. % contraceptives Ever use (n = 1109) Never user 429 38.7 Ever user 680 61.3 Type ever useda IUD 382 56.2 Pills 320 47.1 Condoms 111 16.3 Injectables 49 7.2 Local spermicides 13 1.9 Tubal ligation 9 1.3 Implants 5 0.7 Current useb (n = 1001) Non users 593 59.2 Users 408 40.8 Type currently used IUD 193 47.3 Pills 117 28.7 Condom 67 16.4 Injectables 19 4.7 Tubal ligation 9 2.2 Implants 2 0.5 Local spermicides 1 0.2 aCategories are not mutually exclusive. bExcluding women who reported being pregnant or no longer in a marital union. IUD = intrauterine device 04 Contraception use fc.pmd 2/1/2006, 1:01 PM549 550 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 extended for a mean duration of 45.9 months. The risk of discontinuation of contraception was 1.79 times that in the presence of girls only, while it was 1.5 times that in the presence of boys only. Al- though the duration of contraception use Table 3 Ever use of modern contraceptive methods in relation to the demographic characteristics of the participants Demographic Use of modern contraception ORa 95% CIa characteristic Never (n = 429) Ever (n = 680) No. % No. % Woman’s education No formal educationb 51 11.9 52 7.6 1 6 years 64 14.9 67 9.9 1.03 0.61–1.72 9 years 106 24.7 186 27.4 1.72 1.09–2.71 12 years 89 20.7 173 25.4 1.91 1.20–3.03 > 12 years 119 27.7 202 29.7 1.66 1.06–2.61 Husband’s education No formal educationb 35 8.2 29 4.3 1 6 years 78 18.2 83 12.2 1.28 0.72–2.30 9 years 125 29.1 229 33.7 2.21 1.29–3.79 12 years 113 26.3 205 30.1 2.19 1.27–3.77 More than 12 years 78 18.2 134 19.7 2.07 1.18–3.65 Husband’s occupation Professional & semi- professional 107 24.9 198 29.1 1.24 0.94–1.63 Otherb,c 322 75.1 482 70.9 1 Woman’ work status during marriage Not workingb 320 74.6 489 71.9 1 Working 109 25.4 191 28.1 1.15 0.87–1.51 Mean (SD) Range 95% CI Woman’s age (years) Never user 31.45 (7.595) 19–49 30.73–32.17 Ever user 33.07 (6.701) 18–49 32.56–33.57 Duration of marriage (years) Never user 9.85 (7.876) 1–35 9.10–10.59 Ever user 11.85 (6.992) 1–34 11.32–12.38 No. children surviving Never user 3.42 (2.512) 1–13 3.18–3.66 Ever user 4.25 (2.266) 1–13 4.08–4.42 aOdds ratio (OR) and 95% confidence interval (CI) are computed from univariate logistic regression analysis. bReference category. cIncludes all other occupational categories. SD = standard deviation. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM550 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 551 was shorter in segments in which women experienced the loss of a child, the risk of discontinuation of contraception was not statistically significant (Table 4). There was a statistically significant dif- ference in the 2-year cumulative proportion of continuation of contraception in relation to the number and sex of surviving chil- Table 4 Mean duration of contraception use in relation to women’s characteristics, child’s variables and method of contraception in the segment of use Variable No. of % Mean SE 95% CI Hazard 95% CI segments duration ratio (n = 1389) (months) Woman’s age (years) < 25a 420 30.2 25.1 1.02 23.05–27.07 1.00 25–35 872 62.8 42.2 2.07 38.18–46.30 0.66 0.58–0.75 > 35 97 7.0 87.5 8.03 71.74–103.21 0.25 0.17–0.35 Duration of marriage (years) 1–a 630 45.4 24.8 0.91 22.98–26.56 1.00 5– 662 47.7 49.2 2.67 43.92–54.39 0.56 0.49–0.64 ≥ 15 97 6.9 86.4 8.86 69.03–103.78 0.25 0.18–0.36 Woman’s employment status Not workinga 1037 74.7 39.9 1.82 36.36–43.51 1.00 Working 352 25.3 40.1 2.80 34.62–45.58 0.97 0.84–1.12 No. of children surviving 1a 221 15.9 20.2 1.30 17.67–22.76 1.00 2 337 24.3 27.9 1.24 25.45–30.32 0.69 0.57–0.83 3 295 21.2 36.5 2.41 31.78–41.24 0.56 0.46–0.68 ≥ 4 536 38.6 57.3 3.42 50.55–63.96 0.39 0.32–0.46 Children’s sex Only girls 207 14.9 25.1 2.59 20.02–30.19 1.79 1.51–2.13 Only boys 294 21.2 28.0 1.57 24.94–31.08 1.51 1.29–1.76 Boys and girlsa 888 63.9 45.9 1.98 42.02–49.77 1.00 Child death Noa 1379 99.3 40.6 1.64 37.35–43.78 1.00 Yes 10 0.7 23.5 4.44 14.79–32.20 1.42 0.74–2.76 Type of contraception IUDa 583 41.9 51.9 2.90 46.20–57.58 1.00 Pills 515 37.1 29.6 1.72 26.26–33.00 1.71 1.48–1.97 Condom 217 15.6 30.8 1.80 27.29–34.35 1.44 1.04–1.99 Injectables & implants 61 4.4 34.0 5.15 23.95–44.12 1.44 1.19–1.74 Local spermicidals 13 0.9 18.7 5.10 8.65–28.66 2.45 1.39–4.39 aReference category. SE = standard error. CI = confidence interval. IUD = intrauterine device. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM551 552 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 dren. The cumulative proportion of contin- uation in segments in which women had only 1 child was 87.8% at 6 months, 41.7% at 12 months and 18.1% at 24 months. The cumulative proportion of con- tinuation of contraception at 6 months, 12 months and 24 months increased with in- crease in the number of surviving children to reach 93.7%, 75.4% and 56.0% respec- tively in segments where the number of Table 5 Probability of 2 years continuation of contraception in relation to women’s characteristics, child’s variables and type of contraceptive method in the segment of use Variable Cumulative probability of continuation Wilcoxon 6 12 18 ≥≥≥≥≥ 24 (Gehan) months months months months statistics Woman’s age (years) < 25 0.8872 0.5538 0.5399 0.2907 74.48 25–35 0.9372 0.6777 0.6627 0.4587 P < 0.0001 ≥ 35 0.9582 0.8054 0.8054 0.7347 Duration of marriage (years) 1– 0.9109 0.5234 0.5140 0.2733 115.65 5– 0.9335 0.7449 0.7254 0.5294 P < 0.0001 ≥ 15 0.9371 0.7974 0.7974 0.7012 Woman’s employment status Not working 0.9154 0.6395 0.6268 0.4215 1.06 Working 0.9476 0.6755 0.6590 0.4342 P = 0.3025 Number of children 1 0.8785 0.4172 0.4069 0.1806 113.31 2 0.9250 0.6138 0.6026 0.3499 P < 0.0001 3 0.9298 0.6701 0.6661 0.4454 ≥ 4 0.9375 0.7537 0.7318 0.5604 Children’s sex Only girls 0.9096 0.4468 0.4410 0.2464 65.64 Only boys 0.9043 0.5906 0.5826 0.3185 P < 0.0001 Boys & girls 0.9331 0.7148 0.6974 0.5018 Child death No 0.9238 0.6484 0.6346 0.4262 0.49 Yes 0.9000 0.6882 0.6882 0.2294 P = 0.4828 Type of contraception IUD 0.9755 0.7793 0.7653 0.5472 101.46 Pills 0.8722 0.5143 0.4959 0.3029 P < 0.0001 Condom 0.9308 0.6564 0.6506 0.3966 Injectables & implants 0.8477 0.5869 0.5869 0.4157 Local spermicidals 0.8462 0.2538 0.2538 0.1692 IUD = intrauterine device. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM552 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 553 surviving children was ≥ 4. In segments in which there were both boys and girls in the family, the cumulative proportion of con- tinuation was highest at 6 months (93.3%), 12 months (71.5%) and 24 months (50.2%) (Table 5). The longest mean duration of contra- ception use was observed in segments in which women opted for an IUD (51.9 months). The risk of discontinuation of contraception was about 1.5 times as high in segments where pills, condoms, injecta- bles or implants were used and 2.5 times as high for local spermicidals (Table 4). Seg- ments of contraception use in the 5 years preceding the survey lasted for a mean du- ration of 60.6 months (SE = 8.3; 95% CI: 44.5–76.9) which is significantly long- er than the 35.1 months for segments that started earlier (SE = 1.4; 95% CI: 32.4– 37.8). The risk of discontinuation of con- traception for older segments was 1.5 times that of segments starting in the 5 years preceding the survey (hazard ratio = 1.5; 95% CI: 1.3–1.7). The cumulative proportion of continua- tion for women using the IUD was 97.5% at 6 months, 77.9% at 12 months and reaching 54.7% at 24 months (Table 5). This was significantly higher than for women using pills (paired Gehan statistics = 91.79; P < 0.0001), condoms (paired Gehan statistics = 17.49; P < 0.0001), in- jectables or implants (paired Gehan statis- tics = 8.11; P = 0.0044) as well as local spermicidals (paired Gehan statistics = 13.31; P = 0.0003). Of the 1389 segments of use, contra- ception was discontinued in 71.3% (990) of these segments. Planning for a pregnan- cy was the most frequently stated reason for discontinuation (75.5%). Experiencing side-effects such as menstrual changes, pelvic inflammation, headache and weight gain or fear of adverse effects on fertility came next (16.1%), followed by unplanned pregnancy resulting from method failure (5.4%). In only 3.2% of segments was dis- continuation related to personal issues such as not feeling comfortable with the method, absence of the husband or husband’s ob- jection for continuation. Discontinuation of contraception because of experiencing side-effects or fear of adverse effects on fertility was more frequently encountered in segments where injectables or implants were used (32.5%) followed by the IUD (19.0%) and pills (17.3%). Contraception failure was most commonly encountered in segments where local spermicidals were used (41.7%) (Table 6). Table 7 portrays the results of the multi- variate Cox regression analysis identifying the independent predictors of duration of contraception use. Considering all signifi- cant predictors, longer duration of use is independently predicted by older age of the woman, longer duration of marriage and greater number of surviving children as well as the use of the IUD as a contracep- tive method. Discussion A steady increase in contraception use has been reported among Jordanian women in the last 12 years [5], although considerable variation does exist between different re- gions. Among women in the central region, the prevalence of current contraception use was 58%. This proportion fell to 54% among women in the northern region and reaches its lowest level, 48%, among women in the southern region. The differ- entials in the use of modern contraceptives followed the same pattern [5]. The rate of current use of modern contraceptives (40.8%) among women in Al-Karak gover- norate indicates that these women lag be- 04 Contraception use fc.pmd 2/1/2006, 1:01 PM553 554 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 hind their counterparts in other regions of the country in this respect. Moreover, this is much lower than the 56% fixed for the year 2000 to achieve safe motherhood from which both the mother and infant benefit equally [4]. On a national level, 81% of women were ever users of modern contraceptives [5]. This rate is much higher than the 61.3% revealed in the current survey. Cou- ples who had had 9 or more years of formal education each were more likely to report ever use of modern contraceptives. Several studies have documented the role of educa- tion in this respect [2,3,11–13]. Education is likely to influence contraception use through its effect on women’s preference for small family size, desire to be gainfully employed and the attainment of higher so- cioeconomic status. In the present survey, reversible mod- ern contraceptives were used in 1389 seg- ments for a median duration of 24 months. It has been observed that Jordanian women tend to persist with contraception: seg- ments of use in the 5 years preceding the survey were significantly longer than earli- er ones. Nevertheless, a third of the cou- ples discontinue within 1 year of accep- tance and about half do so within 2 years. Jordan is no exception in this respect as a study of contraception use in 6 developing countries, Ecuador, Egypt, Indonesia, Mo- rocco, Thailand and Tunisia revealed simi- lar findings [6]. Current contraception use is the net dif- ference between acceptance and discontin- uation. It is in fact a dynamic process, involving the decision to adopt contracep- tion, the selection of the method and over time the decision to continue or discontinue contraception use. The nature of behaviour relating to contraception is complex as it is affected by a large set of factors and shows considerable variation throughout the childbearing period [14]. Contraception practice is mainly gov- erned by women’s reproductive status: the combined impact of age [3,12,15], duration of marriage [11] and number of surviving children [3,12,15]. Surveys conducted in Egypt [16], Pakistan [17] and Bangladesh [18] revealed that women over the age of 30 years consistently maintain higher con- Table 6 Reasons stated for discontinuation of contraception Reason for Type of contraception discontinuation Pills IUD Condom Injectable Local (n = 398) (n = 390) (n = 150) & implant spermicidal (n = 40) (n = 12) No. % No. % No. % No. % No. % Planned pregnancy (n = 747) 292 73.4 294 75.4 131 87.3 25 62.5 5 41.7 Side-effects or fear of adverse effect on fertility (n = 159) 69 17.3 74 19.0 2 1.3 13 32.5 1 8.3 Contraception failure (n = 53) 26 6.5 12 3.1 9 6.0 1 2.5 5 41.7 Personal issue (n = 31) 11 2.8 10 2.6 8 5.3 1 2.5 1 8.3 IUD = intrauterine device. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM554 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 555 tinuation rates. These findings are consis- tent with that of the current survey. Gener- ally, women opt for contraception either to end childbearing or to maintain adequate spacing [11]. It is then expected to observe an ever use of modern contraceptives, longer duration of use and lower probability of discontinuation among older women who have been married for a longer dura- tion as they tend to use contraception to end childbearing. In contrast, younger women who have been married for a short duration may have a tendency to use con- traception for child spacing as they are still in the phase of family formation. Previous studies have indicated the higher likelihood of discontinuation of con- traception among women of low parity [18] and those who had not achieved their desired family size at the start of the seg- ment of use [6]. The vast majority of the women in this survey expressed an ideal preference of 4 or more children. This ex- plains the short duration of use and the higher probability of discontinuation among women who have 3 or fewer surviving children in the segment of use. In fact, Asa- ri suggested that family size preference is apparently more important than preference about sex of children in determining con- traception use [19]. It is true that Jordanian women express a higher preference for sons [5] yet, the duration of contraception use and the likelihood for continuation was almost the same whether there were only sons or only daughters in the family. This finding is in disagreement with previous re- ports which documented the influential role of sons in the initial acceptance and mainte- nance of contraception use [18,20]. Rah- man et al. observed that parental preference is not monotonically son-biased but is rath- er for a balanced composition of sons and daughters [21]. The current survey re- vealed that the representation of both sexes among surviving children was significantly associated with longer duration of contra- ception use and lower probability of dis- Table 7 Independent predictors of duration of contraception use Independent Regression Hazard 95% CI P-value predictor coefficient ratio Woman’s age (years) < 25a 25–35 –0.1420 0.87 0.75–0.98 0.0594 > 35 –0.6821 0.51 0.34–0.76 0.0009 Duration of marriage (years) 1–a 5– –0.3424 0.71 0.59, 0.85 0.0003 ≥ 15 –0.6078 0.54 0.34, 0.88 0.0132 Method Different methodsa IUD –0.3559 0.70 0.61, 0.80 < 0.0001 Number of children –0.0588 0.94 0.89, 0.99 0.0470 aReference category. CI = confidence interval. IUD = intrauterine device. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM555 556 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 continuation. It is not unlikely that women who have both boys and girls are also those who have a larger number of surviving children. Actually, the effect of sex compo- sition of surviving children was eliminated when the number of surviving children was considered. Chowdhury, Fauveau and Aziz and Rah- man pointed out the negative effect of in- fant mortality on the initial acceptance and continuation of contraception use [18,22]. In the present study, segments in which women experienced the loss of a child were relatively short with high probability of discontinuation; this was not, however, statistically significant owing to the very few events reported. The specific contraception method that women use varies substantially from coun- try to country, but IUDs, pills and injecta- bles are the most widely used methods by women in developing countries [3]. The current survey as well as a previous one [5] pointed to the high popularity of IUDs among Jordanian women. For properly screened women, the IUD is an excellent contraceptive choice as it is safe and effec- tive [6]. This survey revealed that the IUD is associated with the longest duration of use and the highest probability of continua- tion at 2 years. A high rate of continuation among IUD users has been reported in pre- vious surveys [5,6,23,24]. It has been pos- tulated that women’s fertility intentions govern their choice of method [19]. Wom- en who are highly motivated to avoid preg- nancy and those who wish to end childbearing are more likely to opt for an IUD [15]. Also, IUD discontinuation re- quires a conscious decision and a clinic procedure [6]. Generally, methods not af- fected by women’s compliance such as IUDs, injectables and implants are charac- terized by high rate of continuation [25] and lower probability of failure [5,26]. In this survey, method failure was reported in nearly 4% of segments, being lowest for IUDs, injectables and implants. The main reason given for method dis- continuation was planned pregnancy. This was expected as in the majority of seg- ments of contraception use the women were below the age of 30 and had 3 or few- er children. Besides planned pregnancy, side-effects and health concerns played an important role in discontinuation of contra- ception among Jordanian women [5,26] and in women elsewhere [6,16,27]. This reason was associated with the highest rate of discontinuation within the first year of use. In contrast to a study in Egypt which reported high frequency of side-effects among pill users, prompting discontinua- tion [16], this survey identified the highest rate of side-effects and concerns about ad- verse effects on fertility in segments in which IUDs, injectables or implants were used. This finding indicates that mainte- nance of contraception use does not neces- sarily imply client satisfaction. Health care professionals need to pro- vide counselling regarding contraceptive method before and during use. To improve the rate of continuation, they should dis- cuss possible side-effects and personal concerns with their clients and mitigate any misconceptions related to the selected method. It was pointed out in the Jordan population and family health survey 2002 that 70% of users were informed about side-effects and only 55% were instructed about what to do when they experienced any [5]. In all initial visits, physicians should dedicate more time in obtaining a health his- tory, inquiring into women’s fertility inten- tions in addition to a medical examination in order to recommend the most suitable method. Whenever appropriate, IUDs and injectables should be recommended since 04 Contraception use fc.pmd 2/1/2006, 1:01 PM556 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 557 they are associated with the lowest proba- bility of discontinuation. Methods with known high rates of failure resulting from faulty application should be avoided, partic- ularly for women who intend to end child- bearing and where safe abortion is not acceptable, as is the case in Jordan. Users of pills, condoms and local spermicides should be informed about emergency con- traception and encouraged to use it when- ever the possibility of conception is suspected. In all return visits, inquiry should be made regarding side-effects and satisfaction. Women who fail to attend clin- ics for renewal of supplies should be con- tacted and the reason investigated. Information, education and communication activities should be intensified in the south- ern region of the country, stressing ideal preference and the importance of continua- tion. As fertility is declining in Jordan [5], family planning programmes would profit from a shift in emphasis to reducing dis- continuation [28]. Further research is needed to reveal women’s knowledge and attitude regarding emergency contracep- tion and satisfaction with the service pro- vided. Acknowledgements The author wishes to acknowledge Mu’tah University and the Deanship of Scientific Research for supporting the research and the generous funding that made possible the realization of this study. References 1. Hardee K et al. Reproductive health poli- cies and programs in eight countries: progress since Cairo. International fam- ily planning perspectives, 1999, 25(suppl.):S2–9. 2. Kirk D, Pillet B. Fertility levels, trends, and differentials in sub-Saharan Africa in the 1980s and 1990s. Studies in family plan- ning, 1998, 29(1):1–22. 3. Zlidar VM et al. New survey findings: the reproductive revolution continues. Balti- more, INFO project, Johns Hopkins Bloomberg School of Public Health, 2003. (Population reports, Series M, No. 17). 4. Mother–baby package: a safe mother- hood planning guide. Geneva, World Health Organization, 1994. 5. Jordan population and family health sur- vey 2002. Calverton, Maryland, USA, De- partment of Statistics, Jordan & Macro International Inc., 2003. 6. Ali M, Cleland J. Contraceptive discon- tinuation in six developing countries: a cause-specific analysis. International family planning perspectives, 1995, 21(3):92–7. 7. Grady WR et al. Contraceptive failure and continuation among women in the United States, 1970–75. Studies in family plan- ning, 1993, 14(1):9–19. 8. Singh K et al. Acceptability of Norplant implants for fertility regulation in Singapore. Contraception, 1992, 45(1): 39–47. 9. Youssef RM. Duration and determinants of interbirth interval: community-based survey of women in southern Jordan. Eastern Mediterranean health journal, 2005, 11(4):559–72. 10. Lwanga SK, Lemeshow S. Sample size determination in health studies: a practi- cal manual. Geneva, World Health Orga- nization, 1991. 04 Contraception use fc.pmd 2/1/2006, 1:01 PM557 558 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 11. D’Souza RM. Factors influencing the use of contraception in an urban slum in Karachi, Pakistan. Journal of health and population in developing countries, 2003 (http://www.jhpdc.unc.edu/2003_pa- pers/fpdsz.pdf, accessed 13 September 2004). 12. Mahgoub YM. Socio-economic and de- mographic factors affecting contracep- tion use in Egypt. Egypt population and family planning review, 1994, 28(2): 104–15. 13. Ekani-Bessala MM et al. Prevalence and determinants of current contraceptive method use in a palm oil company in Cameroon. Contraception, 1998, 58(1): 29–34. 14. No authors listed. The dynamics of con- traceptive use in developing countries. Pt 1. Progress in human reproduction re- search, 1991, 18:1–7. 15. Oddens BJ, Lehert P. Determinants of contraceptive use among women of re- productive age in Great Britain and Ger- many. I: Demographic factors. Journal of biosocial science, 1997, 29(4):415–35. 16. Mahdy NH, El-Zeiny NA. Probability of contraceptive discontinuation and its de- terminants. Eastern Mediterranean health journal, 1999, 5(3):526–39. 17. Rehan N, Inayatullah A, Chaudhary I. Ef- ficacy and continuation rates of Norplant in Pakistan. Contraception, 1999, 60(1): 39–43. 18. Chowdhury AI, Fauveau V, Aziz KM. Ef- fect of child survival on contraception use in Bangladesh. Journal of biosocial science, 1992, 24(4):427–32. 19. Asari VG. Determinants of contraceptive use in Kerala: the case of son/daughter preference. Journal of family welfare, 1994, 40(3):19–25. 20. Leone T, Matthews Z, Dalla Zuanna G. Impact and determinants of sex prefer- ence in Nepal. International family plan- ning perspectives, 2003, 29(2):69–75. 21. Rahman M et al. Contraceptive use in Matlab, Bangladesh: the role of gender preference. Studies in family planning, 1992, 23(4):229–42. 22. Rahman M. The effect of child mortality on fertility regulation in rural Bangla- desh. Studies in family planning, 1998, 29(3):268–81. 23. Mezimeche N, Boutsen M. Enquête sur la continuité de la contraception à Alger [Survey on the continuity of contracep- tion in Algiers]. Bulletin trimestriel du planning familial, 1993, 1(3):2–4. 24. Newton J. Contraceptives: regional per- spectives, issues, and unmet needs— the European perspective. International journal of gynaecology and obstetrics, 1998, 62 (suppl. 1):S25–30. 25. Pinter B. Continuation and compliance of contraceptive use. European journal of contraception & reproductive health care, 2002, 7(3):178–83. 26. Albsou-Younes AM, Saleh F, El Khateeb W. Perception of efficacy and safety as determinants for use and discontinua- tion of birth control methods in Muslim Jordanian women. European journal of contraception & reproductive health care, 2003, 8(3):156–61. 27. Rivera R, Chen-Mok M, McMullen S. Analysis of client characteristics that may affect early discontinuation of the Tcu-380A IUD. Contraception, 1999, 60 (3):155–60. 28. Blanc AK, Curtis SL, Croft TN. Monitoring contraceptive continuation: links to fertil- ity outcome and quality of care. 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