Demand and Supply Side Factors Associated with the Use of Contraceptive Methods in Pakistan: A Contemplative Study of Demographic and Health Surveys, 1990-2018

Background: A remarkable decline in fertility rates has been observed in many countries, with a primary determinant being an increase in the use of contraceptives. Therefore, this study aims to assess the effect of demand and supply-side factors associated with the use of contraceptive measures in Pakistan. Method: Secondary data analysis of four data series of the Pakistan Demographic and Health Surveys (PDHS 1990–91, 2006–07, 2012–13, and 2017–18) were used. The data includes ever-married women aged 15–49 years who had given birth in the previous ve years and participated in the family-planning module of the PDHS. A total number of 25,318 women were included in the analysis. Data was analysed by investigating the associations between independent variables (demand and supply-side factors) and the use of contraceptive measures through unadjusted Odds Ratios (OR) and adjusted OR (AOR). Results: A majority of the women were illiterate and not in employment. There was an increase in the number of women who did not use contraceptive methods in rural areas over time. Among demand-side factors, the results indicated that, in 2012–13, women without media exposure were less likely to use contraceptives (OR 0.396, 95% CI 0.353–0.442), and the trend remains almost constant for 2017–18 (OR 0.432, 95% CI 0.391– 0.477). These ndings change slightly in the adjusted analysis (AOR 0.664, 95% CI 0.562–0.784) in 2012–13 and (AOR 0.654, 95% CI 0.483–0.885) in 2017–18; however, they still show a lower likelihood of using contraceptives without media exposure. Among supply-side factors, the results indicated that absence of transport (2012–13) and limited visits by family-planning workers over the previous 12 months (2006–07, 2012–13, and 2017–18) remained signicant factors for not using contraceptive methods. Conclusion: The results of the study indicate that certain demand and supply-side factors are associated with the use of contraceptive measures in Pakistan. It highlights the need for the provision of family-planning


Plain English Summary
Globally, the use of contraceptives has increased. However, the use of contraceptives is not equally distributed.
Several factors drive the demand for contraceptive methods, including the reproductive age of women, knowledge, awareness, and attitudes towards the use of contraceptive methods. If there is demand, then there is a compulsion to provide a supply as well. Supply-side factors include the provision of family-planning resources, health facilities, and the availability of transport as an indicator of the infrastructure. Within this study, we focussed on factors which are associated with the use of contraceptives in Pakistan. The study is based on four large survey within the time frame from 1990 to 2018, to be able to represent changes over time. Data was collected from women at the reproductive age (15-49 years) who had given birth in the previous ve years before data collection. The results indicate that women without media exposure were less likely to use contraceptives. The absence of transport availabilities and limited visits by family-planning workers over the previous 12 months were signi cant factors for not using contraceptive methods. This highlights the need for the provision of family-planning resources and further structural factors, particularly in remote areas.
Background Page 3/21 Over the last twenty years, a remarkable decline in global fertility rates has been observed. A primary determinant of this decline is an increase in the use of contraceptives in many countries (1)(2)(3). Despite this overall increase, it is unevenly distributed, with lower use in developing nations (4)(5).
Pakistan is the sixth most populated country in the world and has one of the highest fertility rates in the South Asian region. The contraceptive prevalence rate increased from 4-28% between 1991 and 2000, but thereafter the rate of increase has diminished, with prevalence only rising from 30% in 2006 to 35% in 2012-13 (6). High fertility is an effect of low use of contraceptives, which also hampers socio-economic development, as indicated in the inverse relationship between high population and low economic indicators (7)(8)(9). Although family-planning programmes were launched in Pakistan during the 1990s, effective implementation remains challenging due to multiple socio-cultural, economic and political factors, together with unmet needs, a preference for male children, supply issues and the strong patriarchal structure (10).
The low use of contraceptives and associated hindrances has been explained by different studies examining various dimensions. A few studies have identi ed the socio-cultural reasons related to the use of contraceptives, and others have explained it in terms of geographical and nancial inhibitions limiting access to family-planning services, limited availability, and associated side effects that damage a mother's health (11)(12)(13). Other barriers include the quality of services and legal restrictions. Network barriers, such as misconceptions and myths associated with contraceptive use, and the need for approval from husband and family to adopt any contraceptive measures, are other contextual factors. Furthermore, the status of women, their independence in decision-making, nancial autonomy, religious inspirations, and cultural beliefs that high fertility is good are the factors that affect the use of contraceptives in the developing world (14)(15)(16).
Several factors drive the demand for contraceptive methods, including the reproductive age of women, knowledge, awareness, and attitudes towards the use of contraceptive methods. If there is demand, then there is a compulsion to provide a supply as well. Supply-side factors include the provision of family-planning resources, health facilities, and the availability of transport as an indicator of the infrastructure. A number of intrusions are required to balance between the demand and supply side in the use of contraceptive measures. The failure to provide a supply to women may affect various female health issues, including unintended pregnancies and abortions (17)(18).
In Pakistan, the in uence of husbands and mothers-in-law in family matters is so strong that they are considered a central decision-making authority in family-planning decisions as well (19). The literature suggests that women's own knowledge, their perception of their husband's reaction to the use of contraceptives and their acceptability are the basic determinants of contraceptive use (20)(21). Another important indicator in this regard is violence. A meta-analysis revealed that women who face intimate partner violence are more likely not to use contraceptive methods (22). Similar ndings have been described by Teitelman et al. (23): Young women who do not experience intimate partner violence are more consistent in their use of condoms than abused women. Supporting this, Fanslow et al. (24) explained that the use of condoms and other contraceptives is low among those women who experience violence from their partners because it further increases the risk of emotional and verbal abuse.
The majority of family-planning services are supplied in urban localities, and the provision and supply of such services is insu cient in rural areas. Access to information and low-cost supply-side services facilitates women to continue their use of contraceptives. Supply-side services include clinic location, well-equipped and trained staff, convenient opening hours, low fees and easy availability of condoms and pills (25). A client's satisfaction and long-term acceptance of the use of contraceptives has an impact on their decision about whether to go on with the services. Many studies have argued that the failure of family-planning programmes in Pakistan is mainly due to the inadequate and limited supply of services (26).
Although previous research has identi ed several predictors for contraceptive use in Pakistan, a holistic view and the inclusion of a trend analysis of contraceptive use is missing. Therefore, the present study uses data from four Demographic and Health Surveys in Pakistan in order to gain a clear understanding of the determinants for the use of contraceptives, allowing us to explore how demand and supply-side factors and sociodemographic characteristics have in uenced the use of contraceptives over the years in Pakistan.

Methods
We used a data-set series of four nationally representative Pakistan Demographic Health Surveys Instrumentation and data classi cation Current use of contraceptive methods was de ned as the dependent variable, including traditional methods (periodic abstinence [rhythm], withdrawal, and abstinence) and modern methods (pill, intrauterine devices, injections, diaphragm, condom, female or male sterilisation, implants, female condom, foam/jelly, and lactational amenorrhea).
Women's socio-demographic, demand and supply-side factors were considered as independent variables.
Women's socio-demographic factors were: age, type of residence (urban vs. rural), region, ethnicity, education (no education, primary, secondary, higher), women's occupation/employment status (not working, unskilled employment [sales, household domestic, unskilled manual], skilled employment [sales, agriculture selfemployed, agriculture employees, skilled manual, clerical], and professional [professional/technical/managerial services]). The wealth index of women was calculated through quintiles and categorised into three categories (poor, middle, rich) for this analysis.
Among the demand-side factors, questions regarding media exposure, desire for children, number of living sons, number of living daughters, history of intimate partner violence, decisional autonomy, permission to attend medical or health facilities, as well as unwillingness to go alone and concerns about going to female health providers were included. Exposure to any source of information (TV, radio, newspaper) was computed and recoded as overall media exposure. Desire for more children was categorised into two categories: Either "No" (wanted no more children, sterilised [respondent or partner], declared infecund) or "Yes" (wanted within or after the next two years, unsure about timing, undecided). Intimate partner violence was part of PDHS 2012-13 in which emotional, physical, and sexual violence were included. Women were asked if they had ever faced any humiliating attitude from their husband, physical violence such as being beaten, having their arms twisted, hair pulled or threatened with a harmful weapon such as a knife or gun, or sexual violence from their husbands, which includes forced sex. All forms of violence were coded as binary categories and, thereafter, combined as overall violence by intimate partners. In women's decisional autonomy, their independent or joint control of income, purchases, healthcare decisions, and visits to relatives were included. Each variable was rst coded into two categories: "Yes" if the respondent contributed to any type of decision either individually or jointly, and "No" if she did not participate in any decision-making. Then all types were combined into overall autonomy as women who have any type of autonomy and those who do not have autonomy. The responses to questions regarding permission to attend medical or health facilities were categorised into two categories ("Big problem" and "Not a big problem"). Similarly, going alone to get medical treatment was categorised into the same two categories. The number of living sons has also been taken as a variable to determine whether use of contraceptives is contingent upon son preference. It has been coded as "No living son", "1-3", "4-6", and "7-10".
Among supply-side factors, the facilitation and provision of governmental and non-governmental familyplanning services was measured through questions about distance to health facilities, transport availability, visits by lady health workers, unmet needs and the availability of contraceptives through different sources. Distance to health facilities and transport availability were categorised as either "Big problem" or "Not a big problem". The sources of family planning were rst categorised into public (government hospitals, familyplanning clinics, lady health workers), private (private hospitals, pharmacies, and clinics), and others (such as shops, friends or relatives, and traditional practitioners). Unmet needs included those for the spacing and limiting of births.

Statistical analysis
Data was analysed using SPSS version 24. Absolute numbers and weighted percentages were obtained through descriptive analysis. The relationship between demographic characteristics, demand and supply-side factors, along with current use and non-use of contraceptives was assessed through the Chi square test (X 2 ) on categorical variables. A p-value of < 0.05 was considered statistically signi cant. Associations between demand and supply-side indicators of non-use of contraceptives were measured using binary logistic regression models to present Odds Ratios (OR). Multivariate analysis was conducted by assessing Adjusted Odds Ratios (AOR) through controlling the demographic variables (age, education, income, wealth, residence). In PDHS 1990-91 and 2017-18, data on ethnicity is missing, so it was not included in the analysis. Furthermore, several variables relating to demand-side factors (media exposure, intimate partner violence, decisional autonomy, permission to attend medical or health facilities, not wanting to go alone for medical help) and supply-side factors (distance to health facility, transport availability, visit by a family-planning worker during the previous 12 months) were not included in the questionnaire in 1990-91 or 2006-07, and therefore were not included in the analysis for these years.

Results
The total sample across all four surveys includes 25,415 ever-married women aged 15-49 years having children under 5 years of age. The mean age of the women was approximately 29 years for each survey.  Table 1).    (Table 2). Table 2 Frequency and weighted percentages of demand and supply side factors of the women who currently use and Demand side factors Association between demand and supply-side factors and nonuse of contraceptives

Demand-side factors
The odds of non-use of contraceptive methods were signi cantly lower among women who reported any source of media exposure in 2012-13 (OR 0.396, 95% CI: 0.353-9.442) and in 2017-18 (OR 0.432, 95% CI 0.391-0.477) compared to those who did not have any media exposure. The odds of not using contraceptive methods were signi cantly higher for respondents who reported a desire for more children in all four waves of data collection. Respondents with decisional autonomy were more likely to use contraceptive methods. Similarly, the likelihood of using contraceptive methods was signi cantly higher among the respondents who had permission to attend medical or health facilities (Table 3). Analysis is adjusted for age of mother, type of residence, region, mothers' education, wealth, and occupation.
Binary logistic results also indicate that the odds of not using contraceptive methods were signi cantly lower among respondents who reported fewer than 7 sons compared to the respondents who reported having 7 or more sons in 1990-91. This association was insigni cant in 2006-07. However, in 2012-13 and 2017-18, the odds of not using contraceptive methods was higher among the respondents who reported 0-6 sons compared to participants with 7 or more (Table 3).

Supply-side factors
The results for supply-side factors also indicate that the odds of not using contraceptive methods were signi cantly lower among respondents who reported distance from a health facility in 2012-13 (OR 0.436, 95%  (Table 3).  (Table 3).

Discussion
The use of contraceptives is considered to be a poverty-reduction mechanism. It is also considered to be a tool to achieve human rights for women in terms of equitable health facilities, allowing decisional autonomy and control over their reproductive rights (31)(32)(33). However, in spite of efforts to increase contraceptive use, high fertility rates and population growth have continued to threaten the socio-economic development of many countries (34). Various interventions have been introduced to address this issue over a signi cant period of time. This study is designed to investigate the effects of various factors associated with birth control. For that reason, this study is based on a trend analysis of four PDHS data collections to determine the trends in demand and supply-side factors associated with the non-use of contraceptives in Pakistan, along with sociodemographic variables.
The study found that socio-demographic factors play a signi cant role in the use of contraceptive measures.
Those who live in rural areas are less likely to use contraceptive measures, with a trend that is increasing over time. These ndings are similar to those of studies conducted by Adebowale et al. (35), who stated that geographical location limits access to family-planning services. Rural residents have less access to health facilities. This trend is the same in this province-wide analysis as in those provinces where health facilities are better and accessibility issues are lower, with a greater prevalence of contraceptives. In Punjab province, a greater use of contraceptives is observed (36).
Comparing results across the years 1990-91, 2006-07, 2012-13 and 2017-18, it is pertinent to note that there is a declining trend in not using contraceptives among illiterate women. The majority of women with a higher level of education are using contraceptive methods and this trend has increased over the years. The ndings con rm the ndings indicated by previous research that higher fertility is mostly associated with a lower level of education (37)(38). Wealth quintile is also signi cantly linked with the ever-use of contraceptive methods.
Those in the poor quintile use contraceptive methods less than those in other quintiles. There is an increasing trend observed in the number of not-working women who have ever used contraceptive methods. Similar ndings appear in a study conducted by Islam et al. (39), which indicates that among unemployed women in Bangladesh the use of contraceptive measures was lower than in employed ones.
A higher prevalence of contraceptive measures is found among women who have more knowledge, awareness, and media exposure (40)(41). Our ndings are consistent with these studies as those women (aged 15-49) who have greater media exposure have more knowledge about contraceptive measures, and among them the use of contraceptives measures is also more likely. Ethnicity is also signi cantly associated with ever-use of contraceptive measures (42). In our study, among different ethnic groups, use of contraceptives was higher among Punjabi women.
The ndings of our study also suggest that those who have a greater desire for children have a lower likelihood of using contraceptive measures (43). This is also associated with the women's decisional autonomy; those women who had more decisional autonomy in their household and health-related decision-making power use contraceptives more than women who do not have autonomy in making decisions (44). Lack of decisionmaking power, discussion of health issues, permission to attend medical or health facilities, and the demand for sons are the socio-cultural factors that also in uence the use of contraceptives (45). Our ndings show that women who see attending health facilities as a big problem and experience pressure to give birth to more sons are less likely to have ever used any method of family planning.
When there is a demand for contraceptives, there is also an obligation to provide the supply. It requires a considerable effort to provide adequate accessibility and supply of contraceptive measures (46). Our ndings show that there is a signi cant association between distance to health facilities and availability of transport with current use of contraceptive measures. Among those who have access to healthcare facilities, have transport facilities, and are being visited by family-planning workers, the use of contraceptive measures is more likely.

Limitations
This study involves the data series provided by four PDHSs, in which a lack of uniformity was found, because not all variables were included in all data sets, leading to missing variables in PDHS 1990-91 and 2006-07.
Lack of uniformity was also found in the variables of ethnicity, wealth quintile, and women's occupation in three sets of data. Therefore, the analysis remains limited to one or two data sets. Due to the cross-sectional study design, causal relationships cannot be determined. A risk of bias is pertinent because information was gained through self-reported measures.

Conclusion
This study concludes that, although the use of contraceptive methods has increased over time, the rate of growth is inconsistent. Several socio-demographic characteristics and demand-side factors, such as media exposure, a desire for more children and the decisional autonomy of mothers, are associated with the use of contraceptives. Among these factors, differences are evident in rural, illiterate, and non-working mothers.
Access to family-planning resources, the availability of transport, a supply of contraceptives in the locality, and unmet needs are the associated supply-side factors found in this study. Overall, the results highlight a need to provide affordable family-planning services to women near their homes, especially for disadvantaged subgroups of women. Targeted community mobilisation and increasing educational levels among mothers in rural communities can further increase awareness about and use of contraceptives. The study is based on a secondary data analysis based on data from PDHSs 1990-91, 2006-07, 2012-13, and 2017-18, a publicly available dataset. Therefore, an ethical approval is not required. Consent to participate has been obtained before data collection.

Consent for publication
Not applicable Availability of data and materials Secondary data, available from the Demographic and Health Survey programme.

Competing interests
The authors declare that they have no competing interests.

Funding
The study received no funding.