Unmet need for contraception among married women in the Kyrgyz Republic from the 2006, 2014 and 2018 Multiple Indicator Cluster Survey: A cross- sectional study

doi:10.21203/rs.3.rs-3577015/v1

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Research Article

Unmet need for contraception among married women in the Kyrgyz Republic from the 2006, 2014 and 2018 Multiple Indicator Cluster Survey: A cross- sectional study

https://doi.org/10.21203/rs.3.rs-3577015/v1

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published 08 Apr, 2024

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Background

This study aims to investigate the prevalence of an unmet need for contraception from 2006 to 2018, and examine the factors associated with an unmet need for contraception among married women over the course of 12 years in the Kyrgyz Republic.

Methods

This study employed three datasets from the Multiple Indicator Cluster Survey 2006, 2014, and 2018. There were 9,229 women aged 15–49 who were married and fecund included in this study. Logistic regression was employed to estimate the relationship of an unmet need for contraception with other factors. A P value < 0.05 was set as statistically significant.

Results

The prevalence of an unmet need for contraception was 19.9% in 2006, 20.4% in 2014, and 22.5% in 2018. Intrauterine devices were the prominent contraceptive method of usage among Kyrgyz women, but the trend of usage drastically declined over time. From 2006 to 2018, factors associated with unmet need for contraception included women’s age, area of residence, mother tongue of household head, age of husband, and number of children ever born.

Conclusion

The unmet need for contraception among married Kyrgyz women slightly increased, and the trend of contraception usage declined from 2006 to 2018. Sexual health education for young people and youth-friendly services should be promoted. An effective and reliable supply chain, including financing, forecasting, and procurement for contraception commodities, should be prioritized and strengthened. Regular supportive supervision visits are essential to improve the knowledge and skills of healthcare providers, and to sustain intrauterine device service as a contraceptive choice for Kyrgyz women.

unmet need

contraception

family planning

Kyrgyzstan

Kyrgyz Republic

Multiple Cluster Indicator Survey

Contraception is one of the cost-effective investments in reproductive health and rights, which women and girls can exercise their choice on pregnancy. (1) Globally, it was estimated that approximately 172 million women want to avoid pregnancies but do not use any contraception methods. (1) An unmet need for contraception refers to a fecund and sexually active woman who desires to delay or limit her pregnancy but does not use any methods of contraception. (2) The unmet need for contraception puts women at risk of unintended pregnancies. Unintended pregnancy refers to women whose pregnancies are not planned, which can be either mistimed or unwanted. (1) In many cultures and countries, it is believed that unintended pregnancy only occurs in unmarried women and is associated with a stigma about becoming pregnant outside marriage. In fact, all fecund and sexually active women and girls can have unintended pregnancies in their lifetime. (1)

Unintended pregnancy is a public health concern because it is associated with maternal morbidity and mortality. (3, 4) A global study conducted in 2020 revealed that approximately 121 million women experienced unintended pregnancies every year. (5) While some unintended pregnancies were later welcomed, 61% of unintended pregnancies were unwanted and ended in abortion. (5) Particularly in countries where abortion is banned or illegal, unsafe abortion is often a preferrable choice for unintended pregnant women. (5) Ensuring that women and girls of reproductive age can exercise their right to reproductive health is one of the global Sustainable Development Goal (SDG) indicators. (1, 4) Therefore, many countries have committed to the global family planning campaign to warrant their progress toward SDGs in 2030 and ensure that women and girls can practice their right to contraception with appropriate and supportive environments, including legislation, policy, supply chains, and service provisions. (6)

The Kyrgyz Republic (Kyrgyzstan) is located in Central Asia. To our knowledge, information on contraception in Kyrgyzstan was first reported in 1998 after the country gained independence. (7) The family planning program was introduced to intervene in the high maternal mortality and infant mortality in the country. (7) In 2015, the maternal mortality rate in Kyrgyzstan remained the highest in the WHO Eastern European region (76 per 100,000 live births). (8) Although the program had success in reducing maternal mortality, many Kyrgyz women still had an unmet need for contraception. According to the Guttmacher Institute in 2022, approximately 245,000 Kyrgyz women became pregnant yearly. Of all pregnancies, 63,100 pregnancies were unintended, and 79% of unintended pregnancies ended in abortion. (9) Despite numerous efforts to improve the unmet need for contraception in Kyrgyzstan, there is limited knowledge on how much the work on contraception has improved over time, and what determinants hamper the country’s progression toward commitments with Family Planning 2030 and SDGs in Kyrgyzstan. (10) This study aims to investigate the prevalence of an unmet need for contraception from 2006 to 2018, and examine the factors associated with an unmet need for contraception among married women over the course of 12 years in Kyrgyzstan.

Multiple Indicator Cluster Survey

The Kyrgyzstan Multiple Indicator Cluster Survey (MICS) is a national survey involving women aged 15–49 years from nine regions, including Batkek, Jalal-Abad, Issyk-Kul, Naryn, Osh, Talas, Chui, Bishkek city, and Osh city. It is designed to provide representative information for a large number of indicators, as part of the Global MICS Programme. The surveys were approved by the Ethics Committee of the Ministry of Health of Kyrgyzstan. The MICS in these three survey years were carried out by the National Statistical Committee of Kyrgyz Republic with technical support from the United Nations Children’s Fund (UNICEF). A two-stage sampling technique is employed as sampling scheme. In the first stage, the urban-rural level of each region was identified as the main sampling strata. A specified number of clusters is allocated for each area within each stratum. Then, the clusters were drawn systematically with the probability proportional to size at the first sampling stage. After that, lists of households within each cluster were prepared. In the second stage, households were drawn systematically and included in the survey. Sample weight was used for computation and reporting purposes to ensure the accuracy and representativeness of the sample results of all strata. (11–13)

Unmet need for contraception

According to the Demographic and Health Surveys Programme, women with an unmet need for contraception refers to the condition in which fecund or sexually active women do not use contraception to fulfil their fertility needs. (2) An unmet need for contraception is subdivided into two groups for reporting purposes as follows: 1) an unmet need for limiting which refers to women who did not want any more children but did not use contraception; 2) an unmet need for spacing that refers to women who wanted to delay pregnancy for more than two years but did not use any contraception methods. (14) In contrast, women with a met need for contraception refers to: 1) women who want to become pregnant within two years and do not use any contraception; and 2) women who say they want to delay pregnancy for more than two years or say they do not want any more children and use contraception. (14)

Study design and participants

This study employed three datasets from MICS 2006, 2014, and 2018, because the same questionnaire related to contraception was used during these times. (11–13) The number of women enrolled in the MICS surveys were 6,973 in 2006, 6,854 in 2014, and 5,742 in 2018. All women aged 15–49 years old who were currently married and in-union, and fecund were included in this study. Women whose marital status was single, divorced, or widowed, who were postmenopausal, had a hysterectomy, had never menstruated, did not use any contraception but did not have childbirth in the five years preceding the survey, and who answered ‘cannot get pregnant’ were excluded from the study. (14) Additionally, women who answered ‘last period was before the last pregnancy and last pregnancy was five years prior to the survey’, and women who had missing values on ‘wantedness of future child’ were also excluded from this study. Ultimately, a total of 9,229 women were included in this study: 3,287 women in 2006, 3,095 women in 2014, and 2,847 women in 2018.

Figure 1. Flowchart of study inclusion and exclusion criteria (Westoff Model, 2012)

Study variables

The outcome variable was an unmet need for contraception. An unmet need for contraception derived from four questions. For pregnant women or postpartum amenorrhea women, if a woman responded that the current pregnancy or the last infant was unwanted or mistimed, they were grouped as having an unmet need for contraception. If the pregnancy/infant was wanted, they were grouped into women with a met need for contraception. For non-pregnant or non-postpartum amenorrheic women, three questions were employed, including the question on current contraception usage, wantedness of future child, and timing of future child if wanted. All non-postpartum amenorrhea women who used contraception at the time of the survey were in the met-need group for contraception. With non-postpartum amenorrhea women who did not use contraception at the time of survey, two probe questions about wantedness of future child and timing of future child were employed to determine the status of met/unmet need for contraception. Non-postpartum amenorrhea women who did not decide on the timing for a future child, who wanted a future child in more than two years, and who did not want any more child but did not use any contraception were grouped as ‘unmet need for contraception’. In contrast, women who did not use any contraception but wanted a future child immediately or in less than two years were grouped as having a met need for contraception. (14) The unmet need for contraception was subdivided into two categories, including an unmet need for limiting and an unmet need for spacing. A met-need for contraception was coded as 0, while an unmet need for contraception was coded as 1.

The independent variables included the following: 1) Sociodemographic information (women’s age, education, area of residence, region, mother tongue of household head, and wealth index quintiles). 2) Information regarding reproductive health (age of husband, number of children ever born, and type of contraception use). 3) Attitudes toward domestic violence (DV) of women in this study. Women’s age was divided into four groups (15–24, 25–34, 35–44, and 45–49 years old). Women’s education was composed of lower secondary education or lower, high school, and higher education or higher. Area of residence was divided into urban and rural. Region was derived from the question on oblast. Issyk-kul, Naryn, Talas, Chui, and Bishkek C were grouped as North. Batken, Jalal-Abad, Osh, and Osh C were grouped as South. There were three groups for the mother tongue of the household head (Kyrgyz, Russian, and others). Wealth index quintiles had five categories: poorest, second, middle, fourth, and richest. The age of the husband had four groups (15–24, 25–34, 35–44 and ≥ 45 years old). The number of children ever born was divided into four groups (0, 1, 2 and ≥ 3 children). The types of contraception used among non-pregnant women and non-postpartum amenorrhea women were divided into three groups (modern contraception, traditional contraception, and no methods). Attitudes toward DV had five questions: beating wife is justified if she goes without telling (yes/no), beating wife is justified if she neglects children (yes/no), beating wife is justified if she argues with husband (yes/no), beating wife is justified if she refuses sex (yes/no), and beating wife is justified if she burns food (yes/no). Women who answered ‘no’ to all DV questions were grouped as ‘DV completely unacceptable’. In contrast, women who answered ‘yes’ to all DV questions were grouped as ‘DV completely acceptable’; otherwise, they were grouped as ‘DV somewhat acceptable’.

Statistical analysis

The analysis was performed using Statistical Package for the Social Sciences (SPSS) version 29.0 (IBM SPSS Inc.). Sampling weights were included in all analyses of MICS 2006, 2014, and 2018. Logistic regression was employed to estimate the relationship of unmet need for contraception with other factors. A P value < 0.05 was set as statistically significant.

Ethical approval and consent

This study employed secondary data from MICS. All data were anonymous and available online. (15) Approval to access MICS data was granted by UNICEF. Since the study used anonymous data, ethical approval for this study was waived.

Table 1 shows the sociodemographic characteristics of Kyrgyz women. Most women were aged 25–34 years old (44.3%), had secondary education (51.2%), lived in rural areas (63.6%), and their mother tongue was Kyrgyz (68.8%). The proportion of women aged 15–24 years who were married, fecund, and sexually active slightly decreased from 22.8% (in 2006) to 20.2% (in 2018). In contrast, the proportion of women aged 25–34 years who were married, fecund and sexually active slightly increased from 43.1% (in 2006) to 45.9% (in 2018). The proportion of women whose household head spoke Russian and other languages gradually decreased over time. On the other hand, Kyrgyz ethnicity increased by 12.9% from 2006 to 2018.

Table 1

– Sociodemographic characteristics of married Kyrgyz women
		2006 (N = 3287) n (%)	2014 (N = 3095) n (%)	2018 (N = 2847) n (%)	Total (N = 9229) n (%)
Women’s age (years old)
	15–24	748 (22.8)	736 (23.8)	576 (20.2)	2060 (22.3)
	25–34	1416 (43.1)	1366 (44.1)	1306 (45.9)	4088 (44.3)
	35–44	948 (28.8)	836 (27.0)	801 (28.1)	2585 (20.0)
	45–49	175 (5.3)	157 (5.1)	164 (5.8)	496 (5.4)
Women’s education
	Lower secondary school or lower	236 (7.2)	318 (10.3)	299 (10.5)	853 (9.2)
	High school	2273 (69.2)	1372 (44.3)	1083 (38.1)	4728 (51.2)
	Higher education or higher	778 (23.7)	1405 (45.4)	1464 (51.4)	3647 (39.5)
Area of residence
	Urban	1324 (40.3)	1009 (32.6)	1023 (35.9)	3356 (36.4)
	Rural	1963 (59.7)	2086 (67.4)	1823 (64.1)	5872 (63.6)
Region
	North	1697 (51.6)	1509 (48.8)	1418 (49.8)	4624 (50.1)
	South	1590 (48.4)	1585 (51.2)	1428 (50.2)	4603 (49.9)
Mother tongue of household head
	Kyrgyz	2015 (61.3)	2240 (72.4)	2099 (73.8)	6354 (68.8)
	Russian	385 (11.7)	255 (8.2)	159 (5.6)	799 (8.7)
	Uzbek	672 (20.4)	475 (15.3)	463 (16.3)	1610 (17.4)
	Others	216 (6.6)	125 (4.0)	125 (4.4)	466 (5.0)
Wealth index quintiles
	Poorest	634 (19.3)	614 (19.8)	585 (20.5)	1833 (19.9)
	Second	595 (18.1)	627 (20.3)	570 (20.0)	1792 (19.4)
	Middle	652 (19.8)	597 (19.3)	560 (19.7)	1809 (19.6)
	Fourth	671 (20.4)	610 (19.7)	595 (20.9)	1876 (20.3)
	Richest	735 (22.4)	648 (20.9)	537 (18.9)	1920 (20.8)

[Table 1 inserts here]

Table 2 shows information regarding reproductive health and attitudes toward DV. Almost half of the women had husbands/partners aged 25–34 years old (44.5%). The majority of Kyrgyz women had three children or more, and the proportion increased from 47.2% in 2006 to 53.6% in 2018. Overall, most women had a met need for contraception (79.2%), but the trend of a met need for contraception gradually declined over time. While the number of women who had an unmet need for limiting slightly decreased, the proportion of women who had an unmet need for spacing increased over time (from 12.0% in 2006 to 16.5% in 2018). The trend in modern contraception usage among non-pregnant women and non-postpartum amenorrhea women declined from 62.1% (in 2006) to 54.7% (in 2018). In contrast, the proportion of women who did not use any contraception methods increased from 34.2% (2006) to 42.4% (2018). Regarding attitudes toward DV, the proportion of women who completely unaccepted domestic violence increased by 14% over the 12 years of the survey.

Table 2

Information regarding reproductive health among married Kyrgyz women
		2006 (N = 3287) n (%)	2014 (N = 3095) n (%)	2018 (N = 2847) n (%)	Total (N = 9229) n (%)
Age of husband/partner (years old)
	15–24	275 (8.4)	234 (7.6)	158 (5.6)	667 (7.2)
	25–34	1430 (43.5)	1401 (45.3)	1271 (44.7)	4102 (44.5)
	35–44	1131 (34.4)	1043 (33.7)	976 (34.3)	3150 (34.1)
	≥ 45	452 (13.7)	417 (13.5)	440 (15.5)	1309 (14.2)
Number of children ever born
	0	244 (7.4)	263 (8.5)	205 (7.2)	712 (7.7)
	1	684 (20.8)	525 (17.0)	407 (14.3)	1616 (17.5)
	2	809 (24.6)	793 (25.6)	709 (24.9)	2311 (25.0)
	≥ 3	1550 (47.2)	1514 (48.9)	1526 (53.6)	4590 (49.7)
Need for contraception
	Met need	2634 (80.1)	2466 (79.7)	2207 (77.5)	7307 (79.2)
	Unmet need for spacing	394 (12.0)	472 (15.3)	469 (16.5)	1335 (14.5)
	Unmet need for limiting	259 (7.9)	157 (5.1)	171 (6.0)	587 (6.4)
Type of contraception used among non-pregnant and non-postpartum amenorrhea women (N = 8271)^*
	Modern contraception	1862 (62.1)	1512 (55.9)	1405 (54.7)	4779 (57.8)
	Traditional contraception	110 (3.7)	109 (4.0)	73 (2.8)	292 (3.5)
	No methods	1027 (34.2)	1083 (40.1)	1090 (42.4)	3200 (38.7)
Beating wife is justified if she goes without telling
	No	2425 (73.8)	2471 (79.8)	2321 (81.5)	7217 (78.2)
	Yes	862 (26.2)	624 (20.2)	526 (18.5)	2012 (21.8)
Beating wife is justified if she neglects children
	No	2390 (72.7)	2232 (72.1)	2096 (73.6)	6718 (72.8)
	Yes	897 (27.3)	863 (27.9)	750 (26.4)	2510 (27.2)
Beating wife is justified if she argues with husband
	No	2219 (67.5)	2567 (83.0)	2307 (81.0)	7093 (76.9)
	Yes	1068 (32.5)	527 (17.0)	540 (19.0)	2135 (23.1)
Beating wife is justified if she refuses sex
	No	2881 (87.6)	2835 (91.6)	2560 (89.9)	8276 (89.7)
	Yes	406 (12.4)	260 (8.4)	287 (10.1)	953 (10.3)
Beating wife is justified if she burns food
	No	2839 (86.4)	2859 (92.4)	2659 (93.4)	8357 (90.6)
	Yes	448 (13.6)	236 (7.6)	187 (6.6)	871 (9.4)
Attitude toward DV
	DV completely unacceptable	1778 (54.1)	1950 (63.0)	1937 (68.1)	5665 (61.4)
	DV somehow acceptable	1371 (41.7)	1073 (34.7)	806 (28.3)	3250 (35.2)
	DV completely acceptable	138 (4.2)	71 (2.3)	103 (3.6)	312 (3.4)
DV, Domestic violence.
^*958 women were pregnant at the time of the surveys and were not asked about contraception methods. There were 288 pregnant women in 2006, 391 pregnant women in 2014, and 278 pregnant women in 2018.

[Table 2 inserts here]

The distribution of contraception usage among Kyrgyz women is shown in Fig. 2. Intrauterine device (IUD) was the prominent method among Kyrgyz women; however, the trend drastically decreased from 2006 (40.5%) to 2018 (25.8%). While the trends for pills and injection usage also declined, the proportion of male condom use in 2018 was almost double of that in 2006.

Figure 2. Distribution of contraception usage among married Kyrgyz women from 2006, 2014, and 2018.

Table 3 shows the multivariate analysis of factors associated with unmet need for contraception in each survey year and across all three survey years. Across three survey years, factors significantly associated with an unmet need for contraception included women whose household was in the second poorest quintile (AOR = 1.23, 95% CI 1.04–1.44, P < 0.05), women who had one child (AOR = 3.87, 95% CI 2.87–5.22, P < 0.001), two children (AOR = 4.84, 95% CI 3.57–6.55, P < 0.001), and three children or more (AOR = 7.43, 95% CI 5.43–10.17, P < 0.001), compared to women whose household was in the poorest quintile and had no children. In contrast, women whom aged 25–34 years old (AOR = 0.60, 95%CI 0.51–0.71, P < 0.001), aged 35–44 years old (AOR = 0.36, 95%CI 0.28–0.46, P < 0.001), aged 45–49 years old (AOR = 0.22, 95%CI 0.15–0.33, P < 0.001), women who lived in a rural area (AOR = 0.82, 95%CI 0.71–0.94, P < 0.01), women whose head of household spoke Russian (AOR = 0.62, 95%CI 0.49–0.79, P < 0.001), Uzbek ethnic (AOR = 0.70, 95%CI 0.59–0.82, P < 0.001), women whose husband was aged 35–44 years (AOR = 0.67, 95%CI 0.51–0.87, P < 0.001) and ≥45 years (AOR = 0.66, 95%CI 0.47–0.92, P < 0.001) were less likely to have unmet need compared to women aged 15–24 years old, lived in an urban area, whose head of household spoke Kyrgyz, and had a husband aged 15–24 years old.

Table 3

Factors associated with unmet need for contraception from MICS 2006, 2014, 2018 and 2006–2018
Variables		MICS 2006	MICS 2014	MICS 2018	MICS 2006–2018
Variables		AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Women’s age (years old)
	15–24	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	25–34	0.62 (0.47–0.81)^***	0.59 (0.44–0.78)^***	0.58 (0.42–0.78)^***	0.60 (0.51–0.71)^***
	35–44	0.40 (0.27–0.60)^***	0.26 (0.17–0.40)^***	0.44 (0.29–0.68)^***	0.36 (0.28–0.46)^***
	45–49	0.35 (0.18–0.69)^**	0.16 (0.08–0.33)^***	0.18 (0.08–0.39)^***	0.22 (0.15–0.33)^***
Women’s education
	Lower secondary school or lower	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	High school	0.67 (0.48–0.94)^*	1.13 (0.80–1.60)	0.97 (0.70–1.34)	0.86 (0.71–1.04)
	Higher education or higher	0.64 (0.43–0.93)^*	1.31 (0.91–1.88)	0.85 (0.61–1.20)	0.88 (0.71–1.07)
Area of residence
	Urban	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	Rural	0.90 (0.71–1.14)	0.71 (0.55–0.91)^**	0.82 (0.63–1.07)	0.82 (0.71–0.94)^**
Region
	North	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	South	1.75 (1.39–2.20)^***	0.89 (0.72–1.11)	0.91 (0.72–1.15)	1.12 (0.99–1.28)
Mother tongue of household head
	Kyrgyz	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	Russian	0.65 (0.46–0.92)^*	0.62 (0.39–0.97)^*	0.53 (0.30–0.92)^*	0.62 (0.49–0.79)^***
	Uzbek	0.57 (0.44–0.74)^***	0.93 (0.69–1.26)	0.72 (0.53–0.98)^*	0.70 (0.59–0.82)^***
	Others	0.77 (0.53–1.13)	0.98 (0.60–1.62)	0.79 (0.50–1.26)	0.85 (0.67–1.09)
Wealth index quintiles
	Poorest	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	Second	1.35 (1.01–1.79)^*	1.21 (0.92–1.61)	1.18 (0.89–1.57)	1.23 (1.04–1.44)^*
	Middle	1.08 (0.81–1.45)	1.09 (0.81–1.46)	1.02 (0.75–1.38)	1.08 (0.92–1.28)
	Fourth	1.21 (0.88–1.67)	0.80 (0.57–1.12)	0.95 (0.68–1.33)	1.00 (0.83–1.20)
	Richest	1.30 (0.89–1.88)	0.95 (0.65–1.38)	0.91 (0.60–1.38)	1.05 (0.84–1.31)
Age of husband/partner (years old)
	15–24	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	25–34	0.89 (0.63–1.25)	0.78 (0.53–1.15)	0.78 (0.50–1.23)	0.82 (0.66–1.02)
	35–44	0.70 (0.46–1.08)	0.60 (0.38–0.97)^*	0.66 (0.39–1.12)	0.67 (0.51–0.87)^**
	≥ 45	0.74 (0.42–1.29)	0.71 (0.39–1.29)	0.51 (0.27–0.96)^*	0.66 (0.47–0.92)^*
Number of children ever born
	0	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	1	2.44 (1.63–3.65)^***	8.58 (4.12–17.89)^***	5.40 (2.77–10.55)^***	3.87 (2.87–5.22)^***
	2	2.24 (1.46–3.44)^***	14.77 (7.10-30.74)^***	7.19 (3.68–14.02)^***	4.84 (3.57–6.55)^***
	≥ 3	2.81 (1.80–4.39)^***	23.45 (11.07–49.69)^***	12.61 (6.37–24.96)^***	7.43 (5.43–10.17)^***
Attitude toward DV
	DV completely unacceptable	1 (reference)	1 (reference)	1 (reference)	1 (reference)
	DV somehow acceptable	0.87 (0.71–1.07)	0.96 (0.79–1.17)	0.87 (0.71–1.08)	0.92 (0.82–1.03)
	DV completely acceptable	1.29 (0.84–1.98)	1.01 (0.55–1.85)	1.30 (0.79–2.12)	1.28 (0.97–1.68)
MICS, Multiple cluster indicator survey; AOR, Adjusted odds ratio; CI, Confidence interval; DV, Domestic violence

[Table 3 inserts here]

To our knowledge, this was the first study on the determinants of unmet need on contraception in Kyrgyzstan. The overall prevalence of an unmet need for contraception slightly increased from 19.9% in 2006 to 22.5% in 2018. While the unmet need for limiting decreased by 1.9% over 12 years, the unmet need for spacing increased 4.5% from 2006 to 2018. The increase in unmet need was consistent with an increased trend of non-contraceptive users across 12 years of surveys. The increase in non-contraceptive users and unmet need for contraception may be related to the insufficient supply of contraceptive commodities and lack of confidence in the continuity of the supply. (16) Contraception commodities in Kyrgyzstan were largely supplied from donations by humanitarian aid. (16) Kyrgyz women could only make a decision in relation to the availability of the humanitarian aid options, and the options could be different or unavailable in the next visit. (16) Therefore, Kyrgyz women might be hesitant to choose any modern contraceptive methods. An effective and reliable supply chain, including financing, forecasting, and procurement for contraception commodities, should be prioritized and strengthened to encourage women who are in need of contraception to be able to use modern contraception. (17)

IUD is a long-acting reversible form of contraception. (18) It is commonly used worldwide because of its high efficacy and cost-effectiveness. (19) In the Kyrgyz Republic, IUD has been a prominent contraception method among married Kyrgyz women since 1997. (7, 20) In our study, IUD was still a dominant choice of contraception until 2018, but the trend drastically declined compared to that of 2006. While an inefficient supply chain may affect IUD provision to Kyrgyz women, confidence in the service provision of healthcare providers may also affect the number of IUD users. (16) It was reported that healthcare providers who had no gynecological background were reluctant to provide IUD services to women, and that IUD services varied from facility to facility depending on the provider’s comfort and confidence level. (16) Regular supportive supervision visits are essential to improve the knowledge and skills of healthcare providers, and to sustain IUD service as a contraceptive choice for Kyrgyz women.

Kyrgyz women aged 15–24 years old were more likely to have an unmet need for contraception compared to women in other age groups. This result was consistent with that of previous studies in Ethiopia and Ghana, and the likelihood of women having an unmet need for contraception decreased as the age of the women increased. (21, 22) According to the youth assessment in the Kyrgyz Republic in 2010, Kyrgyz youths had limited access to reliable information from media, and a high youth unemployment rate was of socio-political concern to the country. (23) Moreover, younger Kyrgyz women might not have adequate information regarding sexual health education. Access to health services, particularly contraception, might also have been limited. (24) Coupled with the limited domestic employment opportunities for young people, (23) young Kyrgyz women might feel unready to have a child. Therefore, young women were prone to have an unmet need for contraception. The Ministry of Health should promote and provide comprehensive sexual health education via offline and online platforms to ensure that young people can access health information from reliable sources. Youth training, such as professional development courses, should be emphasized and strengthened to equip young women with knowledge and skills for employment. Thus, young women should be empowered to be autonomous and financially and mentally prepared for their pregnancy. (1)

In our study, women who had children (1, 2 or ≥ 3 children) were more likely to have an unmet need for contraception compared to women who had no children. The result was partially consistent with a study in Zambia, where women with 0 or 1 child were less likely to have an unmet need compared to women with ≥ 4 children, while there were no differences between women with 0 or 1 child and women with 2 or 3 children. (25) This might be because of the difference in variable categorization between our study and that of Zambia. The study in Zambia divided the categories into four subgroups (0–1 child, 2–3 children, 4–5 children and ≥ 6 children), (25) whereas in our study, four subgroups were divided differently (0 child, 1 child, 2 children, and ≥ 3 children). In this study, the higher the number of children, the higher the likelihood that women had an unmet need for contraception. This indicated that postpartum women might not have adequate access to information and services regarding contraception compared to women with no children. The contraceptive security of the Kyrgyz Republic in 2006 revealed that a healthcare provider shortage in primary healthcare facilities (PHCs) could affect reproductive healthcare services for women. (16) As the number of healthcare providers was insufficient, contraceptive services for postpartum women might be neglected in PHCs. Human resource allocation and distribution should prioritize PHC to ensure the continuity of contraception services to Kyrgyz postpartum women.

This study had some limitations. First, women who responded that they wanted a child in the future but did not answer the question on the waiting time duration were excluded from the study. The prevalence of an unmet need for contraception may change if these women were included. Second, we did not analyze the level of contraceptive knowledge with unmet need for contraception among the samples, because the MICS 2006 did not include contraceptive knowledge in the survey. The questions on contraceptive knowledge were included in MICS 2014 onwards. Lastly, as a nature of the cross-sectional survey of MICS, it was difficult to establish the causal-effect relationship between factors and outcome.

The prevalence of an unmet need for contraception among married Kyrgyz women slightly increased over 12 years (19.9% in 2006, 20.4% in 2014, and 22.5% in 2018). From 2006 to 2018, factors associated with unmet need for contraception included women’s age, area of residence, mother tongue of household head, age of husband, and number of children ever born. Comprehensive sexual health education for young people and youth-friendly services should be promoted. An effective and reliable supply chain, including financing, forecasting, and procurement for contraception commodities, should be prioritized and strengthened. Healthcare provider allocation and distribution should prioritize PHC to ensure the continuity of contraception services to Kyrgyz postpartum women. Regular supportive supervision visits are essential to improve the knowledge and skills of healthcare providers, and to sustain IUD service as a contraceptive choice for Kyrgyz women.

MICS: multiple indicator cluster survey; IUD: intrauterine device; SDG: sustainable development goals; UNICEF: United Nations Children’s Fund; PHC: primary health care.

Ethics approval and consent to participate

This study employed secondary data from MICS. All data were anonymous and available online. Approval for access to MICS data was granted by UNICEF. Since the study used anonymous data, ethical approval was waived.

Consent for publication

Not applicable

Availability of data and materials

Data can be downloaded from the MICS website repository after user registration and approval for dataset access. Multiple Indicator Cluster Survey datasets from 2006, 2014 and 2018 are available at https://mics.unicef.org/surveys by using the filter for country search > Kyrgyzstan.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors receive no specific funding for this work.

Authors’ contributions

ZD, SI & EY conceptualized the research theme. ZD & SI collected the data from UNICEF repository. ZD & SI analyzed the data. ZD, SI, NH & EY interpreted the data after analysis. ZD & SI wrote the main manuscript text. SI prepared figure 1-2. ZD, SI, BD, MI, KN, NH & EY reviewed, revised and approved the article.

Acknowledgment

The authors would like to thank Dr. Arsen Askerov (Kyrgyz Association of Obstetrics), Ms. Baktygul Bozgorpoeva (Kyrgyz Family Planning Alliance), Ms. Smankulova Nurgul (UNFPA) for their advices and valuable inputs into this research. We also appreciated Dr. Nazira Artykova (WHO) for her support in retrieving literatures associated to Kyrgyzstan.

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No competing interests reported.

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Unmet need for contraception among married women in the Kyrgyz Republic from the 2006, 2014 and 2018 Multiple Indicator Cluster Survey: A cross- sectional study

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INTRODUCTION

MATERIALS AND METHODS

Multiple Indicator Cluster Survey

Unmet need for contraception

Study design and participants

Study variables

Statistical analysis

RESULTS

DISCUSSION

Conclusion

Abbreviations

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