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

doi:10.21203/rs.3.rs-50730/v1

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Research article

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

https://doi.org/10.21203/rs.3.rs-50730/v1

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published 30 Nov, 2020

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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 five 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 findings 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 significant 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 resources and further structural factors, particularly in remote areas.

Sexual & Reproductive Medicine

Contraception

Demand

Supply

Pakistan

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 surveys 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 five 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 significant 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.

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 (1–3). 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 (3.5) in the South Asian region (6). 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 (7). High fertility is an effect of low use of contraceptives, which also hampers socio-economic development (8–10). Although family-planning programmes were launched in Pakistan during different eras however, effective implementation remains challenging due to multiple socio-cultural, economic and political factors, together with a preference for male children, supply issues and the strong patriarchal structure (11).

The low use of contraceptives and associated hindrances has been explained by different studies examining various dimensions. A few studies have identified the socio-cultural reasons related to the use of contraceptives, and others have explained it in terms of geographical and financial inhibitions limiting access to family-planning services, limited availability, and associated perceived side effects that damage a mother’s health (12–14). 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, financial autonomy, religious inspirations, and cultural beliefs that high fertility is good are the factors that affect the use of contraceptives in the developing world (15–17).

Several factors drive the demand for contraceptive methods, including the reproductive age of women, knowledge, awareness, and attitudes towards the use of contraceptive methods. When there is a demand, then there is also a compulsion on governments 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 interventions 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 (18–19).

In Pakistan, the influence 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 (20). 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 (21–22). 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 (23). Similar findings have been described by Teitelman et al. (24): 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. (25) 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 insufficient 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 (26). 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 (27).

Although previous research has identified 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 influenced the use of contraceptives over the years in Pakistan.

We used a data-set series of four nationally representative Pakistan Demographic Health Surveys (1990–91, 2006–07, 2012–13, and 2017–18). These PDHS surveys are conducted in order to gain information on mother and child health, fertility, family planning, reproductive health, nutritional status, and immunisation status. The representative samples and response rates of each PDHS of ever-married women were 6,611 (95%) in 1990–91, 10,023 (95%) in 2006–07, 13,558 (93%) in 2012–13 and 15,509 (96%) in 2017–18. Our study focused on the personal, socio-cultural, community-level, and supply-side factors dealing with the use of contraceptives. To obtain the sample for this study, women who had given birth in the previous five years and participated in the family planning module were selected. The selection of women as respondent was made on the basis that in Pakistan almost all of the family planning programs have remained women focused and they are considered the main clients for any family planning interventions. The sample from each data set is: 4,092 women in 1990–91, 5,742 women in 2006–07, 7,461 women in 2012–13, and 8,219 in 2017–18 (28–31).

Instrumentation and data classification

Current use of contraceptive methods was defined 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). The reason behind combining both types of methods was that the focus of study was to see use and non-use of contraceptive measures rather on the types of methods being used.

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 [agriculture self-employed, 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 from male members of family specifically husbands, 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] 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 as “Yes” if faced any type of violence and “No” if did not face violence. In women’s decisional autonomy, their independent or joint control of income, purchases, healthcare decisions, and visits to relatives were included. Each variable was first 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 as “Yes” and those who do not have autonomy as “No”. 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 family-planning 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 first categorised into public (government hospitals, family-planning 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 purpose of weighting was balancing the data to reflect population more accurately that can project the result of large universe of this study. 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 (X²) on categorical variables. A p-value of < 0.05 was considered statistically significant. 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.

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. A majority of women (76.7%) in 1990–91 were uneducated. This proportion decreased in each survey, reducing to 50.7% in 2017–18. The women were mainly not employed, showing proportions of about three quarters or more for unemployment in all surveys.

Association between socio-demographic factors and current non-use of contraceptives

Four data series illustrate that, in the years 1990–91, 2006–07, 2012–13 and 2017–18, the proportions of women who did not currently use any contraceptive method were 86.9%, 72.2%, 63.0%, and 65.6% respectively. The highest use of contraceptives was observed in the age group of 26–34 years. A majority of women with poor wealth index did not use contraceptive methods; this proportion remained almost constant, ranging from 51.8% in 2006–07 to 50.0% in 2012–13 and 51.8% in 2017–18. In rich families, the use of contraceptives decreased over time, from 55.2% in 2006–07 to 47.8% in 2017–18. The non-use of contraceptive methods among illiterate women declined from 81.4% (1990–91), to 71.9% (2006–07) 63.3% (2012–13), and 57.0% (2017–18) (Table 1).

Table 1

Socio-demographic indicators of the current use and non-use of contraceptive among women in reproductive age in Pakistan (all PDHS, n = 25,415, weighted n = 25,318)
	Current use of contraceptives				Current non-use of contraceptives
	1990-91 n = 521	2006-07 n = 1574	2012-13 n = 2674	2017-18 n = 2783	1990-91 n = 3501	2006-07 n = 4132	2012-13 n = 4697	2017-18 n = 5436
Age	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)
15–25	128 (24.6)	331 (21)	651 (23.6)	583 (20.9)	1300 (37.1)	1448 (35.0)	1585 (33.7)	1848 (34)
26–34	282 (54.1)	887 (56.4)	1543 (55.8)	1623 (58.3)	1611 (46.0)	1931 (46.7)	2309 (49.2)	2677 (49.2)
36–49	111 (21.3)	356 (22.6)	570 (20.6)	577 (20.7)	590 (16.9)	753 (18.2)	803 (17.1)	911 (16.8)
Type of residence
Rural	113 (21.7)	779 (50.5)	1507 (54.5)	1490 (53.5)	1903 (54.4)	2921 (70.7)	1771 (33.7)	2216 (40.8)
Urban	408 (78.3)	795 (49.5)	1257 (45.5)	1293 (46.5)	1598 (45.6)	1211 (29.3)	2926 (62.3)	3220 (59.2)
Region
Punjab	219 (42)	775 (49.2)	905 (32.7)	696 (25.0)	1133 (32.4)	1519 (36.8)	1103 (23.5)	1030 (18.9)
Sindh	169 (32.4)	371 (23.6)	504 (18.2)	457 (16.4)	896 (25.6)	1250 (30.3)	1087 (23.1)	984 (18.1)
Khyber Pakhtunkhwa	107 (20.5)	322 (20.5)	518 (18.7)	516 (18.5)	936 (26.7)	791 (19.1)	1014 (21.6)	866 (15.9)
Balochistan	26 (5)	106 (6.7)	270 (9.8)	182 (6.5)	538 (25.3)	572 (13.8)	879 (18.7)	820 (15.1)
Gilgit Baltistan	NA	NA	264 (9.6)	246 (8.8)	NA	NA	445 (9.5)	368 (6.8)
Islamabad (ICT)	NA	NA	303 (11.0)	256 (9.2)	NA	NA	169 (3.6)	285 (5.2)
AJK	NA	NA	NA	272 (9.8)	NA	NA	NA	590 (10.9)
Federally Administered Tribal Areas	NA	NA	NA	158 (5.7)	NA	NA	NA	493 (9.1)
Wealth index
Poor	NA	376 (23.9)	758 (27.4)	835 (30.0)	NA	2141 (51.8)	2348 (50)	2817 (51.8)
Middle	NA	329 (20.9)	515 (18.6)	619 (22.2)	NA	788 (19.1)	914 (19.5)	990 (18.2)
Rich	NA	869 (55.2)	1491 (53.9)	1329 (47.8)	NA	1203 (29.1)	1435 (30.6)	1629 (30.0)
Mother’s education
No education	236 (45.3)	826 (52.2)	1148 (41.5)	1033 (37.1)	2851 (81.4)	2972 (71.9)	2973 (63.3)	3101 (57.0)
Primary	72 (13.8)	270 (17.2)	455 (16.5)	420 (15.1)	299 (8.5)	518 (12.5)	610 (13)	673 (12.4)
Secondary	181 (34.7)	300 (19.1)	648 (23.4)	739 (26.6)	318 (9.1)	459 (11.1)	725 (15.4)	1000 (18.4)
Higher	32 (6.1)	178 (11.3)	513 (18.6)	591 (21.2)	33 (0.9)	183 (4.4)	389 (8.3)	662 (12.2)
Respondents occupation
Not working	450 (86.4)	1166 (75.6)	2213 (80.1)	2372 (85.3)	2965 (84.8)	2915 (72.1)	3723 (79.3)	4753 (87.5)
Skilled	10 (1.9)	180 (11.7)	234 (8.5)	94 (3.4)	215 (6.1)	521 (12.9)	559 (11.9)	216 (4.0)
Unskilled	41 (7.9)	127 (8.2)	40 (1.4)	191 (6.9)	281 (8.0)	530 (13.1)	76 (1.6)	341 (6.3)
Professional	20 (3.8)	69 (4.5)	277 (10.0)	124 (4.5)	37 (1.1)	79 (2.0)	338 (7.2)	125 (2.3)
Ethnicity
Punjabi	NA	568 (37.2)	738 (26.7)	NA	NA	1023 (25.7)	818 (17.4)	NA
Sindhi	NA	140 (9.2)	181 (6.6)	NA	NA	679 (17.0)	561 (11.9)	NA
Pashto	NA	342 (22.4)	583 (21.1)	NA	NA	930 (23.3)	1116 (23.8)	NA
Balochi	NA	40 (6.2)	81 (2.9)	NA	NA	274 (6.9)	269 (5.7)	NA
Others	NA	437 (28.6)	1179 (42.7)	NA	NA	1080 (27.1)	1931 (41.1)	NA
In each sub-sample data was weighted, leading to differences in absolute values.
Overall, 585 cases had missing values.

Demand-side factors and current non-use of contraceptives

Data regarding media exposure and non-use of contraceptive methods showed decreasing trends, from 63.4% in 2012–13 to 54.9% in 2017–18. Women aged 15–49 who desired (more) children who did not use contraceptive methods accounted for 64.6% in 1990–91, 57.4% in 2006–07, 53.4% in 2012–13 and 70.8% in 2017–18. In 2012–13, 41.0% of women who had faced intimate partner violence did not use any contraceptive methods, whereas this number declined to 29.4% in 2017–18. About 59.9% of women who had not faced any kind of violence used contraceptive measures in 2012–13, and this percentage increased to 71.5% in 2017–18. About 41.6% who did not have decisional autonomy did not use any contraceptive methods in 2012–13, and there was an increase in this proportion to 71.8% in 2017–18. About 30.8% of the women who did not use contraceptives reported that it was a big problem to attend any medical facility in 2012–13; this figure remained almost constant, being 30.5% in 2017–18. About 65.3% in 2012–13 and 70.0% in 2017–18 who did not want to go alone to seek medical healthcare and reported this as a problem never used any contraceptive measures. Among those women who did not have sons, 17.8% (1990–91), 20.1% (2006–07), 21.1% (2012–13), and 23.1% (2017–18) did not use any contraceptive methods; this shows an increasing trend of not using contraceptives over the years (Table 2).

Table 2

Frequency and weighted percentages of demand and supply side factors of the women who currently use and do not use contraceptive methods in Pakistan
	Current use of contraceptives				Current non-use of contraceptives
	1990-91 n = 528	2006-07 n = 1574	2012-13 n = 2674	2017-18 n = 2783	1990-91 n = 3501	2006-07 n = 4132	2012-13 n = 4697	2017-18 n = 5438
Demand side factors	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)	f (%)
Media exposure
No	NA	NA	511 (18.6)	728 (26.2)	NA	NA	1715 (36.6)	2449 (45.1)
Yes	NA	NA	2238 (81.4)	2053 (73.8)	NA	NA	2966 (63.4)	2982 (54.9)
Desire for more children
No	392 (75.4)	1010 (64.2)	1732 (62.9)	1626 (58.6)	1218 (35.4)	1757 (42.6)	2150 (46.6)	1557 (29.2)
Yes	128 (24.6)	563 (35.8)	1022 (37.1)	1148 (41.4)	2225 (64.6)	2364 (57.4)	2460 (53.4)	3775 (70.8)
Intimate partner violence
No	NA	NA	489 (59.9)	581 (71.5)	NA	NA	722 (59.0)	1011 (70.6)
Yes	NA	NA	327 (40.1)	232 (28.5)	NA	NA	501 (41.0)	420 (29.4)
Decisional autonomy
No	NA	NA	487 (25.1)	1243 (66.5)	NA	NA	1270 (41.6)	3166 (71.8)
Yes	NA	NA	1450 (74.9)	820 (33.5)	NA	NA	1780 (58.4)	1631 (28.2)
Permission to go for medical or health facility
Big problem	NA	NA	410 (14.9)	564 (20.3)	NA	NA	1442 (30.8)	1656 (30.5)
Not a big problem	NA	NA	2347 (85.1)	2217 (79.7)	NA	NA	3247 (69.2)	3776 (69.5)
Getting medical help for self: Not wanting to go alone
Big problem	NA	NA	1298 (47.1)	1617 (58.1)	NA	NA	3061 (65.3)	3800 (70.0)
Not a big problem	NA		1459 (52.9)	1164 (41.9)	3061 (65.3)	3061 (65.3)	1628 (34.7)	1632 (30.0)
Having sons
No	53 (10.2)	167 (10.6)	363 (13.1)	340 (12.2)	622 (17.8)	823 (20.1)	993 (21.1)	1257 (23.1)
1–3	366 (70.2)	1145 (72.7)	2078 (75.2)	2174 (78.1)	2359 (67.4)	2779 (67.3)	3219 (68.5)	3731 (68.6)
4–6	85 (18.2)	249 (15.8)	311 (11.3)	263 (9.5)	488 (13.9)	495 (12.0)	451 (9.6)	424 (7.8)
7–10	7 (1.3)	13 (0.8)	12 (0.4)	6 (0.2)	32 (0.9)	26 (0.6)	34 (0.7)	24 (0.4)
Supply side factors
Distance to health facility
Not a big problem	NA	NA	2381 (50.8)	3008 (55.4)	NA	NA	856 (31.0)	3008 (55.4)
Big problem	NA	NA	2308 (49.2)	2423 (44.6)	NA	NA	1901(69.0)	2423 (44.6)
Transport availability
Not a big problem	NA	NA	2621 (55.9)	NA	NA	NA	934 (33.9)	NA
Big problem	NA	NA	2067 (44.1)	NA	NA	NA	1823 (66.1)	NA
Visited by family planning worker in past 12 months
No	NA	NA	1526 (53.0)	1112 (40.0)	NA	NA	860 (44.1)	2826 (52.0)
Yes	NA	NA	1353 (47.0)	1671 (60.0)	NA	NA	1089 (55.9)	2609 (48.0)
Unmet need
No	NA	1574 (100.0)	NA	0 (0.0)	NA	2915 (48.2)	NA	2906 (55.7)
Yes	NA	0 (0.0)	NA	2777 (100.0)	NA	2059 (51.8)	NA	2310 (44.3)

Supply-side factors and current non-use of contraceptives

Among supply-side factors, of those women who considered distance to a health facility a big problem, 69.0% in 2012–13 and 44.6% in 2017–18 never used any contraceptive measures. Of those who did not consider access to a health facility a big problem, 50.8% in 2012–13 and 55.4% in 2017–18 used contraceptive measures. Of those who considered transportation a big problem, 66.0% in 2012–13 did not currently use contraceptive methods. In 2012–13, 47.0% and in 2017–18, 60.0% of women who were visited by family-planning workers used contraceptive measures. Of those who were not visited by family-planning workers, 44.1% in 2012–13 and 52.0% in 2017–18 did not use contraceptive measures. In 2006–07, of those who had unmet needs for contraception, 48.2% never used any contraceptive measures and this percentage increased to 55.7% in 2017–18 (Table 2).

Association between demand and supply-side factors and non-use of contraceptives

Demand-side factors

The odds of non-use of contraceptive methods were significantly 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 significantly 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 significantly higher among the respondents who had permission to attend medical or health facilities (Table 3).

Table 3

Association between non-user of contraceptives with demand and supply side factors
	OR (95% CI)				AOR (95% CI)
	1990-91	2006-07	2012-13	2017-18	1990-91	2006-07	2012-13	2017-18
Demand side factors
Media exposure	NA	NA	0.396 (0.353–0.442)	0.432 (0.391–0.477)	NA	NA	0.664 (0.562–0.784)	0.654 (0.483–0.885)
Desire for more children	5.594 (4.528–6.911)	2.414 (2.140–2.722)	1.939 (1.761–2.136)	3.434 (3.120–3.780)	4.835 (3.803–6.147)	4.817 (3.972–5.841)	0.838 (0.627–1.119)	0.860 (0.632–1.161)
Intimate partner violence	NA	NA	1.038 (0.866–1.243)	1.040 (0.860–1.258)	NA	NA	0.801 (0.625–1.026)	0.875 (0.658–1.164)
Decisional autonomy	NA	NA	0.471 (0.415–0.534)	0.781 (0.702–0.869)	NA	NA	0.928 (0.799–1.077)	0.853 (0.647–1.125)
Permission to go for medical or health facility	NA	NA	0.393 (0.348–0.444)	0.580 (0.520–0.647)	NA	NA	0.729 (0.606–0.870)	1.238 (0.888–1.727)
Getting medical help for self: Not wanting to go alone	NA	NA	0.473 (0.430–0.521)	0.597 (0.543–0.656)	NA	NA	0.901 (0.780–1.040)	1.119 (0.816–1.534)
Having sons
No	0.390 (0.164–0.925)	0.401 (0.202–0.797)	1.036 (0.531–2.022)	1.082 (0.439–2.668)	0.692 (0.262–1.830)	0.112 (0.022–0.583)	0.900 (0.413–1.961)	0.271 (0.150–0.490)
1–3	0.709 (0.311–1.619)	0.824 (0.422–1.609)	1.829 (0.945–3.540	2.331 (0.951–5.711)	1.280 (0.534–3.073)	0.211 (0.041–1.076)	1.574 (0.743–3.338)	1.516 (0.846–2.716)
4–6	0.890 (0.382–2.076)	1.006 (0.508–1.992)	1.954 (0.996–3.833)	2.481 (1.001–6.150)	0.923 (0.376–2.263)	0.323 (0.063–1.663)	1.795 (0.840–3.834)	1.779 (0.985–3.216)
Supply side factors
Distance to health facility	NA	NA	0.436 (0.395–0.482)	0.552 (0.503–0.606)	NA	NA	0.775 (0.656–0.916)	0.773 (0.554–1.078)
Transport availability	NA	NA	2.474 (2.244–2.728)	NA	NA	NA	0.654 (0.555–0.777)	NA
Visited by family planning worker in past 12 months	NA	0.583 (0.514–0.660)	1.428(1.271–1.603)	0.614 (0.560–0.674)	NA	0.668 (0.558-0.800)	0.732 (0.651–0.823)	0.631 (0.480–0.828)
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 significantly 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 insignificant 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 significantly lower among respondents who reported distance from a health facility in 2012–13 (OR 0.436, 95% CI 0.395–0.482) and in 2017–18 (OR 0.552, 95% CI 0.503–0.606). The likelihood of not using contraceptive methods was significantly higher among respondents who reported availability of transport facilities (OR 2.474, 95% CI 2.244–2.728) in 2012–13. The odds of not using contraceptive methods were significantly lower among respondents who reported a visit by a family-planning worker during the previous 12 months in 2006–07 (OR 0.583, 95% CI 0.514–0.660) and in 2017–18 (OR 0.614, 95% CI 0.560–0.674). However, the odds of not using contraceptive methods were significantly higher among respondents who reported a visit by a family-planning worker during the previous 12 months in 2012–13 (Table 3).

Multivariate results

Table 3 also includes the results of a multivariate binary logistic regression analysis. These results indicate that the odds of not using contraceptive methods are higher among respondents who had exposure to any source of information compared to respondents who did not have any media exposure, both in 2012–13 (AOR 0.664, 95% CI 0.562–0.784) and 2017–18 (AOR 0.654, 95% CI 0.483–0.885). The odds of not using contraceptive methods was higher among respondents who reported a desire for more children in 1990–91 (AOR 4.835, 95% CI 3.803–6.147) and in 2006–07 (AOR 4.817, 95% CI 3.972–5.841). However, the desire for more children lost significance in 2012–13 and in 2017–18.

Multivariate results indicate that the odds of using contraceptive methods were lower among respondents who reported that they had permission to attend a medical or health facility in 2012–13 (AOR 0.729, 95% CI 0.606–0.870) compared to respondents who reported that they did not have permission. However, this variable lost its significance in 2017–18. The odds of using no contraceptive methods were lower among respondents who reported distance from a health facility (AOR 0.775, 95% CI 0.656–0.916) compared to respondents who did not report distance from a health facility in 2012–13. However, it lost its significance in 2017–18. The results also indicated that non-availability of transport (2012–13) and limited visits by family-planning workers over the previous 12 months (2006–07, 2012–13, and 2017–18) were significant factors for not using contraceptive methods. On the other hand, a desire for more children, intimate partner violence, decisional autonomy, getting medical help, and number of sons lost significance in the multivariate analysis in 2012–13. Similarly, a desire for more children, intimate partner violence, decisional autonomy, permission to attend a medical or health facility, getting medical help and distance from medical care lost significance in 2017–18 (Table 3).

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 (32–34). 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 (35). Various interventions have been introduced to address this issue over a significant period of time i.e. awareness campaigns, celebrity appeals, appeals through religious scholars, access to free services, door to door services through LHWs etc. 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 socio-demographic variables.

The study found that socio-demographic factors play a significant 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 findings are similar to those of studies conducted by Adebowale et al. (36), 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 due to better health facilities and more awareness campaigns as compared to other provinces (37–47).

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 findings confirm the findings indicated by previous research that higher fertility is associated with a lower level of education (38–39). Wealth quintile is also significantly 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 findings appear in a study conducted by Islam et al. (40), 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 (41–42). Our findings 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 (48). Ethnicity is also significantly associated with ever-use of contraceptive measures (43). In our study, among different ethnic groups, use of contraceptives was higher among Punjabi women.

The findings of our study also suggest that those who have a greater desire for children have a lower likelihood of using contraceptive measures (44). 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 (45). Gender disparity, Lack of decision-making power, discussion of health issues, permission to attend medical or health facilities, and the demand for sons are the socio-cultural factors that also influence the use of contraceptives (46–47). Our findings show that women who see attending health facilities as a big problem are less likely to have ever used any method of family planning.

Supply side requires a considerable effort to provide adequate accessibility and resources of contraceptive measures (47). Our findings show that there is a significant 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.

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 sub-groups of women where even LHWs have limited access. Targeted community mobilisation and increasing educational levels among mothers in rural communities can further increase awareness about and use of contraceptives.

AOR

Adjusted odds ratio

Confidence interval

DHS

Demographic and health survey

Odds ratio

PDHS

Pakistan Demographic and Health Survey

SPSS

Statistical Package of Social Science

Ethics approval and consent to participate

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. FF serves on the Editorial Board of BMC Public Health as Associate Editor.

Funding

The study received no funding.

Authors’ contribution

RZ conceived the idea. SJ, MR and AR conducted data analysis and drafted the manuscript. RZ and FF supervised and reviewed manuscript writing and data analysis. All authors reviewed the final version of the manuscript.

Acknowledgements

We acknowledge support from the German Research Foundation (DFG) and the Open Access Publication Fund of Charité – Universitätsmedizin Berlin.

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

Status:

Journal Publication

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Abstract

Background

Method:

Results

Conclusion

Plain English Summary

Background

Methods

Instrumentation and data classification

Statistical analysis

Results

Association between socio-demographic factors and current non-use of contraceptives

Demand-side factors and current non-use of contraceptives

Supply-side factors and current non-use of contraceptives

Association between demand and supply-side factors and non-use of contraceptives

Demand-side factors

Supply-side factors

Multivariate results

Discussion

Limitations

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Funding

Authors’ contribution

Acknowledgements

References

Status:

Journal Publication

Version 1