First-time Users Have Diverse Needs

First-time contraceptive users are a diverse group. Some are adolescents who initiate contraceptive use months after first intercourse, risking unplanned pregnancy or sexually transmitted disease. Some are adult women and men who do not want to use contraception until after the birth of a child and fertility is proven. Others are older women and men who do not begin contraceptive use until they have reached their desired family size or are ready to end childbearing.

Lack of access to services, lack of information about available methods and how they work, or fears about side effects can discourage women and men from starting to use contraceptives. In addition, cultural norms -- such as preference for a large family, the value of sons over daughters, status gained through motherhood, and male control over female behavior -- can affect contraceptive initiation.

Family planning workers should be aware of the multiple needs, concerns and experiences of first-time contraceptive users.

"For many women and men, contraceptive use is not part of a long-term life plan," says Dr. Priscilla Ulin, an FHI researcher and director of the recently completed Women's Studies Project. "Often contraceptive use is a reaction. It comes in response to a pregnancy scare, an unplanned pregnancy, an unwanted pregnancy, or too many pregnancies.

"There are many women who would like to use contraception but do not. They worry erroneously that contraception might make them sick or sterile, so they are afraid to risk that possibility before they have completed their family size. Sometimes new users are clandestine users, especially when they are the first in their community to make a decision that contradicts social and cultural norms."

Health workers can help women and men understand the value of contraceptive use as a way to space, delay or end childbearing.

Older women and men

For some couples, the idea of planning a family is acceptable. However, they do not want to space or limit births until after their first pregnancy or until they have reached their desired family size.

In Zimbabwe, FHI's Women's Studies Project found a pattern in women's reproductive lives. On average, first menstruation occurred at age 14, first sex at 18, marriage at 19, and first birth at age 20, according to a national sample of nearly 2,500 women. For the majority of women, first contraceptive use did not take place until after first birth. Only 11 percent of women reported that they used family planning at first sex, and the figure dropped to 9 percent at marriage. However, the proportion jumped to 58 percent after first birth.¹

"It is extremely necessary to have a first child before a couple contracepts," one woman explained. "Why would one practice family planning if one does not even have a family? You will never know what contraception might do to a woman's system. It might make her sterile before they even have a child."²

Other studies in Africa and elsewhere have also shown that many couples believe first birth should precede contraceptive use. In Turkey, a survey of 918 married women ages 15 to 44 found that 73 percent did not begin contraceptive use until after first birth. Nearly half of those who did use a method chose withdrawal, fearing modern method side effects.³ In Bangladesh, a survey of 128 couples found that one-third of the women and half the men said women should prove fertility before they use family planning. Traditional methods, such as abstinence, herbal preparations and withdrawal, were popular at the beginning of women's reproductive careers, especially during the interval between marriage and first birth.⁴

Older women seeking contraception for the first time at Asociación Probienestar de la Familia (PROFAMILIA) clinics in Colombia are likely to want the intrauterine device (IUD) or sterilization, says María Isabel Plata, executive director. Although it is their first clinic visit, it is often not their first attempt at contraceptive use. Many have tried condoms or pills, which they can get over-the-counter in their country. They are tired of using short-term methods or have experienced a pregnancy from using methods incorrectly.

In India, most new users are interested in permanent, not reversible, methods, says Dr. Nina Puri, president of the Family Planning Association of India (FPAI). "The concept of family planning in India has traditionally been accepted," Dr. Puri says. But many women start using contraception after having three or more children. "They really did not want to come in to space births, and they did not have enough information about temporary methods," she says.

India's National Family Health Survey of nearly 90,000 ever-married women of reproductive age found only 4 percent of women with no children were using family planning. The figure jumped to 19 percent for women with one child, to 46 percent for women with two children, and to more than 50 percent for women with three or more children.⁵

Historically, the Indian government has promoted male and female sterilization in its family planning programs. The emphasis is changing, but for many couples sterilization is the first and only method of contraception they use. In the national survey, sterilization was the most popular method, with few women knowing about or using reversible methods.

Sterilization as a first contraceptive is prevalent elsewhere as well. Studies in 19 countries, conducted by Demographic and Health Surveys, found that one-third of sterilized women in Indonesia and two-thirds in Sri Lanka had not used a modern contraceptive method before being sterilized. Fifty-three percent of women in Kenya and 36 percent in Botswana said they had not used a modern method before sterilization. In Latin America and the Caribbean, the percentage of women who had not used a modern method before sterilization ranged from 17 percent in Trinidad and Tobago to 54 percent in Bolivia.⁶

An FHI study in Nepal surveyed 817 sterilized women and found that, for 81 percent, sterilization was their first contraceptive method, although 93 percent were aware of at least one temporary modern method that could be used for spacing.⁷ Nearly 40 percent of women who were sterilized had five or more children, and nearly two-thirds of women were under age 29. Researchers outlined a reproductive pattern that includes marriage at an early age (47 percent of women are married by age 17), first birth by age 21, and an average of 2.6 births before age 30, at which time the demand for family planning increases. A separate study found that women and men associated family planning with "stopping children." They were not familiar with the concept of child spacing.⁸

For older women and men, the reasons for non-use of contraception are varied. They include lack of access to methods and information, fear of partner disapproval, fear of side effects, fear of loss of fertility and preference for sons.

For health providers who work with older first-time users, an important strategy is to educate women and men that they do have a choice. "If you are very poor, you cannot plan anything -- going to school, your work, improving your home -- you do not even have a home," says Plata of PROFAMILIA. "The idea of planning, creating a future, is out of that person's universe."

Contraceptives can be used not only to end childbearing, but to delay or space children to improve maternal and infant health. Health workers can explain to couples that they can choose between permanent or reversible methods. And they should explain that side effects can be managed or minimized.

In addition, health workers can educate the family and the community -- not just the contraceptive user. "We go to women with their first child and talk about spacing. We talk to men, and we talk to the family as a whole," says Dr. Puri of India. "We have found that programs have to address specific audiences. The way we address issues has to be attuned to sensitivities of the communities where we work."

FPAI has 22 clinics that provide some type of services to men. Condom use has increased, and concern about AIDS has prompted men to take a more active interest in their own reproductive health and the health of their wives. Dr. Puri recommends that family planning programs have special hours for men, including clinic times that do not conflict with men's work hours.

Secret use

Without husband approval or community support, contraceptive use for many women is a difficult and risky decision that can lead to abandonment, violence, ostracism or divorce. Consequently, some women begin contraception secretly, without their husband's knowledge.

"Providers should know whether a woman is coming with the concurrence of her husband or if she is coming in secret," says Dr. Ulin of FHI. "In the case of clandestine users, providers need to assure the client of absolute confidentiality."

A small study in Mali, conducted by FHI and the Centre d'Etudes et de Recherche sur la Population pour le Développement (CERPOD) as part of the Women's Studies Project, found that about one-third of 55 first-time users had come to a family planning clinic without their husbands' knowledge.⁹ Seven of the 17 clandestine users said they were too shy or too afraid to discuss family planning with their husbands, and the remainder had tried but encountered disapproval, including concern that family planning violated religious teachings.

More than half the clandestine users in the Mali study chose injectable contraceptives because they felt this method was easy to keep secret. However, many women who chose oral contraceptives said this was also a good option, since they could carefully hide pill packets.

The Population Council estimates that in countries where contraceptive prevalence is less than 10 percent, secret use of methods accounts for a substantial number of users. For example, in the urban Ndola district of Zambia, 7 percent of some 800 women interviewed said they were using family planning without their husband's knowledge.¹⁰ Conducted by the Population Council and the African Population Policy Research Center, the Zambian study found that reasons for covert use included husbands' disapproval of contraception, husbands' desire for many children, and difficulty between husband and wife in communicating about family planning. Women also said they started using family planning to improve the health and well-being of the children they already had. "You just observe what is happening at home," one woman said. "If there is no support, you start a pill secretly. The children look miserable and not cared for, no clothes, they move about aimlessly, no food, and start begging from the streets."

A study in Uganda found that 15 percent of women who were using family planning did so without their husband's knowledge, while in rural Kenya, 20 percent of women said they used family planning clandestinely.¹¹

Family planning programs can help women using methods in secret by providing a range of contraceptive choices and by helping women manage side effects. As one study participant in Zambia explained, "She has to choose a method that has no side effects, because if she suffers the husband will be furious and tell her to count him out of that problem." Men should also be encouraged to learn more about family planning.

Adolescents

Many young adults do not use contraception at first intercourse; contraceptive use may not begin until months later. There are numerous reasons why contraception is an afterthought. For example, many adolescents do not plan when to have sex, do not know where or how to obtain family planning, are simply too embarrassed to seek contraception or are denied methods by clinic staff or pharmacists. Others may not understand when the fertile time occurs in the woman's menstrual cycle, think they are too young to get pregnant, or are afraid contraceptive use can damage fertility.

"It is scary to use pills or an injection regularly, especially at our ages," one young woman from Zimbabwe explained to FHI researchers. "We are afraid the use of condoms might reduce our chances of getting pregnant when we get married."¹²

In Jamaica, a 1997 national survey of young adults ages 15 to 24 found that the older adolescents were when they had first sex, the more likely they were to use contraception. Among those who had first sex when they were younger than 14, 41 percent of the girls and 17 percent of the boys said they used contraception. Among those who had first sex at ages 18 to 24, nearly two-thirds of the women and 53 percent of the men used contraception. A stable relationship, higher family income, and higher educational attainment also influenced contraceptive use at first sex.¹³

An FHI survey among Jamaican adolescents in their early teens (grades 7 and 8) found similar lack of contraceptive use at first sex. Slightly more than two-thirds of the 51 sexually active girls and less than one-third of the 251 sexually active boys reported using contraceptives at first intercourse. The most popular method was the condom. Young adults had mixed views on family planning, with a majority saying contraceptive use is responsible behavior but others saying it is for people with multiple partners. In focus group discussions, one boy said condom use would draw ridicule from peers, who would laugh and "call him a little boy." Another young man said he would use condoms because he "loves my life, you know" and "cannot bother with no AIDS thing."¹⁴

Similar trends have been observed in other countries. In Kenya, a study of 2,059 secondary school students found that only 25 percent of the boys and 28 percent of girls used contraception at first sex.¹⁵ In Mexico City, a study of more than 1,000 young adults, ages 10 to 25, also found low contraceptive use at first sex.¹⁶

In Colombia, family planning workers are trying to change the trend of adolescents initiating sexual activity without contraceptives, says Plata of PROFAMILIA. The majority of young clients come to PROFAMILIA clinics "because they are already sexually active and they are worried or have had a scare, and they come for a pregnancy test," she says.

To encourage young people to use contraception during first sexual activity, PROFAMILIA distributes contraceptive information and tries to make it easier for adolescents to obtain methods. The organization operates a telephone hotline, provides emergency contraception, and encourages young men to use contraception.

"With the young men, we talk about respect for the girl, self-esteem and sexuality," says Plata. "They become more open, less machista, more democratic, and they start to consider what she wants and also what he can do in the whole question of contraception. We start working with the idea of the responsibility of two."

-- Barbara Barnett

References

1. Mhloyi MM, Mapfumo OM. Zimbabwe: The Effect of Family Planning on Women's Participation in the Development Process. Research Triangle Park, NC: Family Health International, 1998.
2. Mhloyi MM. Family planning and women's participation in the development process. In Mhloyi M, ed. Women's Participation in the Development Process: The Role of Family Planning. (Harare: Friedrich Ebert Stiftung, 1998)32-52.
3. Breslin M. Fearing side effects, many Turkish women choose traditional contraceptives. Int Fam Plann Perspect 1997;23(3):139-40.
4. Gray A, Chowdhury JH, Caldwell B, et al. 'Traditional' Family Planning in Bangladesh, Summary Report. Dhaka: Population Council, 1997.
5. Donovan P. About 40% of Indian women practice contraception; only one in four users rely on reversible methods. Int Fam Plann Perspect 1995;21(2):81-82.
6. Rutenberg N, Landry E. A comparison of sterilization use and demand from the Demographic and Health Surveys. Int Fam Plann Perspect 1993;19(1):4-13.
7. Thapa S, Friedman M. Female sterilization in Nepal: a comparison of two types of service delivery. Int Fam Plann Perspect 1998; 24(2):78-83.
8. Final report, Nepal family planning communications survey. Unpublished paper. Johns Hopkins School of Public Health, Center for Communication Programs, Population Communication Services and Valley Research Group, 1997.
9. Konaté MK, Castle S. The impact of family planning on the lives of women in the district of Bamako, Mali: interim report after third round of interviews. Unpublished paper. Family Health International, 1999.
10. Biddlecom AE, Fapohunda BM. Covert contraceptive use: prevalence, motivations, and consequences. Stud Fam Plann 1998;29(4):360-72.
11. Blanc AK, Wolff B, Gage A, et al. Negotiating Reproductive Outcomes in Uganda. Calverton, MD: Macro International, 1996; Rutenberg N, Watkins SC. The buzz outside the clinics: conversations and contraception in Nyanza Province, Kenya. Stud Fam Plann 1997;28(4):290-307.
12. Taruberekera N. The impact of family planning on young women's academic achievement and vocational goals. In Mhloyi M, ed. Women's Participation in the Development Process: The Role of Family Planning. (Harare: Friedrich Ebert Stiftung, 1998)99.
13. Friedman JS, McFarlane CP, Morris L. Jamaica Reproductive Health Survey 1997. Young Adult Report: Sexual Behavior and Contraceptive Use among Young Adults. Atlanta: U.S. Department of Health and Human Services, 1999.
14. Jackson J, Leith J, Lee A. The Jamaica Adolescent Study. Research Triangle Park, NC: Family Health International, 1998.
15. Karagu K, Zabin LS. Contraceptive use among high school students in Kenya. Int Fam Plann Perspect 1995;21(3):108-13.
16. García-Baltazar J, Figueroa-Perea JC, Reyes-Zapata H, et al. Características reproductivas de adolescentes y jóvenes en la Ciudad de México. Salud Pública de México 1993;35(6):682-91.

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