Indonesia mixed contraception method skewness background 1997-2012: A mixed method study

Introduction

The global population is currently around 7.7 billion people, with an average increase of 2.2 percent per year.¹ The total fertility rate in the world will be 2.406 in 2020.² Within this range, Indonesia ranked 102 with a Total Fertility Rate (TFR) of 2.6 in 2012.³ The population growth rate Laju Pertumbuhan Penduduk (LPP) for the 2000-2010 period was 1.49%, which was an increase compared to the 1990-2000 period, which was 1.45%.⁴

Increasing fertility will reduce economic growth⁵; according to the theory of Malthus (1798), the high fertility rate results in poverty due to limited natural resource carrying capacity.⁶ A study conducted in China in 2007 by Li and Zhang revealed that economic growth negatively correlates with fertility and population growth.⁷

Decreased fertility creates demographic dividends by increasing the ratio of the labor force to total dependency.⁸ The most important factor affecting fertility decline is contraceptives.⁹ Meeting contraceptive needs can change the future and lives of millions of women in poor and developing countries.¹⁰ Smaller families will improve family welfare.¹¹

A factor that can sustain a sustainable decline in fertility is strengthening family planning services by expanding the choice of methods offered to the community. This result is in line with research conducted by Magadi and Curtis. Preferences, needs, and beliefs regarding contraception vary widely in society. Magadi and Curtis' study concluded that family planning programs must be able to accommodate the varying needs of contraceptive users.¹²

50% or more of contraceptive users in a country use mixed contraceptive methods. Shifting the contraceptive mix is very important for the government, donor countries (aid providers), and researchers who study contraceptive dynamics.¹³ The proportion of the contraceptive mix defined by the reproductive health community has no optimal or ideal term, and the ideal distribution can be seen generally from a woman's optimal reproductive time.¹⁴

Skewed contraceptive method mix and unequal access are still a problem in poor and developing countries.^13,15,16 A study in 2006 showed that 34 of the 96 countries studied had a mixed type of contraception that deviated (skewed).¹⁷ A similar study by Bertrand et al. in 2014 indicated that 33 of the 109 countries had a skewed method mix.¹³ A high concentration of one or more specific types of contraception is a sign that the available methods in the community are not evenly distributed.¹⁷

Since 2007, Indonesia has already had mixed views towards hormonal methods, particularly injections.³ This skewness, however, is thought to be the result of several factors, including lack of knowledge among acceptors about the method used, provider preferences for specific methods because the incentives received by providers for using the injection method are too high, and support and promotion for the use of vasectomy and implants. Moreover, tubectomy lacks¹⁵ and limited access, make acceptors choose only available and affordable methods.

The implications of decentralization in health services include service delivery, health financing, and workforce. Decentralization is associated with more positive primary health services women receive.¹⁸ The goverment has the most crucial role in the success of the family planning program through the use of contraceptives.¹⁹

In Indonesia, the problem that developed after establishing the decentralization policy was the decline in the institutional capacity of the family planning program, this happened because the commitment of each region was different depending on political conditions and leadership. Political commitment, policy, and investment in the health system can increase access to family planning.¹⁰ An exploratory study conducted by Budisuari and Rachmawati in 2011 in East Java, Bali, and Central Kalimantan concluded that these policy differences resulted in the absence of a clear vertical path as to who was responsible for causing a lack of coordination in terms of the provision of tools there was an incompatibility between the needs and the tools provided by the central government.²⁰ A study conducted in West Kalimantan concluded that the obstacles to implementing family planning programs were caused by a decrease in the number of Penyuluh Lapangan Keluarga Berencana/Family Planning Educator (PLKB) and the ability of local government budgets to provide contraceptives.²¹

This study aims to:

It is hoped that the results can provide policy input to related stakeholders.

Methods

Results

Quantitative results

The contraceptive mix is described as a frequency distribution with a proportion measure. The contraceptive mix criteria are skewed if there is a contraceptive method whose proportion exceeds 50%.

The results of the dynamics of the contraceptive mix in 1997, 2003, 2007, and 2012 are shown for each of the five or four provinces as follows (the full dataset can be found under Underlying data²³):

In Figure 1 it can be seen that the proportion of the use of injectable contraceptive methods in each province has increased every year.

Figure 1. Proportion of injection methods in each province, 1997-2012.

In Figure 2 it can be seen that the proportion of IUD use in each province has decreased in contrast to the use of injectable contraceptives.

Figure 2. Proportion of IUD methods in each province 1997-2012.

Just as most provinces experienced skewed, the national figure also skewed to the injection method as shown in Figure 3:

Figure 3. Indonesian contraceptive mix trends in 1997-2012.

The following are the results of the multinomial logistic regression analysis used to see the variables that have the most influence on selecting contraceptive methods. The relative risk ratio (RRR) was used to interpret the results of the tendency value, which serves to find a comparison between the probability of an event to the probability of it not occurring.

Table 1. Results of multivariate analysis.

Determinant	Choices of contraception method (baseline MOP/MOW)
	Pill	Injection	IUD	Implant	Condom
	RRR 95%CI	RRR 95%CI	RRR 95%CI	RRR 95%CI	RRR 95%CI
Age
20-35 years old	3.80 (2.57-5.61)	5.85 (3.99-8.56)	2.32 (1.57-3.43)	5.31 (3.43-8.23)	3.97 (2.53-6.24)
Parity
0-2 times	4.93 (3.40-7.17)	4.58 (3.17-6.61)	5.18 (3.50-7.67)	2.88 (1.92-4.31)	6.21 (3.89-9.93)
Education
Medium	1.63 (1.09-2.44)	1.88 (1.28-2.76)	0.62 (0.43-0.89)	1.39 (0.81-2.38)	0.64 (0.38-1.09)
Low	2.54 (1.68-3.85)	2.93 (1.98-4.32)	0.56 (0.38-0.82)	2.00 (1.16-3.45)	0.46 (0.27-0.79)
Wealth index
Poor	0.46 (0.29-0.73)	0.49 (0.32-0.76)	0.61 (0.34-1.1)	0.49 (0.30-0.79)	0.82 (0.34-1.93)
Medium	0.38 (0.23-0.62)	0.43 (0.27-0.68)	0.55 (0.32-0.97)	0.41 (0.24-0.69)	0.82 (0.34-1.94)
Rich	0.35 (0.22-0.55)	0.36 (0.24-0.56)	0.75 (0.44-1.29)	0.28 (0.17-0.47)	0.75 (0.32-1.76)
Richest	0.16 (0.10-0.27)	0.16 (0.10-0.27)	0.66 (0.39-1.24)	0.17 (0.96-0.29)	0.37 (0.15-0.90)
Knowledge
Less	1.93 (1.44-2.61)	2.21 (1.65-2.95)	1.50 (1.06-2.11)	1.15 (0.82-1.62)	0.62 (0.37-1.05)
Evaluation of Side Effect
Yes	0.88 (0.67-1.16)	0.76 (0.59-0.98)	0.90 (0.64-1.27)	0.73 (0.51-1.04)	0.93 (0.61-1.43)
Number of kids wanted
>2 children	1.00 (0.78-1.28)	0.99 (0.78-1.26)	0.77 (0.59-0.99)	0.87 (0.65-1.16)	1.09 (0.77-1.57)
Source of information
Non medical staff information	0.53 (0.39-0.71)	0.35 (0.26-0.46)	0.51 (0.37-0.72)	0.47 (0.34-0.65)	0.51 (0.35-0.75)
Distance
Problem	0.93 (0.63-1.38)	1.04 (0.71-1.51)	1.03 (0.64-1.66)	1.25 (0.82-1.90)	0.79 (0.41-1.54)
Type of Area
Village	1.03 (0.74-1.44)	1.13 (0.82-1.55)	0.86 (0.61-1.22)	1.47 (0.99-2.19)	0.51 (0.32-0.790
Cost
Pay	9.00 (6.34-12.79)	15.8 (11.53-21.66)	0.99 (0.72-1.36)	1.01 (0.72-1.42)	5.18 (3.04-8.83)
Facility
Government	0.33 (0.25-0.45)	0.61 (0.46-0.80)	0.70 (0.51-0.94)	1.22 (0.86-1.73)	0.11 (0.06-0.21)
PLKB Visit Intensity
No	0.85 (0.53-1.37)	1.16 (0.73-1.86)	1.09 (0.64-1.86)	1.07 (0.62-1.88)	0.90 (0.46-1.73)

Discussion

The contraceptive mix refers to the percentage of women who use contraception based on their chosen technique.^13,22 The calculation of the research contraceptive mix used the proportion of each method in each province in the four survey periods. The slope of the proportion of various contraceptives is that 50% or more of contraceptive users in a country use a similar contraceptive method.¹⁴

The contraceptive mix in 1997 showed that three provinces deviate towards use of contraceptives, namely South Kalimantan Province and Central Kalimantan Province. Mixed methods skewedness leads to the pill contraceptive method with 65.01% for South Kalimantan Province and 60.17% for Central Kalimantan Province. The province that skewed towards the injection contraceptive method was East Nusa Tenggara (54.72%). The national contraceptive mix rate has not been skewed.

The decentralization of the family planning program is regulated in Government Regulation Number 38 of 2007 concerning the Sharing of Government Affairs between the Government, Provincial Government, and Regency/City Government. This regulation explains that the family planning program and 31 other functions, including government affairs, are shared between levels and government affairs. In 2007, 21 Provinces experienced a trend toward the injection method. National figures have skewed towards the injection method. This shift is problematic if caused by policy, lack of access to various methods, or provider bias.¹⁷

Twenty-one provinces were skewed in the contraceptive mix toward the injection method in 2021. The national figure has skewed towards the injection method (54.89%). These results are consistent with research in 2006 by Sullivan from 96 countries studied, 34 of which have a skewed contraceptive mix type.¹⁷ The trend toward the injection method confirmed that this type of contraception has increased the most.²⁴ A high concentration of one or more specific types of contraception is a sign that the availability of the method in society is uneven.²⁵

The contraceptive mix is an essential indicator of the achievement of the family planning program. With the commitment of the Indonesian government to Family Planning 2020, 120 million women use modern contraception. Plans made to achieve this commitment include the enforcement of family planning service regulations through the National Health Insurance referring to the Universal Health Coverage scheme, increasing the contraceptive mix, availability, quality, and supply chain management of contraception, encouraging the involvement of the younger generation, implementation of an integrated approach through the Family Planning village.²⁶

The deviation proportion of the contraception mix is the result of several factors, including acceptors' lack of knowledge about the method used, providers' preference for specific methods because the incentives for using injection methods are high, and support and promotion for the use of vasectomy, implants, and much less tubectomy.¹⁵ The shift towards injection methods and the reduction in use of other methods, especially the IUD, had an unexpected impact because the injection failure rate was relatively high.²⁷ The IUD is the most effective method after tubectomy and vasectomy (Stephen Searle, 2014). An increase in the use of IUDs can be achieved by counseling on the use of contraception through to Ante Natal Care (ANC).²⁸

The everyday use of the IUD is partly due to people's assumption that the IUD can cause infertility. The research results state that the IUD is safe for women who have never given birth.²⁹ The IUD does not affect the return of fertility.^28,30 The return of fertility after IUD removal ranges from 3-to 4 months^31,32 to 12 months,^29,33 and 18 months.²⁹ The IUD does not affect fertility after discharge.³⁴

Based on the age of the respondents, it can be seen that respondents aged 20-35 years (compared to those aged <20 and >35 years) have the highest tendency of 5.8 times to select the injection method compared to selecting the MOP/MOW method. Respondents with parity category 0-2 times (compared to those who have given birth >2 times) are 6.2 times more likely to use the condom method than the MOP/MOW method.

There is a lower tendency (compared to higher education levels) at the secondary education level to select the IUD method than the MOP/MOW method. Respondents with secondary education did not show a statistical relationship with the selection of condom method. Respondents with low education have a lower tendency (compared to higher education levels) to select the IUD and condom methods.

In general, the poor, middle, affluent, and richest economic statuses have a lower tendency (compared to the poorest economic status) to select all methods (pills, injections, IUDs, implants, and condoms) compared to selecting the MOP/MOW method. Based on knowledge about family planning, respondents with less knowledge (compared to those who have good knowledge) tend to select the injection method 2.2 times more than the MOP/MOW method.

In general, respondents who have experienced side effects of contraception, choose to have less than two children, and obtain family planning information sources from non-health workers have a lower tendency to select a variety of contraceptive methods such as pills, injections, IUDs, implants, and condoms, compared to the MOP/MOW method.

External factors influence the selection of a particular contraceptive method in the form of exposure to information that increases the individual's knowledge of determining the selection of the right contraceptive. The information exposure can come from field officers (PLKB) and health workers who contact respondents.

There is no statistical relationship between the intensity of field officers' visits and the selection of family planning methods. Statistically, the variable that has the most vital relationship with the selection of contraception is the variable cost, with a significance of 0.001 and an OR of 9.001. These results can be caused by field officers' insufficient numbers and incompetence.

In connection with the decentralization policy, each region needs adequate infrastructure to support the family planning program. The availability of contraceptives and infrastructure can be an impetus for an individual to decide on a suitable contraceptive method. The decentralization policy has had a positive impact in some areas and a negative impact in some other areas. Skewness is due to the inadequacy of existing method alternatives and provider bias.³⁵ This study confirms the availability of contraceptives and the role of providers in influencing the contraceptive methods used by the community. Reasonable access is accompanied by a better balance of contraceptive mix.³⁶

Contraceptive method mix is the proportion of contraceptive usage. The contraceptive method mix is influenced by selecting contraception at the individual level. There are many reasons why a person selects contraception. This study resulted in the variables of respondent's age, parity, education, side effects of contraception, number of children, and sources of information having a significant relationship with the selection of contraceptive method (p-value of 0.05). These results affirm research that the selection of contraceptives can be influenced by age, the number of living children, education, religion, desire to have children, visits by health care providers, and husband's views on contraceptives.³⁷

The results of a study on the number of children variable follow several previous studies. Analysis of Indonesia Family Life Survey(IFLS) data in 1997-2000 in Indonesia states that women most widely utilize contraception with 1-2 children.³⁸ In addition, women with more children tend to want to use contraception more than those who have fewer children.^37-40 The desired child's gender preference influences the number of children owned in some countries.

The results of the analysis on the side effect evaluation variables have a relationship with the selection of family planning methods. A study in Japan regarding the evaluation of the use of oral contraceptives states that a person's experience with a contraceptive and abortion influences the selection of contraception that will be used later⁴¹ and experience related to the selected contraceptive method and attitude factors.⁴²

The variable of education level has a relationship with the selection of contraceptives (p-value 0.001-0.02). The knowledge variable has a significant relationship with the selection of contraceptive pill, injection, implant, and condom method compared to the MOW/MOP contraceptive method (p-value 0.001). The knowledge variable is not significantly related to the selection of the IUD contraceptive method compared to the MOW/MOP contraceptive method (p-value 0.90).

The higher the education level, the more likely women are to use contraception.^37,41,43 if someone has a higher education, they are likely to have more knowledge regarding contraception.⁴⁴ In addition to education, factors that influence knowledge of contraception are exposure to information from mass media, social media, socialization from providers, and information obtained informally from other individuals. Government policies and campaigns to increase public knowledge regarding quality and quantity are needed to promote gender equality further.⁴⁵

Increasing public knowledge about family planning should be initiated as early as possible. An effective way is to include reproductive health education and the introduction of contraceptives in school curriculum. The age of menarche and the high rate of unwanted pregnancies in adolescents make the curriculum on reproductive health important. The optimal time to provide reproductive health education is when children begin to understand sexual activity and can have sex physiologically.⁴⁶ Formal reproductive health education and the introduction of contraceptives do not increase children's early sex activity and can reduce unwanted pregnancies in adolescence.⁴⁷

The results of the analysis of the age variable are related to the selection of contraception. In Indonesia, the results of the IFLS analysis in 1997-2000 show that the majority of contraceptive users are under 40 years old.⁴⁸ Women aged 30-34 years used contraception more than other age groups. Meanwhile, research in Mongolia concluded that the increasing age of women increases the desire to use contraception.⁴⁹ Things to consider in the selection of a contraceptive method among the 40 years+ age group include irregular menstrual frequency, sexual problems, and possible signs of menopause, all of which respond to hormonal contraception.⁵⁰

The results of the parity analysis are related to the selection of contraception. Parity is the number of times a woman has given birth, whether live or stillborn. A woman's age affects her choice of contraception and how many children she wants to have.⁵¹ Research in Japan related to age, parity, and abortion concluded that parity at a young age influences the selection of contraception, and contraception after abortion reduces the risk of repeated abortions.⁵²

The study results show that the distance variable (p-value 0.000) has a relationship with the selection of contraceptive methods. The type of area (p-value 0.000) and facilities (p-value 0.000) have a significant relationship with the choice of contraceptive method of the respondents. These results are in line with research by Khalil et al. in Afghanistan, which states that most women who do not use contraceptives are illiterate and live in rural areas.⁵³ The use of contraceptives in Pakistan tends to decrease among women who live in rural areas, are less educated, and are poor.⁵⁴

In Indonesia, a study conducted by Rahayu et al. (2009) showed that there were more users of modern contraceptives in urban areas than in rural areas.³⁷ Similar results to Kiswanto's (2015) study stated that in 1997 users of contraceptives lived in urban areas. In 2007, users in rural areas increased, but the percentage of users in urban areas remained higher.³⁸ Achana et al. (2015), who conducted a spatial analysis of contraceptive users in Ghana, concluded that most contraceptive users live in urban areas.⁵⁵ Women who live in urban areas and have a high level of education are more likely to use modern contraception.^{37,41,50,53,56}

The variable cost is significantly related to the selection of the pill contraceptive method (p-value 0.000), the injection contraceptive method (p-value 0.000), the IUD contraceptive method (p-value 0.04), and the condom contraceptive method (p-value 0.000). There is no significant relationship between the implant contraceptive method (p-value of 0.009). People in rural areas may select the pill and injection method because of their low cost.³⁷

The type of facility influences the choice of contraception (p-value 0.001). People obtain contraceptive services in two types: public and private services. The quality of the two services influences the perception of selecting contraception. A study in Tanzania comparing public services and private services stated that public services offered more modern contraceptive services and had more guiding protocols than private services.⁵⁷

The results of the provider variable research are not related to the selection of contraception. These results do not follow some previous studies. Research by Ugaz et al. in 2016 stated that the leading cause of stagnation in the number of users of long-term contraceptives is the lack of knowledge of providers causing the information provided to clients to be less accurate. Thus, the perception of long-term contraceptive users, especially IUDs and implants, becomes negative.⁵⁸ Results of the study that are not following previous research are possible because this study only focuses on field officers (PLKB). Meanwhile, the proportion of respondents who received visits from field officers was small.

Various things influence the selection of contraception. The results of the quantitative analysis of this study resulted in the variable that most influenced the selection of contraception method. It was the variable cost—other variables much influence the selection of the method. Several studies have stated that the provider variable has a significant effect.

Health workers have duties at the end of the family planning program because they deal directly with acceptors/families.⁵⁹ An evaluation study with a multilevel analysis in China regarding sterilization methods concluded that family planning officers increased sterilization participation rates, especially in women with high parity.⁶⁰ A study conducted in Bangladesh in 2004 showed that family planning officers have a significant role in the success of contraceptive use, especially the contraceptive pill.⁶¹ The influence of the provider is enormous on the selection of contraceptive methods.⁶² A literature review related to the role of providers in increasing IUD use described that many providers had a low or uneven level of knowledge about IUDs and limited training.⁶²

The results of the qualitative analysis showed that the family planning program facilities and infrastructure received support from a special allocation fund which was realized for supporting facilities and infrastructure such as motorbikes and cars. In 2016, DAK can be used for non-physical facilities like family planning, operational facilities, and infrastructures such as service cars, mobile phones, motorbikes, and uniforms. In other words, it is beneficial to meet the needs of facilities and infrastructure. These facilities are used for outreach operations and family planning village operations. Decentralization improves infrastructure facilities and equipment in primary and secondary health care institutions and expands the scope of health services.⁶³ Decentralization also improves the distribution of public services, people receive easier access to contraceptives, health services, and health information.^{18,26–28,61,64,65}

The provinces of East Nusa Tenggara and Papua stated that the facilities and infrastructure from the BKKBN were sufficient prior to decentralization. After decentralization, due to a lack of local commitment to the family planning program, vehicles and buildings were used/transferred by other agencies. However, facilities and infrastructure are less supportive for remote areas. Therefore, decentralization has successfully led to disparities in the distribution of health services between rich and poor regions.⁶⁶

Decentralization increases equitable access to contraceptives at all levels of society. This condition occurs in several provinces, such as East Nusa Tenggara. The informant from the province of East Nusa Tenggara said “Support for other facilities, vehicles, and contraceptives, is powerful. If we compare the e-infrastructure at that time to the Regional Government, the BKKBN is seen as a luxurious institution if we want. However, when did the reforms take place in what year?" (Informant from East Nusa Tenggara Province). Some remote areas require more operational tools than other regions due to the terrain and topography of the area, and there are still many tribes in the interior, and it is tough to reach services. In line with a study in Spain regarding consumer satisfaction, it is stated that decentralization does not increase consumer satisfaction with the health services provided.⁶⁷

The distribution of contraceptives from the central government to the network of six provinces is considered sufficient. There are no difficulties found with contraception distribution in Yogyakarta, Bali, West Java, and West Nusa Tenggara, both urban and suburban regions. There are contraceptive transport cars that distribute contraceptives to the network level. If the stock of contraception is empty and there is no one from the center, it can apply for transfer of contraception from another province. If the cross-subsidy cannot be fulfilled, the center will intervene to meet ends. A study in Nepal in 2010 stated that decentralization is positively related to service access, utilities, and improving the quality of services provided to the community.^62,68,69

The distribution of contraceptives from the center uses an e-catalog ordered according to the needs of each region. For Papua Province, the distribution of contraceptives was carried out by the central government. Procurement of contraceptives by the central government cannot be done in large quantities at once because the community's needs are minimal. If there is a request from the district/city, then the distribution of contraception will be made. For the Province of Bali, it is stated that stock calculations from the center often do not meet the needs. For example, the calculated proportion of women of childbearing age have the greatest need for intra uterine devices (IUD). However, the available contraceptives are pills and injections.

Until 2017, the procurement of contraceptives by the central government through the BKKBN was carried out based on the BPJS (Social Security Administrator for Health) Law. The procurement of medical devices in 2018 is under the province's authority. In this case, more vigilance is needed because procurement requires auctions prone to fraud.

Decentralization has great potential and can be optimal if district/city leaders understand the importance of family planning programs. In general, the main objective of decentralization to bring services closer to the community is not believed to have been achieved. This is because Family Planning programmes are mostly financed by the province, and contraception is still fully borne by the central government. The informant from Bali province said that “… yes now, in 2018, the procurement of contraceptives is returned to the regions, if in the past it was in the regions, now it is being reversed again. So before, we have procured at the center for several years, because following the laws including the BPJS Law that contraceptives are 100% by BKKBN, provided by BKKBN…” (Informant from Bali Province).

Provision of contraceptives is performed by calculating the number of acceptors, community demand, type of contraception (recurring or not), and planning targets for new participants. The calculation results are then recalculated with the remaining contraceptives from the previous year both in regional warehouses, district warehouses, and on the network. Minimum stock production is two years and three years for Bali Province. Due to the nature of the cooperation with the BPJS, practical midwives are included in the network and must deliver contraceptives to health facilities and networks that have partnered with the BPJS. Contraceptives for low-income families must be covered and free regardless of the type of contraception used. These results confirm the theory that decentralization increases budget allocation for the poor.⁷⁰

The limitations of this study were: 1) Qualitative research is carried out at the provincial BKKBN representative level. For a more in-depth study, research should be carried out at the district/city level; 2. Analysis at the individual level uses data from one survey, namely IDHS 2012, to represent current conditions. With the implementation of the 2017 IDHS, it is hoped that further research will be carried out to reflect actual conditions better.

Conclusions

Generally, decentralization has different outcomes in different regions; some areas face negative consequences, according to a study done in 22 countries using panel data that indicated decentralization is not linearly correlated to equal distribution of health services.⁷¹ Decentralization in Southeast Asia is considered not achieving the expected goal of bringing services closer to society.⁷² The studies in Gana and Guatemala resulted in fewer (centralized) options associated with better performance for two main functions (inventory control and information systems). In contrast, more choice (decentralization) was associated with better performance in budgeting and planning.⁷³

Contraception is closely related to a person's reproductive rights, part of human rights. Thus, the government must fulfill the rights of every citizen as stated in the 1945 Constitution, which mandates guarantees of human rights. The right to health is also stated in national instruments in article 28H paragraph (1) and Article 34 paragraph (3) amendments to the 1945 Constitution, Article 9 of Law no. 39 of 1999 concerning Human Rights, and article 12 of Law no. 11 of 2005 concerning Ratification of the Covenant on Economic, Social and Cultural Rights. The provisions in the 1945 Constitution above are further regulated in Law no. 36 of 2009 concerning health. Thus, the government must provide the family planning program's infrastructure.

Suggestions that can be conveyed based on the research findings include: