F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.121725.1 Research Article Articles Indonesia mixed contraception method skewness background 1997-2012: A mixed method study

[version 1; peer review: 1 approved with reservations]

 Utari Dyah Conceptualization Data Curation Formal Analysis Funding Acquisition Investigation Methodology Project Administration Resources Software Validation Visualization Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-6808-0209 a 1 Public Health, Faculty of Health Science, Pembangunan Nasional Veteran University Jakarta, R.S Fatmawati Street No. 1, Cilandak, South Jakarta, 12450, Indonesia dyahutari@upnvj.ac.id

No competing interests were disclosed.

 7 11 2022 2022 11 1266 1 11 2022 Copyright: © 2022 Utari D 2022 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Indonesia's decentralization policy adopted in 1999 had implications for the programs of national ministries and agencies, including the family planning program. Since 1999, there has been a "relaxation in family planning program effort" since many districts have a low commitment to family planning. The trend of contraceptive mix in Indonesia leading to hormonal methods, especially injections, has occurred since 2007. This study aimed to describe the mixed conditions of contraception in Indonesia from 1997 to 2012 and explore the link between the availability of facilities and infrastructure with this plan. Methods: The quantitative research used was a cross-sectional design using secondary data from the Indonesian Demographic and Health Survey (IDHS), and In-depth interviews were employed as the qualitative approach in this study. It was found based on the results of the quantitative analysis that the trend of contraceptive mix tilted to the injection method. Results: The qualitative study results indicate that the contraceptive mix is affected by infrastructure as the main factor. Conclusion: In conclusion, there is a close relationship between the decentralization policy and the condition of the contraceptive mix. Thus, it is recommended that the central and local governments re-prioritize family planning programs and assure the availability of supporting facilities and infrastructure.

 contraceptive mix family planning programs decentralization The author(s) declared that no grants were involved in supporting this work. 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 growth 5 ; 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 lacks 15 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:

Obtain an overview of trends in the contraceptive mix in Indonesia in 1997, 2003, 2007, and 2012;

Analyze the variables that most influence the selection of contraceptives;

Analyze the implications of decentralization policies on the contraceptive mix in Indonesia.

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

 Methods Study design

This study used a combination approach including quantitative methods and qualitative methods. The quantitative research used was a cross-sectional design using secondary data from the Indonesian Demographic and Health Survey (IDHS). The data used were the 1997 IDHS, 2003 IDHS, 2007 IDHS, and 2012 IDHS to see the contraceptive mix trend. The qualitative element of the research used in-depth interviews which were conducted in December 2017 with six informants from each of the selected provinces.

The research was carried out in two stages:

The first stage examined the trend of the contraceptive mix in 1997 (before decentralization), 2003, and 2007 (when decentralization was implemented), and 2012 (representing current conditions). The data used in this stage was data on the percentage distribution of the use of various contraceptive methods, collected from the Indonesian Demographic and Health Survey (IDHS) in 1997, 2003, 2007 and 2012. The data was then processed to determine the occurrence of skewed contraceptive mix by looking at the distribution. If there is one method that has a distribution of more than 50%, it can be concluded that there was a downward trend in the contraceptive mix in that year.

The second stage examined the implications of the decentralization policy on the contraceptive mix. This stage was carried out through in-depth interviews with informants

Quantitative phase

Sample population

The sample of this study were all women who met the inclusion criteria in 1997, 2003, 2007, and 2012 IDHS data. The inclusion criteria for the study were as follows:

Age 15-49 years

Married and or been married before

Using modern contraceptives

Meanwhile, the exclusion criteria were incomplete data. The number of samples obtained after selecting the inclusion criteria for the survey was 18,186 respondents.

 Data collection

This study was a further analysis of the Demographic and Health Survey (IDHS) data. The data used were the 1997 IDHS, 2003 IDHS, 2007 IDHS, and 2012 IDHS data.

The sample in the 1997 IDHS is a replication of the 1994 IDHS sample. The sample is stratified by province and type of urban and rural areas. The first stage of sample selection was Area Enumeration. Samples were selected systematically using proportional probability according to the size of the population. The second step involved selecting approximately 70 families with clear boundaries and only one segment was selected with a proportional probability measure. The third step was to select 25 families for each segment using systematic sampling.

The sample frame used in the 2007 IDHS was differentiated according to the stages of selecting the sampling unit, namely the sample frame for selecting the census block and the sample frame for selecting households. In the selection of census blocks, the sample frame used was the list of selected 2007 SAKERNAS (Survei Angkatan Kerja Nasional/National Labor Force Survey) census blocks. For household selection, the sample frame used was the list of households resulting from the 2007 SAKERNAS listing.

The sample size of census blocks and households for all selected provinces has been determined to be 1,694 census blocks and 42,350 households. From all the household samples, it is hoped that 33,880 female respondents who have been married aged 15-49 years can be obtained.

The 2012 IDHS was implemented in all 33 provinces in Indonesia and spread over 1,840 census blocks covering urban and rural areas. With a census block sample of this size, a total sample of 46,000 households was obtained for this survey. From all the household samples, i55,200 female respondents of childbearing age aged 15-49 years can be obtained.

From the IDHS survey sample, the research sample was then selected according to the inclusion criteria as described in the population sample section.

 Data analysis

For the data analysis, we used univariate analysis on the variables of contraceptive use to see contraceptive method mix trends from 1997 to 2012 in each province. Multinomial logistic regression analysis was used to analyze the determinants of the selection of contraception and the most influencing variables. The dependent variable used was the contraceptive method. The independent variables included age, parity, knowledge, side effects, the desired number of children, economic level, sources of family planning information, access, types of area, costs, facilities, and information. This study does not require validity and reliability tests because it uses Demographic and Health Survey data.

Qualitative phase

In-depth interviews were employed as the qualitative approach in this study to see the policy process from the perspective of the policyholder so that the Indonesian family planning policy process could be better understood.

 Sample population

The selection of informants in this study focused on the representation of the problems studied. In-depth interviews were conducted with informants who met the basic criteria of Neuman as follows:

The informant is familiar with the problem and is in position to witness the events;

The individual is currently involved in the field;

The person can make time for interview 22

The informants involved were policymakers, namely representatives of the provincial Badan Kependudukan dan Keluarga Berencana Nasional/The National Family Planning Coordinating Agency (BKKBN). They were selected according to the mapping of the contraceptive mix in each province.

The provinces selected were the most balanced contraceptive mix, the most skewed contraceptive mix, and the provinces with special conditions. From the results of the contraceptive mix trend in the previous stage, representatives of the three criteria above were selected for in-depth interviews as follows:

Bali Province and Yogyakarta Province represent groups with a relatively balanced contraceptive mix;

The provinces of West Nusa Tenggara, East Nusa Tenggara, and Papua Province represent groups with skewed contraceptive mixtures;

West Java Province represents a group with special conditions, namely provinces with good family planning programs, but the contraceptive mix is skewed.

The informants were contacted during the 2018 BKKBN national work meeting.

 Data collection

The research location was Jakarta. In-depth interviews were held on 2-3 February 2018 during the 2018 BKKBN national work meeting. In-depth interviews were divided into six sessions with one informant in each session. The duration of interviews ranged from one to two hours per session.

The interviewer conducted an in-depth interview that used a semi-structured interview guide. A copy of the interview guide used can be found under Extended data. 23 The interviewer could develop questions to explore more in-depth information from the informant but focused on the set research objectives. The equipment used for the interview were:

Voice recorder;

Stationery for taking notes;

Interview guide

The interview guide included several points: Organizational structure, Legacy policies Policy socialization, Policy implementation, Situation analysis and evaluation, and Infrastructure

 Data analysis

The qualitative data processing began with transcribing the voice recordings, then cleaning the voice recording data with the results of transcripts and data notes to check accuracy.

The stages of data analysis were as follows:

Sorting transcript data into numerical matrices based on themes and characteristics that have been adapted to the research objectives

Data management and security, verification of data, and anonymization

Data triangulation was carried out by re-checking the relevant stakeholders. This triangulation process was carried out in March 2017 using the expert judgment method. The selected experts are experts from the central BKKBN

Theme analysis is the process of coding information that produces a complex and complete list of themes or indicators, groupings related to themes and a combination of several themes of this research. The theme analysis consists of three lines, namely data reduction, data presentation and conclusion drawing.

Ethical statement

We obtained ethical approval for this study from University of Indonesia Faculty of Public Health Research Ethical Clearance Commission on 03-08-2017 (456/UN2.F10/PPM.00.02/2017).

Written informed consent was sought from the participants for their involvement in this study and the publication of their data. Only one participant consented to the sharing of their data. Participants were informed of their right to withdraw and that they could refuse to answer any questions. Participants were given information related to in-depth interview procedures, documentation, data confidentiality, and the risks and benefits involved in the research.

 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 data 23 ):

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

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.

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:

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.

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)
Qualitative results

From the three groupings related to the trend of the contraceptive mix in each province, the informants then took part in in-depth interviews:

Province of Bali and Province of Yogyakarta represent group I

Provinces of West Nusa Tenggara, East Nusa Tenggara, and Papua Provinces represent group II

West Java province is grouped separately because it has a good family planning program but with a skewed contraceptive mix.

The focus of the in-depth interviews was to obtain information on conditions prior to decentralization and the current condition of the Human Resources, Institutional, Funding, and Infrastructure variables. Decentralization policies that were explored through in-depth interviews were used as a barrier. The results of the interviews found which components of the decentralization policy supported the selection of the right contraceptive method and which components hindered the selection of the right contraceptive method.

The Human Resources variable of this study was focused on field officers, namely PLKB. Aspects that are observed from human resources are adequacy, government efforts to meet human resource needs, competency improvement programs, payroll systems, and problems that arise with the decentralization policy. Institutional variables include organizational structure, district/city commitments, and current conditions and problems that arise with the decentralization policy. Budget variables include budget sources, allocations, adequacy, accountability and transparency, and problems that arise with the decentralization policy. The infrastructure variables include infrastructure, provision of contraceptives, and distribution of contraceptives.

Results of in-depth interviews with six informants from three provincial groups.
Province/Item Group I Group II Group III
Bali (Informant from Bali Province) Yogyakarta (Informant from Yogyakarta Province) Papua (Informant from Papua Province) West Nusa Tenggara (Informant from West Nusa Tenggara Province) East Nusa Tenggara (Informant from East Nusa Tenggara Province) West Java (Informant from West Java Province)
Human Resources Human Resources Adequacy Sufficient ratio (1:1) - Sufficient human resources - The lowest ratio is 1:2 village - Very less - There are 53 PLKB for all of Papua -Less ratio - Ratio of PLKB 1 person handling 4 to 5 villages - less PLKB - Ratio of 1 to 2-3 villages - In terms of PLKB, it is sufficient even though it is not optimal - Ratio 1:1
Government efforts to meet human resource needs (Recruitment) Some Regencies/Cities add PLKB Procurement of honorary PLKB by Regency/City Some Regencies/Cities add PLKB There are honorary PLKB and PPPK (Government Employees with Work Agreements) Regencies/Cities add honorary PLKB - There are 2000 village movers from the province (appointed through a Governor's Decree) and 416 from the Regency/City with APBD funds - The main function of the village driving force is the same as PLKB
Institutional Organizational structure Institutions vary Institutions vary Institutions still vary depending on regional commitments Institutions still vary depending on regional commitments Institutions still vary depending on regional commitments Institutions vary
Regional commitment High commitment High commitment Commitments vary City district commitment is minimal Commitments vary High commitment
Fund Source Source of funding from APBN (Anggaran Pendapatan dan Belanja Negara/State Revenues and Expenditures Budget) and APBD (Anggaran Pendapatan dan Belanja Daerah/Regional Revenues and Expenditures Budget) Source of funding from APBN and APBD Source of funding from APBN and APBD Source of funding from APBN and APBD Source of funding from APBN and APBD Source of funding from APBN and APBD
Allocation - APBN for PLKB salaries - APBN through DAK for physical and non-physical DAK (Dana alokasi Khusus/The Specific Allocation Fund) for physical and non physical - APBN for PLKB salaries - APBD for program operations - There are partners who help the family planning program - DAK allocation for physical facilities and infrastructure - APBD for operations - The allocation for the family planning program is minimal because it is considered not a priority program APBN allocation through DAK for physical infrastructure - APBN for PLKB salaries - APBN through DAK for physical and non-physical After decentralization, APBN funds can go down to regencies and cities through DAK and DOKB (Funds for Family Planning Operations)
Infrastructure Infrastructure Family planning operational facilities and infrastructure such as service cars, cellphones, motorbikes, uniforms, etc. are obtained from DAK Get support for special allocation funds that are realized for supporting infrastructure such as motorcycles, cars - Supporting facilities and infrastructure but distribution to the regions is still very limited - Need more operational equipment compared to other areas due to terrain and topography of the area - There are still many tribes in the interior and it is very difficult to reach services - Prior to decentralization, BKKBN facilities and infrastructure were sufficient - Vehicles and buildings used/transferred by other services infrastructure is less supportive for remote areas Family planning operational facilities and infrastructure such as service cars, cellphones, motorbikes, uniforms, etc. are obtained from DAK
Contraception Distribution - There is a contraceptive transport car - If the stock of contraceptives is empty and not available from the center, you can submit shipments from other provinces - Order using e-catalog - Distribution of contraceptives from the central level to the network - There are no problems with the distribution of contraceptives in Yogyakarta, both in urban areas and in suburban areas such as Gunung Kidul - Distribution of contraceptives is done by dropping - Dropping cannot be done at once in large quantities because the community's needs are very minimal. - If there is a request from a new district/city, alkon distribution will be carried out - Distribution of contraceptives is the same as in other regions - If the stock of contraceptives is empty, you can take it from another province The distribution chain is the same as in other regions - There is a contraceptive transport car - If the stock of contraceptives is empty and not available from the center, you can apply for the transfer of contraceptives from other provinces - Distribution using e-catalog
Provision of contraceptives - In Bali the calculation is 3 years - Calculation of central contraceptive devices is too high for Bali, especially for the need for the IUD method - Availability of sufficient alkon - Availability of alkon up to network level guaranteed - The poor are free - Contraceptive devices are provided according to the request of each district/city Fully providing contraceptives by BKKBN Contraceptives are still from the central government - Until 2017 the procurement of contraceptives was carried out by the center by the BKKBN in accordance with the Law related to BPJS - Minimum stock making is 2 years
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 later 41 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:

More attention should be given to remote areas in terms of distribution of contraceptives, provision of infrastructure, and availability of human resources

The policy direction should include aspects of quality and guarantee of availability

Making areas with poor family planning programs (can refer to indicators of the contraceptive mix and program coverage) a top priority

Formulating substance guidelines related to family planning programs so that district/city leaders understand the essence of choosing the right contraceptive method so that the program implemented can be on target

Incorporate reproductive health education into the primary and junior secondary school curriculum.

Data availability Underlying data

Data used in this study are from the Demographic and Health Survey (DHS). Access to the dataset requires registration and is granted only for legitimate research purposes. A guide for how to apply for dataset access is available at: https://dhsprogram.com/data/Access-Instructions.cfm.

IDHS 1997: https://dhsprogram.com/data/dataset/Indonesia_Standard-DHS_1997.cfm?flag=0

IDHS 2003: https://dhsprogram.com/data/dataset/Indonesia_Standard-DHS_2003.cfm?flag=0

IDHS 2007: https://dhsprogram.com/data/dataset/Indonesia_Standard-DHS_2007.cfm?flag=0

IDHS 2012: https://dhsprogram.com/data/dataset/Indonesia_Standard-DHS_2012.cfm?flag=0

Due to ethical restrictions, the interview transcripts from the informants from Bali, Yogyakarta, West Nusa Tenggara, East Nusa Tenggara, and West Java are available upon request from the corresponding author at dyahutari@upnvj.ac.id.

Figshare: Indonesia mixed contraception Method skewness 1997-2012. https://doi.org/10.6084/m9.figshare.20405907. 23

This project contains the following underlying data:

CURRENT CONTRACEPTIVE METHOD 1997 UNTIL 2012.xlsx

MIX METHODE COMPARISON FROM IDHS 1997_2012.xls

WEIGHTED IDHS DATA FROM 1997 UNTIL 2012.sav

Fix_Transkrip Papua.pdf (interview transcript from Papua Province participant)

Extended data

This project contains the following extended data:

DEPTH INTERVIEW GUIDANCE.doc

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

 Acknowledgments

The author would like to thank you to Dr. Tris Eryando, MA and Prof. dr. Purnawan Junadi, MPH., Ph. D and also Universitas Pembangunan Nasional Jakarta.

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Health Policy Plan. 2003;18(4):357–369. 14654512 10.1093/heapol/czg044 10.5256/f1000research.133620.r170870 Reviewer response for version 1 Amran Yuli 1 Referee https://orcid.org/0000-0001-7907-6646 Public Health Program Studies, Faculty of Health Sciences, Universitas Islam Negeri Syarif Hidayatullah Jakarta, South Tangerang, Banten, Indonesia

Competing interests: No competing interests were disclosed.

 22 5 2023 Copyright: © 2023 Amran Y 2023 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

1. Is the work clearly and accurately presented and does it cite the current literature? --> Partly

The article does not cite the current literature (Most of the literature used was more than 5 years old when this article was first published).

Abstract section; I think is less relevant than the problems presented with the research objectives. The author observed that during 1997-2012 the use of contraceptive mixes that were not by the optimal time for women's reproduction was one of the effects of decentralization. Even though the decentralization of the family planning program officially started with Presidential Decree No. I03 of 2001, then it was updated to become Presidential Decree No. 30 of 2003, that in early 2004, various family planning programs became the authority of the local government. Meaning that decentralization was not the main reason for irregularities in the selection of contraceptives in 1997 and 2003.

I cannot properly understand the urgency of the results of this research. In my opinion, women who are young (<35 years), and want children or increase the number of children, have no problem using injectable contraception or pills. However, if a woman wants to space or limit pregnancies, using both types of contraception may not be effective because the behavior of most contraceptive users in Indonesia lacks discipline while using both contraceptives requires high discipline so as not to experience failure. Instead of the authors only describing contraceptive use by region, I suggest the authors to study contraceptive options in the age group >= 35 years and have had more than two children if the data is available. Maybe the results can describe the problem in choosing the type of contraception and what causes it?

 2. I don't see a comprehensive interpretation of the results of multivariate analysis (multinomial regression analysis). I suggest the author make a clear interpretation so that the reader understands well the research results presented in Table 1.

3. It is not clear whether the qualitative research describes the situation in 1997, 2003, 2007 or 2012?

4. In my opinion the conclusions made do not answer the research objectives. It is best if the points of exposure to the conclusions are made relevant to the research objectives.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Partly

Are all the source data underlying the results available to ensure full reproducibility?

Partly

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Health biostatistics, Family Planning (behavior on contraceptive use)

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.