Determinants of contraceptive use among married women in Indonesia

Background: Contraceptives in family planning are used to control the timings between pregnancies. Although the number of those using family planning has increased, determinants of contraceptive use among married women in Indonesia remain insufficient. This research aimed to identify the factors associated with contraceptive use among married women in Indonesia. Methods: This study employed data from the Indonesian Demographic and Health Survey 2017. We selected 35,621 married women aged 15–49 years. Then, the determinants of contraceptive use among married women in Indonesia were examined by binary logistic regression. Results: Women’s age (Adjusted Odds Ratio (AOR)=0.529; 95% CI=0.470–0.597), the number of living children (AOR=44.024; 95% CI=33.193–58.390), education level (adjusted odds ratio=2.800; 95% CI=2.181–3.594), wealth index (AOR=1.104; 95% CI=0.978–1.246), frequency of watching television (AOR=1.555; 95% CI=1.321–1.829), and frequency of using the Internet (AOR=0.856; 95% CI=0.794–0.924) were significantly associated with contraceptive use among married women. Conclusions: This study highlights the determinants of contraceptive use among married women in Indonesia. Women’s age, the number of living children, education level, wealth index, and access to information may influence contraceptive use among these women. This study emphasizes that health education and promotion on the importance of using contraception should be initiated in innovative ways.


Introduction
Family planning is a conscious effort made by couples to limit the number of children through the use of contraceptive methods. Both developed and developing countries worldwide have demonstrated increased contraceptive use to control the population 1 . Though contraceptives have been used globally, they remain less prevalent in poorer countries 2 . In Indonesia, the prevalence of contraceptive use among married women is still low and varies between provinces, economic status, education level, and residential location 3 . Based on data from the Indonesian health ministry, the percentage of contraception is divided into the following four categories: 59.3% of married women aged 15-49 years use modern contraception methods (implants, tubectomy, vasectomy, intrauterine devices, condoms, injections, and pills), 0.4% use traditional methods (lactation amenorrhea methods, periodic abstinence, and interrupted into intercourse), 24.7% have done family planning at least once, and 15.5% have never done family planning [3][4][5] . Although the number of those who actively use family planning has increased, it has not been able to sustain or increase the prevalence of contraceptive use 6 .
National data show that contraceptive use fell from 61.75% in 2014 to 59.98% in 2015 6 . One of the challenges in increasing the number of family planning participants is the high level of concern from couples of reproductive age regarding the side effects of contraceptive drugs and equipment 6 . Researchers in Ghana have performed a study to identify the factors related to the low contraception use. They found that such factors included the residential location, knowledge, marital status, religion, and partner's approval and support 7 . All efforts that can improve women's health should be implemented, particularly regarding maternal healthcare services 8 . Thus, the current study aimed to identify factors that are associated with contraceptive use among married women in Indonesia.

Data
The data for this study were collected from the 2017 Indonesia Demographic and Health Survey (DHS), which is the eighth survey since 1987. The IDHS in 2017 was performed with the cooperation of the Central Statistics Agency, the National Population and Family Planning Agency, and the Ministry of Health, with technical assistance from the Inner City Fund (ICF) internationally through the Demographic Project and Health Surveys (DHS) Program. We used the individual recoded dataset in this study.

Sample size and sampling
Our sample was composed of married women aged 15-49 years who were using contraception in Indonesia. The survey successfully interviewed 49,627 women. Based on the inclusion criteria, 35,621 women remained. The IDHS used two-stage stratified cluster sampling to select the sample, including 1,970 census blocks covering urban and rural areas. The inclusion criteria in this study were all married women aged 15-49 years and who answered the questionnaire properly, whereas the exclusion criterion was women who were not married.

Variables
The dependent variable of this study was contraceptive use, which was defined in this study as the use of contraception by married women at the time of the survey. For the explanatory variables, we used the women's age, the number of living children, education level, wealth index, residential location, the frequency of watching television, and access to the Internet.

Data analysis
The data were analyzed using the STATA statistical software version 14. Before the analysis, the dataset was weighted to account for any differences, considering the nature of the sampling design method. Univariate analysis and bivariate analysis were performed using the chi-square test. Finally, the determinants of contraceptive use among married women were identified using the binary logistic regression.

Ethical review and consent
The IDHS in 2017 obtained ethical permits from the Ministry of Health of Indonesia. All respondent identifiers were deleted from the data, and written informed consents were provided by each participant. The ICF International, which is part of the DHS program, approved the use of such data in this study.

Results
More than half of the respondents used contraception (63.60%) in which majority of them aged 35-49 years (54.77%). According to the data, contraceptive use was most prevalent in married women who had 1-2 children (62.58%). Furthermore, most of the respondents had completed secondary education (52.03%) and were classified as richer by the wealth index (21.22%). Meanwhile, slightly more than half of them were from rural areas (51.62%). Regarding information access, 34,367 (96.48%) relied on watching television, whereas 12,733 (35.74%) relied on the Internet. Data are presented in Table 1. In the bivariate analysis, all of the variables, except for the residential location, were significantly associated with contraceptive use among married women (Table 2).
In the multivariate analysis, the association between the independent and dependent variables was assessed by binary logistic regression (Table 3). Married women aged 35-49 years were less likely to use contraceptives than married women aged 15-24 years (Adjusted Odds Ratio (AOR) =0.529; 95% CI=0.470-0.597). Furthermore, married women with more than five children were more likely to use contraception than those without children (AOR=44.024; 95% CI=33.193-58.390). Women who had completed higher education had 2.8 times greater odds of using contraceptives (AOR=2.800; 95% CI=2.181-3.594) than those who had not completed any formal education. Women classified as the richest by the wealth index were 1.1 times more likely to use contraceptives than those classified as poorest (AOR=1.104; 95% CI=0.978-1.246). Women who watched television were more likely to use contraceptives (AOR=1.555; 95% CI=1.321-1.829) than those who never watched television. In comparison, married women who

Discussion
This study sought to assess the determinants of contraceptive use among married women in Indonesia. We first found that women's age, especially older age, was significantly associated with contraceptive use among married women. This result is consistent with the previous studies conducted in Ghana and Nigeria, documenting that older women have a lower level of concern with modern contraceptive use 7,9 . This finding is related to their lower fecundity rates and less active sexual desires 10 . The benefits of using contraception are to delay or space subsequent pregnancies and to limit the number of children 2,11,12 .
Although older women use contraception less often than young women, they still considered the use of contraceptives; of note, only a small proportion of women aged 35-49 reported having gone through menopause.
Women with five or more living children were more likely to use contraceptives. This finding is consistent with those of studies performed in Ghana 7,13 . The addition of one child will increase the tendency of married women to use contraception  by 7%-8%. Another study also found that women with more than three living children were more likely to use contraceptives than those without children, and their reason of using contraceptives was to prevent from having more children 9,10,14,15 . Women will choose to use contraception when they have reached their ideal family size 7 . Therefore, women who have many children are more likely to use contraception because they are more likely to have reached their ideal family size. The World Health Organization has reported that maternal mortality is increased in women who have more than four children 1 . Multiparous women have the highest risk of maternal death; therefore, contraceptive use should be encouraged to reduce this mortality 16 .
Moreover, education levels were significantly associated with contraceptive use among these married women. Higher education levels correlated with higher use of contraceptives. Two previous studies conducted in Bangladesh and Ghana reported that education has an extremely significant influence on contraceptive use. In this report, women with higher education were more likely to use contraception than those without formal education 14,15 . This finding is the result of highly educated people being more likely to be aware of the benefits and importance of using contraception 14 . Another study in Nigeria also found that educated women were more likely to use contraceptives 9 . Education is commonly assumed by someone's knowledge. Someone with higher education level has better knowledge. Education remains an important factor in terms of increasing women's knowledge regarding family planning.
Wealth index was also significantly associated with contraceptive use among these married women. Women from the richest tier of the wealth index also had odds that progressively increased to using a contraceptive. Similar findings regarding the strong association between wealth index and contraceptive use were obtained by studies conducted in Malawi and Ghana; women classified within the richest wealth index were more likely to use contraception than those grouped in the poorest index 7,9,15,17 . In 2017, Ofonime stated that financial factors play an important role in the decreased use of contraceptives among the poorest married women 18 . Providing free access for contraceptives to poor women would be beneficial to increase the use of contraceptives.
Meanwhile, access to information showed a significant association with contraceptive use among these married women.
Mubashar et al. in 2016 found that most sources of contraception information were from media, such as television, radio, the Internet, local news, newspaper, and magazine 19 . Access to information from television was significantly associated with contraceptive use. Women who watched television had approximately 1.5 greater odds of using contraceptives than those who never watch television. This finding is consistent with the previous study conducted in Ethiopia and Ghana 20-22 . Exposure to media, such as television, is an important factor related to women's knowledge about contraceptive use 20 . Watching television is important to increase the knowledge of the wider community to understand the types, benefits, and methods of using contraception correctly. In contrast, this study also showed that access to information via the Internet was significantly associated with less likelihood of contraceptive use among married women. This finding is supported by a previous study conducted in Australia 23 . In such study, 50% of women reported that they felt dissatisfied with the quality and quantity of information about contraception, especially oral contraceptive pill, they obtained through the Internet. Improving the sources of information about contraceptives for married women will be the best approach to encourage contraceptive use and avoid bias information from unreliable media sources.

Conclusions
Factors such as women's age, the number of living children, education level, wealth index, and access to information remain significant issues in determining contraceptive use among married women in Indonesia. Overall, the study results suggest that policymakers should target certain women and create a campaign regarding contraception. Targeting older, poor, and uneducated or less educated women may have a positive impact in terms of increasing their use of contraception.

Data availability
Source data Data used in this study is available online from the Indonesian 2017 Demographic and Health Survey (DHS) website under the 'Individual Recode' section.
Data can be accessed by applying through the DHS website. Please see their data access help page for information.