Contraception, a family planning imperative

Authors: Baochang Gu, Renmin University, and Yan Che, SIPPR

Regulating childbearing through contraception, particularly via modern contraceptives, revolutionised human reproduction in the 20th century.

Condoms on parade in Bangkok. The devices are effective in preventing the spread of AIdS but are only  the third most popular contraceptive method in Asia. (Photo: AAP)

It is also crucial to achieving United Nations Millennium Development Goal 5 (MDG 5) — that is, to provide universal access to reproductive health and reduce the maternal mortality ratio by three-quarters. Between the ages of 20 and 44, a fertile, sexually active woman is capable of giving birth about 12 times, even if she breastfeeds each baby for one year. Thus, to limit her family to 2–4 children, for example, a sexually active woman would have to effectively practice contraception for 16–20 years of her roughly 25 childbearing years to avoid unplanned pregnancies and a need for abortion.

A variety of contraceptive options are now available worldwide. Couples can use traditional methods, such as periodic abstinence and coitus interruptus. Alternatively, they can adopt modern contraception, including the oral pill, condoms, injectable contraceptives, implants, intrauterine devices (IUDs) and male or female sterilisation. Modern contraceptive methods are much more effective than traditional methods. For instance, the failure rate of sterilisation is less than 1 per cent, compared to 25 per cent for periodic abstinence.

Asia is home to 66 per cent of the world’s 1.2 billion married women who are aged 15–49. Two-thirds of these women use some form of contraception, compared with 48 per cent in 1980. Thus the prevalence of contraception in Asia has increased by about 40 per cent during the past 30 years.

Yet the prevalence of contraceptive use varies greatly by region across Asia. It is relatively higher — about 83 per cent — in East Asia, and a bit lower — 54–57 per cent — in South, West and Central Asia. The use of modern contraceptive methods also varies, ranging from 81 per cent in East Asia to 36 per cent in West Asia. Variation between countries is even greater, ranging from 19 per cent in Afghanistan (with modern methods accounting for 16 per cent) to 85 per cent in China (with modern methods accounting for 84 per cent).

Regional differences in method-use patterns also vary substantially across Asia. Overall, the most commonly used contraceptive method in Asia is female sterilisation, which accounts for 32 per cent and 52 per cent of married contraceptive users in East and South Asia, respectively. However, this result is mainly attributable to the large numbers of sterilisations in India and China. The compulsory sterilisation of a couple after they had had a certain number of children was applied to all Indian citizens residing within the country until the mid-1990s. And in many Chinese provinces, it was common practice for women to be asked to adopt an IUD after their first birth and to undergo sterilisation after the second. This was the case until ‘informed choice’ was introduced to the family planning program in the mid-1990s. Currently, the prevalence of female sterilisation is 37 per cent in India and 28 per cent in China.

With 140 million users, who account for 18 per cent of married women of reproductive age, IUDs are the second most popular contraceptive method in Asia. In Central Asia, 26 per cent to 50 per cent of married women aged 15–49 use IUDs, accounting for 63 per cent to 77 per cent of the region’s married contraceptive users. The IUD is also very popular in East Asian countries like North Korea, China and Mongolia, with use ranging from 44 per cent to 62 per cent of married, contraceptive-using couples.

Much of the IUD’s popularity stems from its effectiveness and long-lasting nature. Its failure rate is less than 1 per cent over the first year and about 2 per cent over 10 years of use. Its use involves only one action and is reversible. The IUD is thus highly appreciated in developing countries, particularly in rural areas.

However, this method is much less popular in South Asia. For example, in India only about 2 per cent of women using contraception rely on IUDs. The low rate of use is largely attributable to the inadequate training of personnel and lack of facilities to handle side-effects, as well as the absence of efficient follow-up services. This situation partially reflects the Indian Government’s preference for irreversible contraceptive methods as a way to control the country’s rapid population growth. Since IUD insertion and removal both require medical involvement, difficulty in accessing medical services may also be one of the main reasons for low usage in poor Asian countries like Afghanistan.

Condom use has increased globally in recent decades. One important reason is the effectiveness of condoms in preventing HIV/AIDS and other sexually transmitted infections (STIs). When used consistently and correctly, condoms prevent 80–95 per cent of potential HIV transmission. Yet the effectiveness of condoms depends on the user. For typical users, the failure rate is about 15 per cent over the first year of use; for those who use it correctly, however, the failure rate reduces to about 2 per cent.

Condoms are the third most popular contraceptive method in Asia, but are only used by 54 million Asian couples, or 10 per cent of contraceptive users. The low prevalence of condom use in many Asian countries may result in part from a cultural bias against male methods of contraception. However, it is particularly favoured in three more-developed Asian countries — Japan, South Korea and Singapore — where condom use ranges from 22 per cent to 41 per cent of those using contraception. The total fertility rate of these three countries is around 1.3, the lowest across Asia, which could partially stem from the popularity of condoms in these countries. In Japan, the government has issued condoms to prevent STIs since World War II, while oral pills and IUDs were not officially approved until 1999. Condoms were thus the only available modern contraceptive method in Japan for a long time.

Hormonal contraceptives, including the oral pill, injectables and implants, are used by 10 per cent of married contraceptive users in Asia. The oral pill alone accounts for 6 per cent. Pill use varies across the region, ranging from about 1 per cent in East Asia to 16 per cent in Southeast Asia. Although the oral pill is one of the safest contraceptive drugs, ill-informed concerns about its side-effects and the inconvenience of having to take it regularly may have prevented more widespread acceptance in Asia.

Traditional methods are practiced by 6 per cent of married women aged 15–49 in Asia. They are most popular in West Asia: between 10 and 30 per cent of married women of reproductive age in most West Asian countries practice traditional methods, which may partly be due to religious reasons. However, the popularity of traditional methods in Japan (17 per cent) may largely be due to the limited choice of modern methods other than condoms.

Many factors influence prevalence and patterns of contraceptive use, such as a method’s availability and women’s characteristics and preferences. In turn that reflects differences in geographic and cultural contexts and the development of family planning policies across Asia. While much of the increase in contraceptive use reflects a transition from high to low desired family size, it also reflects the continuing efforts of national and international family planning organisations and a wider availability of contraceptive choices.

Figure 1 shows two regression lines. One presents the relationship between contraceptive prevalence and total fertility rates among 45 Asian countries. The least-squares regression line shows the expected inverse relationship between contraceptive use and fertility at country level. The other line shows that the level of unmet need for contraception increases along with the total fertility rate, suggesting the desire for smaller families seems to be outpacing the availability and use of contraception in Asia, which may lead to unwanted births and high rates of abortion in some countries. Strengthening family planning services should therefore be given a high priority in countries with a high level of unmet need.

 Relationship between the prevalence of contraceptive use and unmet need for contraception and the total fertility rate in Asia (Source: UN 2011).

Figure 1: Relationship between the prevalence of contraceptive use and unmet need for contraception and total fertility rate in Asia

Baochang Gu is Professor of Demography at Center for Population and Development Studies, Renmin University of China.

Yan Che is Professor of Reproductive Health & Senior Epidemiologist at the Shanghai Institute of Planned Parenthood Research.

This article appeared in the most recent edition of the East Asia Forum Quarterly,‘Demographic Transition’.