CHAPTER 4

FAMILY PLANNING

Information on contraceptive use is of particular interest to policymakers, program managers, and researchers in the areas of population and family planning. Family planning is a powerful tool for improving the health of mothers and children as well as for reducing the levels of infant and maternal mortality. Providing easy access to reliable and safe methods of family planning increases women's control over their own fertility. This chapter describes women' s knowledge of family planning methods and sources where they can be obtained, and use of contraception in Yemen. Differentials in knowledge and use are also discussed. In addition, problems with current methods, reasons for first use and current use, and reasons for not intending to use in future are included in this chapter.

4.1 K N O W L E D G E O F F A M I L Y P L A N N I N G M E T H O D S A N D S O U R C E S

Familiarity with contraceptive methods and sources for methods are among the prerequisites for the adoption of fertility regulation. Knowledge o f methods is a necessary but not always sufficient condition for use. The Yemen Demographic and Maternal Child Health Survey (YDMCHS) provides information on the level of knowledge of family planning methods and providers of family planning services. Data on knowledge of contraceptive methods were collected in the Woman's Questionnaire. Each respondent was asked to name the methods or ways a couple could use to avoid or postpone pregnancy, The interviewer then read the names of specific methods (without any description), omitting those that the respondent had already mentioned, and asked whether the respondent had ever heard of the method. The questionnaire included seven specific modem methods: the pill, IUD, injection, vaginal methods (diaphragm/jelly/foam), condom, female sterilization, and male sterilization. Three traditional methods, safe period (rhythm/periodic absti- nence), withdrawal, and prolonged breastfeeding, t were included. Any other methods mentioned by re- spondents, such as herbs were also recorded. To determine knowledge of sources of modem contraceptive methods except sterilizations, for each method the respondent recognized, she was asked if she knew any source for obtaining the method.

Table 4.1 indicates that 60 percent of currently married women 2 have heard of at least one family planning method. The most widely known method is the pill, which is known to more than half of currently married women; almost all women who know of a modem method (53 percent) have heard of the pill) About one-third of the women know about the IUD and injection, and one-fourth have heard of female sterilization. Knowledge of other modem methods is much lower: male sterilization (13 percent), condom (10 percent), and vaginal methods (7 percent). Four in I0 women know of a traditional method, mainly breastfeeding (38 percent), while safe period and withdrawal were known by much smaller proportions of respondents.

aYemen, Jordan, and Egypt are the only DHS countries that included prolonged breastfecding in the list of family planning methods on which respondents were prompted.

~l'he results for ever-married and currently married women are almost the same.

3Contraceptive knowledge in Mauritania is ahnost the same as in Yemen, according to a 1990/91 PAPCHILD survey. In Mauritania, 61 percent of currently married women know a family planning method, and 48 percent know a modem method.

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Table 4,1 Knowledge of contraceptive methods and source for methods

Percentage of ever-married women and currently married women who know a specific contraceptive method and who know a source for services, by specific methods, Yemen 1991/92

Know method Know a source

Ever- Currently Ever- Currently Contraceptive married married married married method women women women women

Any method 60.3 60.2 27.2 27.0

Modern method 53.5 53.2 27.2 27.0 Pill 51.7 51.3 24.9 24.5 IUD 34.2 33.5 15.7 15.3 Injection 32.1 31.9 12.8 12.8 Diaphragm/foam/jelly 7.2 7.0 3.5 3.3 Condom 10.4 10.3 5.2 5.0 Female sterilization 24.1 24.0 NA NA Male sterilization 13.6 13.4 NA NA

Any traditional method 39.7 39.7 NA NA Safe period 13.2 13.1 NA NA Withdrawal 8.6 8.5 NA NA Prolonged breastfeeding 37.7 37.7 NA NA Other traditional methods 1.1 1.1 NA NA

Number of women 5687 5355 5687 5355

NA = Not applicable

The results presented in Table 4.1 show that only 27 percent of married women know where to go to get a modem method of contraception (the YDMCHS did not include a question on sources for female and male sterilization). Knowledge of sources for specific methods shows that one-fourth of married women know a source for the pill. Only 15 and 13 percent, respectively, know a source for the IUD and injection; sources for other methods are even less well known.

The percentage of married women who know at least one modem contraceptive method and know a source for the method, by various background characteristics, is presented in Table 4.2. Only small differences by age exist in knowledge of modem methods among women 15-44:54-58 percent of women 20- 44, and almost half of the women 15-19 arc aware of a modem method of family planning. Older women, 45-49, are the least knowledgeable (42 percent).

There is a greater variability in the level of contraceptive knowledge by residence and region. About 9 in 10 urban women are aware of at least one modem method, compared with less than half of rural women. Knowledge of modem methods is much higher in the southern and eastern govcmoratcs (over 70 percent), while only half of women in the nonhero and western govemorates know a modem method. Differentials in knowledge by education are even more striking. Among illiterate women, only half know a modem method, compared with 86 percent of women who have completed primary education, and an overwhelming majority of women with higher education (94 percent). The differences in knowledge of family planning by

38

education may account, in large part, for the greater knowledge of family planning in urban areas and in the southern and eastem govemorates, since a greater proportion of educated women live in those areas.

Differentials in knowledge of service providers show relatively more variability than differentials in knowledge of modem methods (see Table 4.2). By age groups, between 24 and 31 percent of married women age 15-44 know a source for a modem contraceptive method. The differences are much greater by residence. Sixty-seven percent of urban women know a source compared to only 18 percent of rural women. Regionally, it is twice as likely for a woman in the southern and eastern governorates (46 percent) to know a contraceptive source as a woman who lives in the northern and westem govemorates. The most striking difference in knowledge of service providers is by educational level. Only 22 percent of illiterate women know a source. Among women who are literate or have completed primary school, knowledge of service providers is almost three times that of illiterate women, or approximately 40 percentage points higher, while knowledge of a source is 60 percentage points higher among women who have completed more than primary school.

Table 4.2 Knowledge of modern contraceptive methods and source for methods r by selected background characteristics

Percentage of currently married women who know any contraceptive method and a modem method and who know a source for services, by selected background characteristics, Yemen 1991/92

Know a Know Know source for Number

Background any a modem modem of characteristic method method I method 2 women

Age 15-19 55.4 50.7 23.7 406 20-24 63.7 57.7 27.9 788 25-29 62.1 54.3 27.6 1229 30-34 60.6 54.1 31.4 933 35-39 60.9 53.5 27.4 909 40-44 60.7 53.5 26.0 615 45-49 50.3 42.1 18.4 476

Residence Urban 88.8 86.2 67.3 951 Rural 54.0 46.0 18.3 4404

Region North./West. 57.3 49.3 23.2 4458 South./East. 74.3 72.4 45.8 897

Education Illiterate 56.6 48.9 22.0 4792 Literate 91.8 91.8 60.5 57 Primary 87.8 86.0 6¢/.8 291 More than primary 95.0 93.6 84.3 216

Total 60.2 53.2 27.(} 5355

tlncludes pill, IUD, injection, vaginal methods (diaphragm/foam/jelly), condom, female sterilization, and male sterilization. 2Source for female and male sterilization not asked.

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4.2 E V E R USE OF C O N T R A C E P T I O N

In the YDMCHS, all respondents were asked if they had ever used the methods they reported knowledge of. As shown in Table 4.3, almost one-fifth of ever-married women have used a method to regulate their fertility at some point in their lives. Thirteen percent have used a modem method and l0 percent a traditional method (including prolonged breastfeeding); thus, the majority of ever-users have had experience with a modem method, and some have used more than one method. Currently married women have about the same level of ever-use experience as ever-married women.

The age differentials for ever-use among currently married women show that the rate for women 15- 19 is only 8 percent, it doubles for women 20-24, and increases to 20 percent among women 25-29; ever-use peaks at around 25 percent among women in their thirties before declining among older women (19 percent and 15 percent for women 40-44 and 45-49, respectively).

Two methods, the pili (11 percent) and prolonged breastfeeding (8 percent), are used most commonly. At the most, 3 percent of currently married women have ever used any other method-- IUD (3 percent), injection and safe perio(~l (2 percent each), and female sterilization (1 percent).

T a b l e 4.3 Ever u s e o f contraception

A m o n g ever-marrled w o m e n and currently married w o m e n , the percentage w h o have ever used a contraceptive method, by spec i f ic method and age, Y e m e n 1 9 9 1 / 9 2

Age

Modern method Traditional method

Any Dia- Female Male Pro- modem phragm/ steri stcri- Any With- longed Number

Any meth- Injec- foam/ Con- liza- tlza- trad. Safe draw~ breast of method od Pill IUD tion jelly dora tion Lion method period ai feeding Other women

E V E R - M A R R I E D W O M E N

15-19 g.0 3,0 2 .6 0.1 0.3 -- 0.1 -- 6.0 0.8 0.3 5.7 -- 4 2 7 20 -24 16.1 9.1 7,2 1.8 I . I -- 0.6 -- -- 9.3 1.9 0.9 7 .2 0.2 815 2 5 - 2 9 19.1 13.5 9.8 3.2 2 .6 0.6 1.2 0.2 -- 9,2 2.1 2.0 7.1 0.2 1295 30 -34 25.3 17.8 14.8 3.2 1.7 0.6 1.4 0.7 0.1 12,2 3 .0 3.0 9.1 0.1 995 35 39 24.2 17.3 13.9 3.4 1.6 0.4 0 .9 1.6 0.3 12.9 2.3 1.7 10.5 0.3 972 40 -44 19.3 15.0 11,3 1,6 2.8 0.4 1.7 2.1 0 .6 9.7 1,6 1.6 8.0 0.2 653 4 5 - 4 9 15.1 11.1 7.8 1.2 1.5 0,0 0,8 1.4 0.3 6.3 1,0 2.0 5.3 0.5 529

Total 19.5 13.4 10.4 2.4 1.8 0.4 1.0 0.8 0.2 9.9 2 .0 1.8 7.9 0.2 5687

C U R R E N T L Y M A R R I E D W O M E N

15-19 7 .6 2.7 2 .2 0.2 0. I 6.0 0.5 0.4 5.7 -- 4 0 6 2 0 - 2 4 16.2 8.9 7 .0 1.9 1.1 - 0 .6 9.6 2 .0 1.0 7.5 0.2 788 2 5 - 2 9 19.6 13.9 10.1 3.4 2.7 0.6 1.3 0.2 - 9.4 2.1 2 .0 7.3 0.2 1229 30 -34 25.9 18.4 15.3 3.4 1.7 0.4 1.4 0.8 0 .2 12.4 3.1 2.8 9.3 0.1 933 35 -39 25.1 17,9 14.3 3.4 1.7 0.d 0.9 1.7 0,3 13.4 2.5 1.8 10.9 0.3 909 40 -44 19.2 15.0 11.1 1.6 2.9 0.3 1.8 2.1 0 .6 9.3 1.7 1.4 7.8 0.2 615 4 5 - 4 9 15.2 11.5 7.9 l .d 1.7 -- 0.9 1.6 0.3 6.1 1.0 2.0 5.2 0.3 4 7 6

Total 19.8 13.7 10.6 2.5 1,9 0.3 I . l 0.8 0,2 10.1 2,1 1.8 8.0 0.2 5355

-- Less than 0.05 percent

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4.3 NUMBER OF CHILDREN AT FIRST USE

Table 4.4 shows the percent distribution of ever-married women by the number of living children at the time they first used contraception. It is interesting to note that 5 percent of women, or one-fourth of ever- users, started using contraception before having their second child. This tendency to start contraception early, probably for the purpose of spacing births, is most noticeable among younger women, i.e., women under 35 years of age. For example, more than three-quarters of women 20-24 who had experience with contraception had initially started using a method before they had three children.

Table 4,4 Number of children at first use of contraception

Percent distribution of ever-man-ied women by number of living children at the time of first use of contraception, according to current age, Yemen 1991/92

Number of living children at time Never of first use of contraception Number

Current used of age contraception 0 1 2 3 4+ Missing Total women

15-19 92.0 1.4 5.5 0,7 0,3 0.0 0.1 100,0 427 20-24 83.9 0.9 8.0 3.6 2.2 0.8 0.5 100,0 815 25-29 80.9 0.2 5.9 3.3 3.8 5,8 0.1 100.0 1295 30-34 74.7 0.7 4.6 4.1 3.7 11.6 0.6 100.0 995 35-39 75.8 0.3 2.9 3.3 2.9 14.2 0.7 100.0 972 40-44 80.7 0.3 2.5 1.1 2.1 13.3 0.0 100.0 653 45 49 84.9 0.2 2.0 0.9 1.2 10.7 0.1 100.0 529

Total 80.5 0.5 4.7 2.8 2.7 8.4 0.3 100.0 5687

4.4 REASON FOR FIRST USE

Women were asked about their reproductive intentions when they first began using family planning. Table 4.5 shows among ever-married women who ever used contraception (20 percent), more than half (11 percent) had first used family planning for spacing births because they wanted more children later. Seven percent of ever-users wanted to stop childbearing at the time they began using a method. The majority of women 40 and over started using contraception in order to limit family size. Proportionally, ever-users who adopted a family planning method for the first time for purposes of spacing births rather than for limiting family size were higher among urban women than rural women, and higher among more educated women than among those with primary education or those who are illiterate.

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Table 4.5 Reproductive intentions at first use of contraception

Percent distribution of ever-marrled women by reproductive intentions at the time of first use of contraception by selected background characteristics, Yemen 1991/92

Never used Wanted Wanted Number

Background comra- child no more Other/ of characteristic ception later children Missing Total women

Age 15-19 92.0 5.0 2.7 0.4 100.0 427 20-24 83.9 11.0 4.1 1.0 100.0 815 25-29 80.9 12.9 5.5 0.7 100.0 1295 30-34 74.7 15.0 8.9 1.4 100.0 995 35-39 75.8 12.1 10.6 1.5 100.0 972 40-44 80.7 8.9 10.4 0.1 100.0 653 45-49 84.9 6.6 8.2 0.3 100.0 529

Residence Urban 50.8 30.4 17.1 1.8 100.0 1054 Rural 87.3 6.9 5.2 0.7 100.0 4633

Region Nor th.AVest. 83.3 8.8 7.1 0.8 100.0 4708 South./l~ast. 67.2 22.7 8.9 1.2 100.0 979

Education Illiterate 84.2 8.4 6.6 0.8 100.0 5075 Literate 47.2 36.1 16.7 0.0 100.0 61 Primary 57.2 27.1 13.5 2.2 100.0 316 More than primary 41.3 44.5 13.1 1.0 100.0 235

Total 80.5 11.2 7.4 (1.9 100.0 5687

4.5 CURRENT USE OF CONTRACEPTION

Only nonpregnant currently married women were asked if they were using any contraceptive method at the time of the survey. Including prolonged breastfeeding as a method, the contraceptive prevalence rate in Yemen for allcurrently married women (pregnant and nonpregnant) is 10 percent. It is 7 percent if breast- feeding is not included (see Table 4.6). Although the contraceptive prevalence in Yemen is low compared with many other Arab countries,4 it is much higher than the one percent prevalence rate reported in 1979 by the Yemen Arab Republic, which, in this report is referred to as the northern and western govemorates and has a prevalence rate of 8 percent. The pill, the most popular method, is used by 3 percent of women and accounts for more than half of the modem method use in Yemen. The other modem methods-- IUD and female sterilization--are each used by one percent of women. Prolonged breastfeeding is the most frequently used traditional method and the second most popular method overall (2 percent). Around one-half of one per- cent of married women rely on the safe period or withdrawal. Table 4.6 also shows the percent distribution of currently married women by contraceptive method currently used, according to age. The pattem of differ- entials in current use by age is similar to the pattern for ever-use of contraception, i.e., women in their thirties have the highest levels of use. An extremely large difference in prevalence is observed between urban and rural areas. 5 At the time of survey, 28 percent of urban women were using a contraceptive method compared

4For example, in countries in North Africa and the Middle East where a PAPCH1LD survey and the DHS surveys have been conducted, the contraceptive prevalence rates range from a low of 4 percent in a PAPCH1LD survey in Mauritania (1990/91 ) and 9 percent in Sudan (1989/90), to a high of 50 percent in Tunisia (1988). The prevalence rates are 35 percent in Jordan (1990), 42 percent in Morocco (1992), and 47 percent in Egypt (1992).

5Contraceptive rates are higher in urban areas than in rural areas in 'all of the North African and Middle Eastern countries in which DHS surveys have been conducted. In terms of absolute percent differences between urban and rural women, the difference is greatest in Tunis ia (1988) where the rates are 60 and 35 percent in urban and rural areas, respectively. However , relatively speaking, the ratio (over 4 times) of urban to rural use of contraception is highest in Yemen and Sudan (1989/90) , and lowest (1.5 times) in Egypt (1992).

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T a b l e 4 . 6 C u r r e n t u s e o f c o n t r a c e p t i o n b y a g e

P e r c e n t d i s t r i b u t i o n o f c u r r e n t l y m a r r i e d w o m e n b y c o n t r a c e p t i v e m e t h o d c u r r e n t l y u s e d , a c c o r d i n g to a g e , Y e m e n 1 9 9 1 / 9 2

Modern method Traditional method

Background characteristic

pi-o~ All Female Male All longed Not

m o d e m steri- steri- tred. With breast- cur- Number Any meth- lnjec- Con- liza- liza- meth- Safe draw- feed- rently o f

method otis I Pill IUD tion dorn tion tion ods 2 period al ing using Total women

15-19 5.1 1.3 1.1 0.2 3.8 -- 0.1 3.7 94.9 1(30.0 406 20-24 8.5 4.3 2.8 1.0 0.4 4.2 0.2 0.5 3.5 91.5 1(30.0 788 25-29 10.5 7.2 3.8 2.3 0.9 0.1 0.2 -- 3.3 0.6 0,6 2.0 89.5 100.0 1229 30-34 11.7 6.8 3.7 1.0 0.7 0.3 0.8 0.1 4.9 0.5 0.6 3.8 88.3 100.0 933 35-39 12.5 8.3 4.4 1.3 0.6 -- 1.7 0.3 4.2 0.6 0.6 2.7 87.5 100.0 909 40-44 8.8 6.4 2.4 0.9 0.7 -* 2.0 0.4 2.4 0.6 0.6 1.1 91.2 100.0 615 45-49 5.1 4.1 1.5 0.6 0.3 0.1 1.6 0.1 1.0 0.3 0.6 0.2 94.9 IGO.0 476

Total 9.7 6.1 3.2 1.2 0.6 0.1 0.8 0.1 3.6 0.5 0.6 2.5 90.3 100.0 5355

-- Less than 0.05 percent llncindes users of vaginal methods 2Includes users of c4her traditional methods

with only 6 percent of rural women (see Figure 4.1 and Table 4.7). Rural women are also relatively more likely than urban women to rely on prolonged breastfeeding.

Figure 4.1 highlights the differentials in contraceptive prevalence by region, educational level and current family size. The prevalence rate in the southern and eastern governorates is twice as high in the nonhem and western govemorates, but the ratios of preference, of modem to traditional methods, are almost

Figure 4.1 Contraceptive Prevalence by

Selected Background Characteristics

RESIDENCE Urban Rural

REGION North./West. South./East.

EDUCATION Illiterate Literate

m 6

/ 8

/ 7

17

28

29

NO. OF CHll

0 10 20 30 40 50

Percent

* Includes prolonged breastfeeding, YDM CHS 1991/92

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T a b l e 4.7 Current use of contraception by background characteristics

Percent distr ibution o f currently married w o m e n b y contraceptive method currently used, according to selected background characteristics, Y e m e n 1 9 9 1 / 9 2

All modem

Background Any meth- characteristic method ods I Pill

Modern method "rr aditinnal method

Pro- Female Male All longed Not steri- steri- trad. With breast- cur- Number

in jec- Con- l lza- liza- raeth- Safe draw- feed+ rently of IUD tlon dora tion tion ods 2 period al ing using Total women

Residence Urban Rural

Region North.AVest. South-East

Education Illiterate Literate Primary M o t e than primary

No. of living children 0 1 2 3 4+

Total

28.2 18.8 9.8 4 .6 0.5 0.4 2 .7 0 .6 9.5 1.7 2.5 5.2 71.8 100.0 951 5 .7 3.3 1.8 0.5 0 .6 -- 0.4 2.3 0.2 0.1 1.9 94.3 100.0 4 4 0 4

8.3 5,1 2 .2 1.3 0 .7 -- 0.8 -- 3.2 0.3 0.3 2.4 91.7 100.0 4 4 5 8 16.7 l l . l 8.2 1.1 0.1 0.2 0.8 0.7 5.6 1.1 1.6 2 .9 83.3 100.0 897

7.2 4.3 2 .0 0.8 0.7 -- 0.8 0.1 2 .9 0.3 0.4 2 .2 92.8 100.0 4 7 9 2 29.1 16.7 11.6 3.3 0.7 1.1 12.4 3 .6 1.1 7.7 70.9 100.0 57 24.3 16.8 11.2 4 .2 -- 0 .6 0 .6 0.3 7.5 0.8 1.1 5.5 75.7 100.0 291

38.5 27.7 16.8 7.3 0.2 1.0 1.4 0.9 10.7 2 .7 3.8 4 .2 61.5 100.0 2 1 6

0.7 0 .7 0.5 0.1 0.1 . . . . . . . . 99.3 100,0 611 7.7 4 .2 3 .6 0.5 -- 0,1 3.6 0.2 0 3 3,1 92.3 100.0 5 6 0 9.2 4 .8 3 .0 1.1 0.2 0. I 0.3 0.1 4.4 0.5 0.8 3.1 90.8 l ~ ) . 0 568 9.8 5.7 3.2 1.1 0.8 0.2 0.4 0 .2 4.1 0.4 0.7 2.9 90.2 100.0 672

11.9 7.9 3.7 1.7 0.9 0.1 1.3 0.2 4.1 0 .6 0 .6 2.7 88.1 100,0 2945

9.7 6.1 3.2 1.2 0 .6 0.1 0.8 0.1 3.6 0.5 0 .6 2.5 90.3 100.0 5355

-- Less than 0.05 percent I Includes users of vaginal methods 2Includes users of othez traditional methods

the same in both regions (see Table 4.7). Pronounced differences in current use exist by level of education. The proportion of married women using contraception increases dramatically from 7 percent among illiterate women to 24 percent among those with primary school completed, and then jumps to 39 percent for women with postprimary education. Contraceptive use varies slightly with the number of living children. Current use is negligible among women who have yet to start childbearing and is 8 percent among women with a single child. The prevalence rate increases to around 10 percent among those with 2-3 children, and is slightly higher among women who have four or more children.

4.6 R E A S O N FOR C U R R E N T USE

Table 4.8 indicates that the major reason for using of family planning in Yemen is to limit family size (51 percent) rather than to space births (32 percent). A small proportion (18 percent) of currently married women are using contraception for "other" reasons. Among rural women, less than half are using to limit the number of children, and only one-third practice family planning to space births. On the other hand, those with more than primary education are more likely to be using contraception for spacing than for limiting purposes. The table also shows that for various background characteristics, the proportion of women using contraceptive method for limiting purposes varies only slightly, from 51 to 54 percent.

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Table 4.8 Reasons for current use of contraception

Percent distribution of currently married women who are using contraception by reason for use, according to selected background characteristics, Yemen 1991/92

Want Want Number Background child no more Other of characteristic later children reason Total users

Residence Urban Rural

Region Nor th./West. South./East.

Education

29.6 53.6 16.8 10O.0 268 34.0 47.3 18.6 100,0 249

31,8 50.1 18.1 100.0 368 31.6 51.8 16.6 100.0 150

Illiterate 27,7 53.3 19.0 100.0 347 Literate * * * 1130.0 17 Primary 37.1 51.0 I1.8 100.0 71 More than primary 44,3 38.3 17.5 100.0 83

Total 31.7 50.6 17.7 100.0 518

Note: An asterisk (*) indicates that the figure is based on fewer than 25 cases and has been suppressed.

4.7 P R O B L E M S W I T H T H E C U R R E N T M E T H O D O F C O N T R A C E P T I O N

W o m e n w h o w e r e u s i n g any c o n t r a c e p t i v e m e t h o d e x c e p t s t e r i l i z a t i on w e r e a sked i f they had

e x p e r i e n c e d any p r o b l e m s wi th the i r c u r r e n t me thod . F e w c o n t r a c e p t i v e users r epor t ed any p r o b l e m s . N o n e

o f the w o m e n w h o re l i ed on w i t h d r a w a l and on ly a s m a l l p ropor t ion o f those u s i n g the safe p e r i o d ( 1 0

pe rcen t ) o r p r o l o n g e d b r e a s t f e e d i n g (8 pe rcen t ) repor ted any p r o b l e m s (see T a b l e 4 .9 ) . H a l f o f I U D and

in j ec t ion use rs , and o v e r 6 0 pe rcen t o f p i l l use rs sa id they e x p e r i e n c e d no p r o b l e m s wi th the i r m e t h o d . W h e n

Table 4.9 Problems with current method of contraception

Percent distribution of currently married women who are using contraception by the main problem with current method, Yemen 1991/92

lnjec- Safe With- Breast- Main problem Pill IUD tion I period I drawal I feeding

No problem 62.5 51.1 51.4 89.7 100.0 92.5 Health concerns 26.4 32.3 19.1 4.5 0.0 5.6 Method failed 0.5 0.0 0.0 1.6 0.0 0.5 Access/availability 0.2 0.0 0.0 0.0 0.0 0.0 Cost 0.0 0.0 3.9 0.0 0.0 0.0 Inconvenient to use 0,5 3,3 8.0 4.1 0,0 0.0 Other 1.5 1.9 2.0 0.0 0.0 0.0 Missing 8.3 11.4 15.7 0.0 0.0 1.4

Total 100.0 100.0 100.0 100.0 100.0 100.0 Number 171 66 32 25 30 136

Note: Excludes users of vaginal methods, condoms and other traditional methods (fewer than 25 cases). No questions were asked about current use of female/male sterilization. Figures are based on fewer than 50 cases.

45

problems were mentioned, health concerns were cited most frequently. One-third of IUD users, one-fourth of pill users, one-fifth of injection users, and a small proportion of women using other methods reported experiencing health problem. It should be pointed out that information for 8-16 percent of users of modem methods on the question of problems with contraception was not available.

4.8 S O U R C E O F C U R R E N T C O N T R A C E P T I V E M E T H O D

The identification of sources of contraceptive methods lor current users is important for evaluating the role played by various providers of family planning services and supplies in the public and private sectors. Women using modem methods at the time of survey wcre asked where they obtained the method last time. Their responses are summarized in Table 4.10.

Table 4 .10 Source of supply for modern contraceptive methods

Percent distribution of currently married women who are using modem contraceptive methods by most recent source of supply, according to specific methods, Yemen 1991/92

Female All Injec- sterili- mc, dern

Source of supply Pill IUD Lion I zation I methods 2

Public hospital 19.4 27.1 54.5 77.1 33.2 Public family planning clinic 18.4 18.6 3.6 1.4 14.2 Private family planning clinic 0.5 4.4 3.9 4.3 2.2 MCI] center 12.4 11.2 6.0 0.0 9.4 Private medical doctor/clinic 2.2 31.8 1.5 8.0 8.8 Pharmacy 37.5 1.4 26.6 0.0 24.2 Other 3.5 3.7 3.9 0.9 3.1 Don't know/missing 6.2 1.7 0.0 8.3 4.9

Total 100.0 100.0 100.0 100.0 100.0 Number 171 66 32 44 325

IFigures are based on fewer than 50 cases. 2Includes vaginal methods, condom, and male stcrili/ation.

The public sector, including nongovernmental organizations (NGOs), is a major provider of family planning in Yemen. It provides methods to 6 out of every 10 users of modem methods (57 percent in government sources, and 2 percent in private family planning clinics), while the private sector serves almost 3 in 10 users. In the private sector, pharmacies are the major source of contraceptive methods; they serve one-fourth of all modem method users (sec Figure 4.2).

As for sources of speci tic methods, Table 4.10 shows that the main source for pill users is the public sector: government hospitals (19 percent), public family planning clinics (18 percent) and Matemal and Child Health centers (12 percent). Pharmacies supply a substantial proportion of pills users (38 percent). For IUD users, private doctors and clinics are the largest single source. One-third of IUDs were obtained from these private sources; however, public hospitals (27 percent) and family planning clinics (19 percent) together with matemal and child health centers (11 percent) are the largest source of this method. More than half of injection users go to public hospitals and one-fourth to private doctors. Among women who had chosen voluntary female sterilization as their family planning method, three-fourths had their operations done in government hospitals; only a small proportion went to a private doctors and family planning clinic.

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Figure 4.2 Source of Family Planning Supply Current Users of Modern Methods

Other/Missing 8%

Pharmacy 24%

ate doctor/Clinic 9%

NGO FP clinic 2%

MCH center 9%

ub]ic FP clinic 14%

Public hospital 33%

YDMCHS 1991/92

4.9 TIME TO SOURCE OF CONTRACEPTIVE METHOD

Women who were using a modem contraceptive method were asked about the time it takes to go to their method source. The answers, summarized in Table 4.11, show time to source of contraceptive method by urban- rural residence. One-fifth of current users of modem methods can reach their source in less than 15 minutes, one-fifth reach it in 15-29 minutes, and an additional one-fifth take between one-half and one hour to arrive at the source they last used. A substantial proportion of users, almost one-fifth have to spend more than two hours in travel to go to the place where they obtain the family planning method they use. As expected, urban women have easier access to family planning than those living in rural areas (see Figure 4.3). The median travel time for urban users is just 16 minutes, whereas the median for rural users is over one hour; 40 percent of rural users spend more than 2 hours traveling to their source of contraceptive methods.

Table 4.11 Time to source of supply for modern contraceptive methods

Percent distribution of currently married women who are using a modem contraceptive method by time to reach a source of supply, according to urban-rural residence, Yemen 1991/92

Minutes to source Urban Rural Total

0-14 26.8 7.2 18.0 15-29 26.2 10.8 19.2 30-59 26.1 18.2 22.6 60-119 10.5 12.6 11.5 120-239 1.4 33.1 15.7 4 hours or more 0.6 6.8 3.4 Not stated 8.3 11.1 9.5

Total 100.0 100.0 100.0 Median time to source 16.0 60.9 30.4

Number of women 178 147 325

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Figure 4.3 Time to Source of Modern Methods

Missing 8% < 15 minutes 27% 2 hours + 2% ....---V--~.,~

60-119 minutes 11%

30-59 minutes 26% 15-29

minutes 26%

Missing 11%

2 hours + 40%

< 1 5 minutes 7%

~ 15-29 minutes 11%

30-59 ~ minutes 18%

60-119 minutes 13%

Urban Rural

YDMCHS 1991/92

4.10 I N T E N T I O N T O U S E C O N T R A C E P T I O N IN T H E F U T U R E

Women who were not using any contraceptive method at the time of the survey were asked if they would use a family planning method in the future. Those who responded in the affirmative were also asked how long they would wait to use a method and what method they would prefer to use.

Table 4.12 shows the distribution of currently married women who were not using contraception, by their intention to use in the future. The results in the table are presented according to the number of living children (including a current pregnancy) and past experience with contraception. Eighty-three percent of currently married women who were not using any method indicated that they did not intend to use a contraceptive method in the future. Only 16 percent expressed a desire to use some method--6 percent in the next 12 months and 2 percent after 12 months; 8 percent were unsure about when they would use a method. Surprisingly, of the women who had used a method in the past, more that half (6 percent) reported that they did not intend to use any method in the future.

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Table 4.12 Future use of contraception

Percent distribution of currently married women who are not using a contraceptive method by past experience with contraception and intention to use in the future, according to number of living children, Yemen 1991/92

Past experience with contraception and future intentions

Number of living children I

0 1 2 3 4+ Total

Never used contraception Intend to use in next 12 months 0,2 3.2 2.8 3.5 4.1 3.4 Intend to use later 1,2 3.1 1.6 0.7 1.5 1,5 Unsure as to timing 9.9 7.3 5.1 4.8 6.1 6.3 Unsure as to intention 0.0 0.0 0.0 0.0 0.0 0.0 Do not intend to use 86.3 82.8 80.0 80.5 72.5 76.8 Missing 0.9 0.2 1.1 1.2 0.6 0.7

Previously used contraception Intend to use in next 12 months 0.0 0.5 2.2 0.9 3. l 2.2 Intend to use later 0.4 0.5 1.3 1.0 0.9 0.9 Unsure as to timing 0,0 0.8 1.9 2.1 2.7 2.1 Unsure as to intention 0.0 0.0 0.0 0.0 0.0 0.0 Do not intend to use 1.2 1.7 3,9 5.3 8.4 6.1 Missing 0.0 0,0 0.0 0.0 0,1 0.0

Total I00.0 100.0 100.0 100.0 100.0 100.0

All currently married nonusers Intend to use in next 12 months 0.2 3.7 5.0 4.4 7.3 5.6 Intend to use later 1.6 3.6 2.9 1,7 2.4 2.4 Unsure as to timing 9.9 8.1 7.0 6.9 8.8 8.4 Unsure as to intention 0.0 0.0 0.0 0.0 0.0 0.0 Do not intend to use 87.5 84.5 83.9 85.8 80.9 82.9 Missing 0.9 0.2 1.1 1.2 0.7 0.8

Total 100.0 100.0 100.0 100.0 100,0 100.0

Number of women 459 558 495 624 2701 4838

llncludes current pregnancy

Method preferences of potential future users are shown in Table 4.13. The pill is by far the most popular choice (44 percent). Injection is a distant second (13 percent), followed by the IUD (12 percent). Female sterilization is the preferred method for 5 percent of women, but none of the women selected male methods---condoms, withdrawal, and male sterilization. Women's preferences for methods differ by the time in which they intend to use contraception (in the next 12 months or later). However, the pill, the IUD, and injection are the most popular methods regardless of timing. The pill and female sterilization are preferred more by those who intend to use a family planning method after 12 months, while the IUD and prolonged breast feeding are more often chosen by those who want to use family planning sooner. Compared to women who intend to use in the next 12 months, those who plan to use later show a slightly stronger preference for the pill and slightly weaker preference for prolonged breastfeeding.

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Table 4.13 Preferred method of contraception for future use

Percent distribution of currently married women who are not using a contraceptive method but who intend to use in the future by preferred method, according to whether they intend to use in the next 12 months or later, Yemen 1991/92

Intend to use

In next After Unsure Preferred method 12 12 as to of contraception months months timing Total

Pill 41.1 56.7 42.3 43.8 IUD 15.5 10.3 9.7 11.7 Injection 12.3 11.5 14.2 13.1 Diaphragm/Foam/Jelly l.l 0.4 1.0 0.9 Condom 0.6 0.0 0.1 0.3 Female sterilization 4.9 7.4 4.6 5.1 Male sterilization 0.2 0.0 0.7 0.4 Safe period 3.4 7.7 4.1 4.4 Withdrawal 0.9 0.0 0.4 (I.5 Prolonged breastfeeding 10.0 4.7 7.5 7.9 Other 9.5 1.2 14.6 10.8 Don't know 0.5 0.0 0.5 0.4 Missing 0.0 0.0 0.3 0.5

Total 100.0 1 0 0 . 0 1 0 0 . 0 100.0 Number 271 1 l 7 405 796

4 .11 R E A S O N F O R N O N U S E O F C O N T R A C E P T I O N

Currently marr ied non-pregnant women who had indicated that they would not use any method in the future were asked the reason for not planning to use family planning. The percent distribution of these women by reason proffered lot not intending to use any method are presented in Table 4.14. The results in the table are shown by (a) broad age groups, and (b) fertility intentions, according to past experience or no experience with contraception. "Other" is a residu'al category and includes women who could not be assigned to the categories "want more" or "want to limit."

The expressed reasons for not intending to use family planning can be broadly grouped into the fol lowing categories: reasons related to contraceptive methods; attitude toward family planning, fatalistic attitude and "other" reasons. The reasons that are related to contraceptive method are: lack o f knowledge, side effects, inconvenience o f use, and difficulty obtaining method. About one-fourth of nonusers said they would not use any method because they lacked knowledge of contraceptive methods. One in 10 women had no plan to use contraception because of fear o f side effects, 3 percent considered the methods inconvenient to use, and 1 percent mentioned difficulty in obtaining methods. One-third of women gave attitudinal reasons: although only 2 percent were personally opposed to family planning, the remaining were split equally between religious prohibition (15 percent) and disapproval o f husbands (16 percent). Ten percent o f women were fatalistic as far as family size was concerned and implied there was little they can do to control their

fertility. Only 3 percent o f women were menopausal; 13 percent gave "other" reason for nonuse.

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Table 4.14 Reasons for not intending to use contraception

Percent distribution of women who are not using a contraceptive method and who do not intend to use in the future by main reason for not intending to use, according to age, fertility intentions and ever use o f contraception, Yemen 1991/92

Fertility intentions

Want more Want to limit Reason for not intending Age Never Never to use Used used Used used contraception 15-29 30-49 method method method method Other I Total

Religious prohibitions 13.9 16.4 9.8 14.8 4.6 17.6 16.3 15.3 Opposed to family planning 2.3 1.0 3.4 2.3 0.0 0.9 0.5 1.6 Husband disapproves 18.2 14.1 13.4 17.1 9.1 15.9 14.2 15.9 Relatives disapprove 0.4 0.0 0.7 0.3 0.0 0.1 0.2 0.2 Side effects 8.9 10.2 29.9 5.6 46.1 11.0 6.6 9.6 Lack of knowledge 22.1 24.3 3.6 23.9 0.2 23.4 31.8 23.3 Difficult to obtain 0.6 1.5 0.7 0.7 1.6 2.1 0.5 1.1 Costs too much 0.2 0.8 0.0 0.3 0.9 1.2 0.3 0.5 Inconvenient to use 2.5 3.3 3.4 2.6 8.6 3.0 2.1 2.9 Fatalistic 8.6 10.5 12.8 8.8 11.4 8.9 13.5 9.7 Menopausal/subfecund 0.5 5.1 1.3 0.7 7.0 7.9 0.5 3.0 Other 17.5 8.8 19.3 19.0 6.5 4.7 6.7 12.7 Unsure/Don't know 4.2 3.9 1.6 3.9 4.0 3.3 6.6 4.0 Missing 0.1 0.1 0.0 0.0 0.0 0.1 0.2 0.1

Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Number 1786 2223 101 2027 166 1183 532 4009

IAnswers other than "want more" or "want no more" to the question on future reproductive intentions.

The major differences in reasons by age were attitudinal reasons, religious prohibitions and disapproval of husbands. Religious prohibition was mentioned more often by women over 30 than by those who were younger, and disapproval of husbands was cited by a greater proportion of younger women. The reason mentioned most often by those who had never used a method was lack of contraceptive knowledge. Among those who had some experience with contraception, the major reason for not intending to use was the side effects associated with contraceptive use. Thirty percent of women who want more children and 46 percent of those who want to limit their family size gave this reason. Religious prohibition and husband's opposition to using family planning are mentioned by a substantial proportion of women whether or not they want more children in the future. It is surprising that, irrespective o f reproductive intentions, a slightly higher proportion of women who have used a family planning method than those who have not used a method are fatalistic.

4.12 SPOUSAL COMMUNICATION AND APPROVAL OF FAMILY PLANNING

An indication of the acceptability of family planning is the extent to which couples discuss the subject with each other. TheYDMCHSinc ludedanumberofques t ionsona t t i tudesofspouses . Respondents who were not using any method at the time of survey were asked, "In your opinion, in general, does your husband approve or disapprove of couples using a family plarming method?" Respondents were also asked if they had ever talked with their spouses about family planning. Respondents who had previously given "husband's disapproval" as the major reason for not intending to use contraception in the future were not asked these

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questions. It was assumed that they had already talked with their husbands about family planning. Table 4.15 presents a cross tabulation of the responses on spousal communication and approval of family planning given by currently married women who know of a contraceptive method (includes assumed answers). Of 2,705 women included in the table, 1,225, or 45 percent have talked about family planning with their husbands. Among women who talked with their husbands, 51 percent said that their husbands approved, 3 percent said their husbands approved conditionally, and 44 percent said that their husbands disapproved of family planning. In contrast, one-tenth of those who had not talked about family planning believed that their husbands approved of couples using a method of family planning. However, understandably, most of the women who had not talked with their spouses did not know about their husband's attitude toward family planning (55 percent).

Table 4.15 Communication with husband and husband's opinion

Percent distribution of currently married women who know a contraceptive method and are currently not using any method by their husband's attitude toward family planning, according to whether they discussed family planning with their spouse, Yemen 1991/92

Discussed with spouse

Husband's Not opinion Yes I No stated Total

Husband approves 50.6 10.6 0.0 28.5 Husband conditionally approves 3.0 0.6 0.0 1.7

Husband disapproves 44.3 33.6 2.3 37.9 Don't know 2.1 55.2 97.7 31.9

Total 100.0 100.0 100.0 100.0 Number 1225 1432 48 2705

lIncludeswomen who were not askedifthey ever talked withtheir husbands about family planning because they cited husband's disapproval &s reason ~ r not planning to use a con~aceptive method in the future.

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