Academic journal article International Family Planning Perspectives

Community and Health Facility Influences on Contraceptive Method Choice in the Eastern Cape, South Africa

Academic journal article International Family Planning Perspectives

Community and Health Facility Influences on Contraceptive Method Choice in the Eastern Cape, South Africa

Article excerpt

CONTEXT: Although a growing number of studies have examined how community factors influence contraceptive use, few have explored how such factors affect method choice.

METHODS: Data from the 1998 South Africa Demographic and Health Survey and the 1998 Eastern Cape Facility Survey were used to examine community and health facility influences on the method choices of 1,165 women aged 15-49 who lived in the Eastern Cape. Relative risk ratios from multilevel multinomial models assessed how method choice varied between communities.

RESULTS: The likelihood of using the pill or a more permanent method rather than the injection rose with the proportion of women in a community who controlled their earnings (risk ratios, 3.2 and 3.8, respectively). In communities with higher proportions of females with only a primary education, women were less likely to use the pill instead of the injection (0.1). Higher doctor staffing levels were associated with a greater likelihood of using the pill or a more permanent method (1.5 and 1.4), and having more expired methods in stock was associated with increased use of a more permanent method (2.1), Several facility factors were associated with a decreased likelihood of using the pill rather than the injection: higher numbers of community health workers in an area and higher numbers of facility nurses who had received training on HIV/AIDS in the last year (0.9 for each). Yet a substantial amount of variation in method choice was not accounted for by these variables.

CONCLUSION: Future research should emphasize the collection of community-level data on structural behavioral and cultural factors to help explain the variation in method choice between communities.

International Family Planning Perspectives, 2008, 34(2):62-70

South Africa's demographic transition is considerably more advanced than those of other Sub-Saharan African nations; its total fertility rate (TFR) has declined from approximately 6.0 births per woman in 1980 to 2.2 in 2007. (1), (2) Over the same period, contraceptive use among the four major population groups (black, white, colored and Asian) has increased. (3), (4) Yet the overall modern contraceptive prevalence of 61% (urban 66%, rural 53%) masks wide racial disparities, and injectables represent 30% of all use. (1), (4) These contraceptive patterns exist in the context of high levels of HIV, which in 2007 infected 19% of all adults. (5) Previous studies of the determinants of contraceptive use in South Africa have focused on individual and household-level influences. (3), (5), (6) In general, little research has examined the role of community context in shaping contraceptive method choice, although a few studies have examined how communities shape contraceptive adoption. (7-9)

Contraceptive method choice is a fundamental indicator of quality of care in a family planning program: The more contraceptive methods that are available, the more likely it is that a program can meet the range of contraceptive needs of a diverse client population. (10) Method choice is particularly important in settings with a high prevalence of HIV, such as South Africa. For women who wish to avoid pregnancy, the dual method approach-combining condoms for HIV and STI prevention with longer acting, more effective contraceptives for added protection against pregnancy--prevents both heterosexual and perinatal HIV transmission. (11) Some studies have shown that seropositive women are more likely than seronegative women to adopt permanent or barrier meth-ods of contraception as a way to prevent pregnancy or HIV transmission, respectively, (11, 12) whereas others have shown that preseroconversion fertility desires often reemerge in an environment of low contraceptive use and cultural constructs that support high fertility. (13), (14)

This study uses data from the Eastern Cape Province, an area with poor economic and health indicators, to examine how community and health care infrastructure characteristics may influence a woman's method choice, particularly the use of contraceptives other than injectables, which are currently the most popular method in South Africa. …

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