Academic journal article International Perspectives on Sexual and Reproductive Health

Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study

Academic journal article International Perspectives on Sexual and Reproductive Health

Contraceptive Dynamics in Rural Northern Malawi: A Prospective Longitudinal Study

Article excerpt

Malawi is a poor country in Sub-Saharan Africa that has made attempts to address its population and fertility problems, (1-5) by initiating programs to encourage birthspacing (6) and by organizing conferences on population and development. (1,7-9) Such activities may be showing some results. Malawi's modern contraceptive prevalence rate (mCPR)-- the proportion of women of reproductive age who report that they (or their partner) are currently using a modern contraceptive--was six times as high in 2010 as it was in 1992 (42% vs. 7%),10 a remarkable achievement and a higher level of use than in other countries in the region. (11) During that period, the percentage of married women using the injectable rose from 1.5% to nearly 26%. (10)

The mCPR is the most widely used measure of success of contraception programs. (12,13) It is typically captured in Demographic and Health Surveys (DHS), the Multiple Indicator Cluster Survey and other large-scale national surveys with the question "Are you currently doing something or using any method to delay or avoid getting pregnant?" If the reply is "yes," the woman is asked what method she is using; nonmodern methods (e.g., withdrawal, the calendar method) are excluded for calculation of mCPR.

Given Malawi's high mCPR, the country has been heralded by the international community as a success story. (14) However, the country's total fertility rate (TFR) has decreased only marginally, from 6.7 births per woman in 1992 to 5.7 in 2010, (10) and remains among the highest in the region.11 That Malawi's greatly increased contraceptive use rate has not translated into notably lower fertility is surprising. Mozambique attained a similar TFR (5.9) in 2011 with just 11% of women using modern contraceptives; likewise, Tanzania had a TFR of 5.8 in 1996, when its mCPR was only 13%. (11)

One explanation for Malawi's fertility remaining high despite relatively high contraceptive use could be that although mCPR is estimated cross-sectionally, the DHS uses births from the five years preceding the survey to calculate the TFR; thus, any increase in mCPR might not be reflected in the TFR until a few years later. Another possibility is an ecological analysis fallacy, in which contraceptive users might tend to be at low risk of pregnancy (e.g., women who are single, older or experiencing postpartum amenorrhea) and nonusers might contribute a disproportionately high number of births. Alternatively, proximate determinants of fertility other than contraceptive use might play a significant role: for example, short breast-feeding periods and early age at sexual debut and marriage.

Another potential explanation is that fertility might be overreported. It is more likely, however, that contraceptive use is overreported. Women who have adopted the pill or the injectable might consider themselves contraceptive users and report themselves as such, even though they missed their last appointment to pick up a new supply of pills or get their next injection, and so technically are not current users. There could be something different about provision of contraception services in Malawi (e.g., more common stockouts) that means women there are more likely than women in other countries to miss reinjection or resupply appointments and, thus, overreport their contraceptive use. The mCPR, which tends toward a measure of period prevalence rather than point prevalence, might fail to capture these gaps; long-term inconsistent use of short-term methods amplifies this issue. Moreover, Malawian women may give what they perceive to be the desired response, as a result of exposure to media campaigns and multiple provider-initiated family planning conversations.

One way of assessing the quality of contraceptive data is to compare linked husband and wife reports, and identify any discrepancies. (15,16) Typically, husbands report higher levels of contraceptive use than their wives. (16) In addition, findings from Malawi suggest that when couples give discordant responses to survey questions (e. …

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