Indonesia has the fourth largest population in the world (World Population Review, 2022). The Indonesian government has put in place a family planning programme that aims to reduce population density, with the goal of each family having no more than two children. Data collected by the National Population and Family Planning Board (2022) show that the total fertility rate (for women aged 15–49 years) in 2021 was 2.24, a reduction from the total fertility rate of 2.45 in 2019. Total fertility rate is used as an indicator of population density and the target of the family planning programme is thus a rate of 2.0.
Results from the inter census population survey show that Indonesia's maternal mortality rate was 305 per 100 000 live births in 2015 (Nuraini et al, 2015). According to Indonesia's sustainable development goals roadmap for 2030 (Bappenas, 2017), the policy trajectory for 2020–2024 is to reduce this rate to 232 per 100 000 live births. The family planning programme has three main goals that are intended to reduce maternal mortality (Kementarian Kesehatan Republik Indonesia, 2022): to reduce the number of children each woman has, reduce the rate of women giving birth when they are at either the extreme lower or extreme upper range of reproductive age, and improve birth spacing. Encouraging the use of contraceptives forms part of the first and third goals.
The prevalence of contraceptive use in the community influences maternal mortality. Around two thirds of couples of childbearing age were found to use contraceptives in 2020 (67.6%), while in East Java, the prevalence of use was 64.1% (Dinas Kesehatan Provinsi Jawa Timur, 2022). East Java is a region of Indonesia that has good economic stability (Pemerintah Daerah Provinsi Jawa Timur, 2015). Good economic growth is believed to affect choice of contraception in couples of childbearing age (Aryanty et al, 2021).
Data from Indonesia show that in 2020, most couples who chose to use contraception used the injection method (72.9%), with almost a fifth using contraceptive pills (19.4%) (Dinas Kesehatan Provinsi Jawa Timur, 2021). Both methods, when used properly, are over 99% effective in preventing unwanted pregnancies. However, there are factors that can decrease their effectiveness of contraception, including inaccurate doses, inconsistency or forgetting to take the contraceptive (Festin, 2020).
Understanding trends in contraceptive use in Indonesia is essential for stakeholders to determine strategies for increasing contraceptive use. The COVID-19 pandemic had an impact on health services, with travel restrictions and the fear of infection preventing people from accessing healthcare facilities, including contraceptive services (UNICEF, 2021). There was also a surge in births after the pandemic, threatening the progress made by the family planning programme in reducing population density and reducing maternal mortality. Strategies are therefore needed to improve contraceptive use among couples of childbearing age.
One way to increase contraceptive acceptance and use is to provide counselling about contraceptive methods from health workers, especially midwives. Counselling has been shown to affect a couple's choice of contraceptive method (Cris, 2012), and can play a role in increasing commitment to using contraceptives correctly, increasing their effectiveness (Mears, 1965).
The Indonesian National Population and Family Planning Agency and the Indonesian government have facilitated the estbalishment of contraceptive services. These services can be accessed free of charge by government health facilities or for a fee by private health facilities. Contraceptive counselling is provided by family planning field officers and health providers, including midwives and doctors. Midwives have the authority to communicate and provide information, education, counselling and contraceptive services (Republik Indonesia, 2019).
Counselling is provided to couples of childbearing age at healthcare centres (puskesmas), independent midwife practices, hospitals, the community, integrated health service posts (posyandu) and at other sites. This study was carried out to provide an overview of couples' choice of contraceptive methods before and after receiving counselling in 10 districts/cities of East Java, Indonesia.
Methods
This study used a cross-sectional design to collect data from 10 districts/cities in the East Java province: Sidoarjo, Gresik, Mojokerto, Lamongan, Pasuruan, Ponorogo, Malang, Jombang, Malang City and Surabaya. District/city locations were selected based on expenditure and high average income, as these areas were predicted to yield a more diverse range of findings on contraceptive methods. Communities with significant financial capacity were thought to be more likely to use both traditional and modern contraceptive methods.
Participants
This research was conducted with the help of 50 midwives (five per district/city) who provide routine counselling at contraceptive services. Midwives conduct counselling in independent practices, posyandu, puskesmas and the community. During a visit to an integrated healthcare centre, women are provided with a single counselling session. Midwives engage in outreach activities at the centre on a monthly basis, addressing various issues. The recipients of counselling services at the centre primarily consist of mothers with infants and those who express an interest in counselling sessions on specific subjects. Counselling is carried out for 1–1.5 hours on types of contraceptive, their side effects and the advantages of contraceptive use. All midwives who conduct counselling have a contraceptive training certificate.
Total sampling was used to select 10 790 women who attended counselling and who had a history of having given birth at least once. They were recruited for the study when they attended counselling.
Data collection
Before counselling, the participants were asked to fill out an online questionnaire, which was used to assess their current contraceptive method, if used, and their ideal method. The same questionnaire was distributed following counselling. It asked for participants' age and number of children, and details of contraceptive methods used before and after counselling.
The questionnaire was subject to validity testing using Pearson Correlation statistical analysis, and all questions were found to be valid with a P value of 0.00. The reliability of the questionnaire was assessed using Cronbach's Alpha, which was calculated as 0.65 indicating satisfactory dependability.
Participants completed the survey before attending their counselling session. Following the conclusion of the session, the participants were asked to repeat the questionnaire. Their responses were given via online survey, which they accessed using mobile phones. Data collection was carried out during September 2021.
Data analysis
The data were analysed using descriptive statistical analysis and paired t-tests. P<0.05 was used to indicate significance.
Ethical considerations
Ethical approval to conduct the study was granted by the Faculty of Nursing at the Universitas Airlangga (approval number: 2613-KEP). All mothers who attended counselling received an explanation about the purpose and procedure of the research and were asked to participate. All those who agreed were asked to provide written informed consent.
Results
Table 1 outlines participants' characteristics. The largest proportion of participants were aged 31–40 years (36.7%). Almost half of the respondents had two children (43.8%), and 19 respondents were grande multipara having more than five children.
Table 1. Participants' characteristics
| Characteristic | Frequency, n=10 790 (%) | |
|---|---|---|
| Age (years) | ≤20 | 226 (2.1) |
| 21–30 | 4444 (41.2) | |
| 31–40 | 3959 (36.7) | |
| 41–50 | 1752 (16.2) | |
| >50 | 407 (3.8) | |
| Living children | 0 | 495 (4.6) |
| 1 | 3503 (32.5) | |
| 2 | 4729 (43.8) | |
| 3 | 1591 (14.7) | |
| 4 | 371 (3.7) | |
| 5 | 70 (0.6) | |
| >5 | 19 (0.2) |
Table 2 outlines participants' use of contraceptives before and after counselling. Before counselling, the majority (75.8%) were using contraception. Of those who used contraception, the majority used short-term methods, including 3-month injection (22.6%), 1-month injections (16.0%) and pills (16.7 %).
Table 2. Contraceptive use pre- and post-counselling
| Variable | Frequency, n=10 790 (%) | ||
|---|---|---|---|
| Pre-counselling | Post-counselling | ||
| Using contraceptives | Yes | 8174 (75.8) | 10 788 (99.98) |
| No | 2614 (24.2) | 2 (0.02) | |
| Method used | Pill | 1797 (16.7) | 4415 (40.9) |
| 1-month injection | 1724 (16.0) | 1438 (13.3) | |
| 3-month injection | 2436 (22.6) | 1829 (17.0) | |
| Spiral or intrauterine device | 906 (8.4) | 1486 (13.8) | |
| Implant | 449 (4.2) | 552 (5.1) | |
| Sterilisation | 384 (3.6) | 598 (5.5) | |
| Condom | 310 (2.9) | 470 (4.4) | |
| Other | 168 (1.6) | 0 (0.0) | |
| None | 2614 (24.2) | 2 (0.02) | |
After being counselled by midwives on the advantages and side effects of each method, there was a significant change in participants' choice of contraceptive method, with 40.9% choosing the pill. There was also an increase in use of long-term contraceptive methods, including spiral or intrauterine devices (pre-counselling: 8.4%, post-counselling: 13.8%), implant (pre-counselling: 4.2%, post-counselling: 5.1%), and sterilisation (pre-counselling: 3.6%, post-counselling: 5.5%).
A paired sample t-test was carried out to determine the differences in contraceptive use before and after counselling. The results showed a significant difference method (P<0.001), indicating that counselling on contraceptive methods greatly influenced the participants' choice.
Discussion
Contraceptive use can promote birth spacing and prevent unwanted pregnancies. Couples should be aware of when it is safe to become pregnant again following a birth, and should plan for how many children they want and when they wish to have them. Good family planning is expected to reduce the risk of unwanted pregnancy and increase family welfare. This is an important goal of the family planning programme in Indonesia, which aims to reduce population density.
Women who are more than 35 years old are at increased risk of pregnancy complications (Gantt et al, 2022). The use of contraceptive methods in women >35 years old is therefore encouraged. The present study's participants were mostly women aged 21–40 years old, with 16.2% being 41–50 years old. Data from 2019 in East Java showed that 64.2% of maternal mortalities occurred among women aged 20–35 years old, while 32.3% were women aged >35 years (Fatmaningrum et al, 2022).
Decision making on contraception is influenced by social factors (individual, interpersonal, community) and perceptions of hormonal contraception (Dombola et al, 2021). Research in Bangka Belitung found that factors influencing contraceptive use include a woman's age, education, number of living children, area of residence, wealth index, knowledge and visits to health facilities (Antarini, 2021). Health promotion can influence a couples' decision as to which contraceptive method to use (Afriyie and Tarkang, 2019), but other efforts are also needed, such as improving economic status, education and healthcare access.
The family planning programme in Indonesia uses the motto ‘two children is better’, a recommendation to families to have no more than two children (Isnawati, 2017). However, the present study's results showed that almost a fifth of the participants had more than two children, and some had been pregnant more than four times. Using contraception does not guarantee the prevention of unwanted pregnancies, and socioeconomic and cultural factors will influence a couple's decision as to how many children they want. The main predictive factors that influence number of children include income, a preference for sons (which may encourage some couples to continue having children until they have a son), government policy and ethnicity (Asadi Sarvestani et al, 2017; Dewi et al, 2020).
Before counselling, almost a quarter of the present study's participants were not using contraceptives. The family planning programme in Indonesia should include consideration of influencing factors when promoting contraceptive use. Maternal age, education, economic status, employment, place of residence and number of living children have all been shown to impact contraceptive use in Indonesia (Idris, 2019). Parity, ethnicity, media exposure and wealth index have also been linked to contraceptive use (Ajmal et al, 2018). Specifically, living in urban areas, younger age, low education, unemployment and low economic status have all been linked to a lack of contraceptive use (Wulundari et al, 2021).
The results of the present study showed that short-term contraceptives are still the primary method used, and the use of a contraceptive injection was highly prevalent. This is despite recommendations, such as from the American College of Obstetricians and Gynecologists, for long-term contraceptive use, such as the intrauterine device, because of their relatively high effectiveness and minimal side effects (Savage and Lindsay, 2018). Long-acting reversible contraception has been shown to be more effective effectiveness than pills, patches or ring contraception methods and is safe for use among adolescents (Winner et al, 2012). However, there are obstacles to their use, including insurance costs, the requirement for training of health workers, and the need for increased knowledge and encouraged interest among couples (Shoupe, 2016). As a result, a multisector strategy is needed to encourage their use, that involves patients, providers, stakeholders and the community (Shoupe, 2016).
The use of traditional contraceptive methods such as the calendar method and coitus interruptus have also been found to have increased in Indonesia, mainly among women with higher education, those who are employed work and those living in urban areas (Gayatri and Utomo, 2019). Barrier contraceptive methods were not highly prevalent among the present study's participants, with only 1.6% using condoms. Other barrier methods such as the diaphragm, cervical cap, spermicidal foam, jelly, cream and sponge were also not commonly used.
Providing counselling to increase knowledge of contraceptive methods is essential, as their efficacy depends on following their guidelines for use. For example, the contraceptive pill is most effective if taken at the same time each day. Consequently, it has been recommended that family planning counselling should be given as part of antenatal services. A study in Surabaya found that 50% of postpartum mothers were unable to correctly answer questions related to contraceptive methods (Anis et al, 2022).
Improving the quality and timing of counselling on contraceptive methods will encourage appropriate decision making regarding postpartum contraceptive use for birth spacing. Several countries also recommend contraception counselling for adolescents to guide appropriate and effective decision making for contraception (Potter and Santelli, 2015). The American College of Obstetricians and Gynaecologists recommends that discussions about contraception should begin with information about the most effective method, to encourage their use (Gerancher, 2017; Savage and Lindsay, 2018). The quality of contraceptive counselling can be improved by understanding the importance of a positive relationship between a healthcare professional providing counselling and the woman or couple whom they are supporting in family planning (Dehlendorf et al, 2014).
The present study reported that after counselling from a midwife, a significant number of participants elected to use contraception; almost a quarter of women who had previous opted not to use any contraception chose to use it following the counselling sessions. Counselling that includes effective communication on the benefits of intrauterine devices has previously been shown to increase their use (Franklin et al, 2021). Similarly, previous studies have recommended that family planning policies should coaching, education and communication programmes, and consider factors that can affect the use of contraception (Idris, 2019).
Although counselling on contraception has the potential to empower women to avoid unwanted pregnancies (Dehlendorf et al, 2014; Anis et al, 2022), its success depends on a number of factors related to mothers, health workers and the environment. A counsellor's ability to facilitate couples to select a contraceptive method that suit their needs is essential to the success of counseling (Bajos et al, 2003).
Strengths and limitations
A strength of this study is that it has a large sample size, taken from a range of study sites, from whom preferred methods of contraception and the effect of counselling on choice of method was elucidated.
The absence of standardised counselling is a limitation for this study. There may have been variation in themethods and tools midwives used when counselling the participants at different sites. Future research should standardise the content and methods of midwives' counselling, so that its effect can be accurately assessed.
Conclusions
Most women in the present study elected to use short-term contraceptive methods, both before and after counselling. A significant difference was seen in the number of women who chose to use contraceptives following counselling, indicating that counselling can contribute to increased use. Additionally, there was increased interest in long-term contraceptive methods.
Key points
- This study was carried out to explore the effect of contraceptive counselling on choice of contraceptive method across 10 provinces of Indonesia.
- The participants showed a preference for short-term contraceptives, and there was a significant increase in uptake of contraceptive methods following counselling on types, efficacy and side effects.
- Counselling has the potential to encourage contraceptive use, which is important for the ongoing efforts to reduce the fertility rate in Indonesia and minimise maternal morbidity and mortality.