Constrained Contraceptive Choice: IUD Prevalence in Uzbekistan
Reported, January 10, 2012
CONTEXT: Because individuals’ and couples’ needs vary, the availability of a variety of contraceptive choices is a key component of successful family planning programs. Most women in Uzbekistan rely on a single contraceptive method (the IUD), but it is unclear whether this reflects constraints on choice or simply a widespread preference.
METHODS: Nationally representative data from the 1996 Uzbekistan Demographic and Health Survey and the 2002 Uzbekistan Health Examination Survey were used to evaluate the relationship between demographic characteristics and knowledge and use of contraceptives among sexually active women. Separate multivariate regression analyses were performed for 1996 and 2002.
RESULTS: Nearly all sexually active women knew about contraceptives, and in 2002 most reported that they had ever used the IUD (71%) or any modern method (77%). In both surveys, women with higher levels of wealth (odds ratios, 2.23.1) and education (1.92.5) were more likely than other women to know about contraceptive methods other than the IUD. Higher levels of wealth and education, as well as urban residence and non-Uzbek ethnicity, were also associated with the use of contraceptives other than the IUD, although these relationships were generally weaker in 2002 than in 1996.
CONCLUSION: Despite the high prevalence of contraceptive use in Uzbekistan, the country’s reproductive health program may be constraining method choice. Expanded programmatic efforts emphasizing choice from a range of methods are needed, especially among subgroups of women who have little knowledge or experience with methods other than the IUD.
The focus of most family planning programs is to promote the adoption of modern methods of contraception. The ability to choose among multiple methods is central to the decision to practice contraception,because individuals’ and couples’ contraceptive needs differ according to their motivations for pregnancy prevention (delaying, spacing or stopping), their concerns about STIs and the cultural acceptability of available methods. When programs offer a range of contraceptive options, users have the ability to make active and educated method choices.Moreover, evidence indicates that contraceptive prevalence tends to increase if a wide variety of methods are available.Within family planning programs, however, the decisions of institutional actors and the actions of health care providers can constrain contraceptive choices for women. In attempting to increase overall contraceptive prevalence, some national programs are charged with prescribing specific methods of contraception, rather than providing information aboutand access toa variety of modern contraceptives.
Uzbekistan, the most populous of the former Soviet republics in Central Asia, had a one-method family planning regime when it was part of the Soviet Union: Abortion was the only widely available means of controlling fertility.Since Uzbekistan’s independence in 1991, the country’s extensive state-sanctioned family planning programs have been associated with reduced reliance on abortion and dramatic increases in contraceptive use.Yet, as during the Soviet period, one primary method of contraception remains dominant in Uzbekistan, in this case the IUD. Does knowledge of methods other than the IUD vary by women’s social and demographic characteristics? Does the nearly universal adoption of the IUD in Uzbekistan reflect a preference shared across social groups, or is the choice of other contraceptive methods limited to certain groups of women? We examine these questions using data from the 1996 Uzbekistan Demographic and Health Survey (UDHS), the 2002 Uzbekistan Health Examination Survey (UHES) and interviews with medical professionals.
The family planning literature identifies three interactive levels of factors that influence contraceptive method choice: institutional, clinical and individual. First, when governmental entities and international agencies seek to increase access to family planning and control fertility, their interest in expanding the range of methods offered may be secondary; as a result, method choice may be sacrificed due to issues of cost, supply and availability. In addition, cultural, structural and historic factors influence institutional preferences, which are slow to change. Second, the preferences of health care providers and family planning educators directly influence the information provided to clients, thus swaying women’s decisions concerning method adoption. Specific method recommendations by doctors and other health care workers reflect their training and may be partially motivated by incentives to adopt the same preferences expressed by other individuals and institutions.Finally, couples’ and individuals’ perceptions about available contraceptive methods (based on their own and others’ past experiences) and the information and ideas they gather through social interactions also play a substantial role in method choice
During the Soviet period, when fertility was regulated primarily through induced abortion, women’s knowledge about modern contraceptives was low in Uzbekistan.Barbieri and colleagues estimate that the number of abortions in Uzbekistan increased by 231% between 1956 and 1973.12 In the 1970s, official warnings about the risks associated with hormonal contraceptives lessened interest in use of the pill and generated negative attitudes toward hormonal methods among medical professionals and the public.Other than abortion, methods of controlling fertility were seldom available in Uzbekistan until the mid-1980s,when the IUD was advocated in the local medical press.
Today, awareness of modern contraceptive methods is quite high in Uzbekistan, as nearly 99% of married women know of some form of modern contraception. In the 2002 UHES, the IUD was the most widely known method among married women (98% were aware of it), yet high proportions had also heard about the pill (85%), injectables (78%) and male condoms (68%). These figures represent increases over the already high proportions reported in the 1996 UDHS (although neither survey measured the depth of women’s knowledge).
The study had two primary goals. The first was to assess the importance of individual characteristics in determining women’s knowledge of contraceptive methods other than the IUD in Uzbekistan. We found that knowledge of these alternative methods differed sharply by women’s age, material well-being and level of education, both in 1996 and in 2002. This suggests that individual characteristics are relevant for predicting women’s knowledge of less widely used contraceptive methods, even when overall awareness of contraceptives is high.
We also examined patterns of social and demographic differences in women’s ever-use of alternative contraceptive methods. We found that individuals who had never used a modern method and those who had ever used a method other than the IUD differed from women who had used only the IUD, supporting our hypothesis that women with higher levels of socioeconomic status tend to use a wider range of contraceptives. Our findings were largely stable across survey years, indicating little change in the relationship between socioeconomic characteristics and the use of methods other than the IUD.
Scholars and policymakers increasingly note that method choice is a key element of successful family planning programs. As more varied groups of people begin to use contraceptives, the method requirements for a population may become increasingly diverse. Previous research indicates that access to multiple contraceptive methods is a successful strategy for increasing overall prevalence. In Uzbekistan, success in increasing contraceptive use does not appear to have coincided with a widening of the contraceptive mix. Rather, the Soviet reliance on a single method of limiting fertility (abortion) has been replaced by the almost exclusive use of a different method (the IUD). More than 80% of married women used modern contraceptive methods in 2002,a dramatic improvement from the Soviet period, yet more than 85% of all users relied on the IUD. Anecdotal evidence indicates a strong state-level preference for the IUD in Uzbekistan, a preference reflected in the composition of international aid to promote family planning and the behavior of medical care professionals. These findings and observations raise questions regarding the structural context within which individuals’ contraceptive decision making takes place.
Our analyses suggest that contraceptive choice in Uzbekistan is constrained, such that the only contraceptive option for many women is the IUD. Women who possess higher levels of material wealth or who are well educated appear to be more knowledgeable than other women about multiple contraceptive methods, and thus may be better able to choose from a variety of methods. Women who are highly educated, urban residents, relatively wealthy or not ethnic Uzbeks have elevated odds of ever having used a method other than the IUD. These findings are consistent with the argument that contraceptive choices are determined within a multilevel network of influences related to method availability, to women’s and providers’ knowledge of and experience with various methods, and to social pressures. Individual characteristics affect women’s responses to these influences and pressures, widening or constricting channels of access to contraceptive information, supplies and services. Compared with individuals with higher socio-economic status, women with relatively few resources may be more strongly influenced by structural or programmatic constraints on women’s knowledge of and access to contraceptives, and by strong encouragement for IUD adoption from the medical community in Uzbekistan.
The relationship between most individual characteristics and the use of alternative contraceptive methods weakened between 1996 and 2002, which may indicate increased equity in method access, perhaps due to family planning efforts that focus on rural, poor, less educated and unemployed women. Nonetheless, substantial differentials remain. Expanded programmatic efforts emphasizing choice from a range of methods are needed, especially among groups of women who almost exclusively use the IUD.
This investigation raises several questions for future analysis. Examinations of the content of family planning materials and family planning directives to state clinics can provide better understanding of the institutional context in Uzbekistan and enable evaluations of the means and motives behind the observed state preferences for the IUD. Additional investigation into women’s preferences and priorities in method selection would further illuminate the demand for methods other than the IUD and shed light on how women’s contraceptive needs vary according to their desire to delay, space or prevent future births. More research on the level of method knowledge and availability in Uzbekistan is also justified by our findings. Observation of workers in public health clinics and birthing hospitals may clarify the role that medical professionals play in influencing method choice. Sadly, given the increasingly restrictive research climate in Uzbekistan,the possibilities for more detailed qualitative work are presently limited.
Our findings indicate a potential conflict between international goals concerning successful reproductive health programs and the ways in which state and institutional interests in Uzbekistan influence individual decision making. They also suggest that a critical evaluation of Uzbekistan’s reproductive health achievements and remaining needs is warranted, as such an assessment can contribute to our understanding of institutional processes and individual decision making in the realm of reproductive health.
