Reassessing the level and implications of male involvement in family planning in Indonesia.

BACKGROUND: Although there is global recognition of the importance of involving men in family planning and reproductive health matters, this issue has received insufficient attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify the correlates thereof and assess the implications of male involvement for unmet need for family planning. METHODS: A mixed methods research design was used. The main source of quantitative data was 2017 Indonesian Demographic Health Survey (IDHS) data from 8,380 married couples. The underlying "dimensions" of male involvement were identified via factor analysis. The correlates of male involvement were assessed via comparisons across the four dimensions of male involvement identified in the factor analysis. Outcomes were assessed by comparing women's and couple's unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants. RESULTS: Indonesian male involvement as family planning clients remains limited, with only 8% of men using a contraceptive method at the time of the 2017 IDHS. However, factor analyses revealed three other independent "dimensions" of male involvement, two of which (along with male contraceptive use) were associated with significantly lower odds of female unmet need for family planning. Male involvement as clients and passive male approval of family planning, which in Indonesia empowers females take action to avoid unwanted pregnancies, were associated with 23% and 35% reductions in female unmet need, respectively. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher levels of involvement. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males highlight the quantitative findings. CONCLUSIONS: Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

Despite global recognition of the importance of involving men in family planning and women's health matters, this matter has received insufficient the attention in many countries. The present study sought to characterize married Indonesian males as to their level of involvement in family planning, identify correlates of male involvement, and assess the implications of varying levels of male participation for family planning outcomes.The study used a mixed methods research design. The main source of quantitative data was a 2017 Indonesian Demographic Health Survey (IDHS) data set of 8,380 married couples. Factor analyses were undertaken to identify the underlying dimensions of male involvement. The correlates of male involvement were assessed via comparisons across the four underlying dimensions of male involvement group identified in the factor analysis. Outcomes were assessed by comparing women's and couple's unmet need for family planning for the four underlying dimensions of male involvement. Qualitative data were collected via focus group discussions with four groups of key informants.The study found that male involvement as family planning clients remains limited, with only 8% of men using contraceptive methods themselves. However, Indonesian men are involved in other ways such via approval of family planning and active communications that contribute to lower female unmet need for family planning. The analyses suggest that age, education, geographic residence, knowledge of contraceptive methods, and media exposure distinguish men with higher versus lower levels of involvement. The most important contribution of males to realizing couple-level desires to limit or space births is via the approval of family planning, which empowers females take action to avoid unwanted pregnancies. Socially mandated gender roles concerning family planning and perceived limited programmatic attention to males are highlighted in the quantitative findings.In the way of an overall conclusion, Indonesian males are involved in family planning in several ways, although women continue to bear most of the responsibility for realizing couple reproductive aspirations. Gender transformative programming that addresses broader gender issues and targets priority sub-groups of men as well as health service providers, community and religious leaders would seem to be the way forward.

Contraceptive use and maternal mortality in Indonesia: a community-level ecological analysis.

BACKGROUND: Prior studies have shown that contraceptive use reduces maternal mortality independently of other maternal health services. The present study took advantage of geographically detailed Indonesian data to study the interplay between contraceptive use and other risk and protective factors for maternal mortality at the community level, a level of analysis where the protective effects of family planning can be best understood. METHODS: Data from the 2015 Intercensal Population Survey (SUPAS) and the 2014 Village Potential Survey (PODES) were used to construct a series of census block-level variables measuring key risk and protective factors for maternal mortality. The relationships between these factors and maternal mortality, measured via natural log-transformation of past five-year maternal mortality ratios in each of the 40,748 census blocks were assessed via log-linear regressions. RESULTS: Higher community maternal mortality ratios were associated with lower community contraceptive prevalence, higher percentage of parity four-plus births, higher proportion of poor households, lower population density of hospitals, higher density of traditional birth attendants (TBA), and residence outside of Java-Bali. For every percentage point increase in CPR, community maternal mortality ratios were lower by 7.0 points (95% CI = 0.9, 14.3). Community-level household wealth was the strongest predictor of maternal mortality. CONCLUSIONS: Community contraceptive prevalence made a significant contribution to reducing maternal mortality net of other risk and protective factors during 2010-2015. Increased health system responsiveness to the needs of pregnant women and reductions in socioeconomic and geographic disparities in maternal health services will be needed for Indonesia to reach the 2030 SDG maternal mortality goal.

The impact of family planning on maternal mortality in Indonesia: what future contribution can be expected?

BACKGROUND: Although efforts to reduce high maternal mortality in countries such as Indonesia tend to focus on addressing health risks among pregnant women, family planning has been shown globally to reduce maternal mortality by reducing both total and higher-risk pregnancies. This article assesses past contributions of family planning to the reduction of maternal mortality in Indonesia and the potential future contribution toward achieving the 2030 SDG maternal mortality goal. METHODS: The study takes advantage of data from long series of population censuses and large-scale surveys that are available in few other low- and middle-income countries. We use the decomposition method suggested by (Matern Child Health J, 16:456-463, 2012) and regression-based policy simulations to estimate the number of maternal deaths averted during 1970-2017 due to contraceptive use and project potential future contributions to the year 2030. RESULTS: It is estimated that between 523,885 and 663,146 maternal deaths were averted from 1970 to 2017 due to contraceptive use, a 37.5-43.1% reduction. If the contraceptive prevalence rate (CPR) were to rise from 63% in 2017 to 70% in 2030 and unmet need for family planning were to fall to from 10 to 7%, an additional 34,621-37,186 maternal deaths would be averted, an 18.9-20.0% reduction. A 2030 CPR of 75% and unmet need for family planning of 5% would result in 51,971-54,536 maternal deaths being averted, a 28.4-29.4% reduction. However, the CPR growth rate would have to nearly double the 2000-2017 rate to reach 70% CPR by 2030 and more than triple to reach 75%. Achieving the most ambitious target would still leave the maternal mortality ratio at 125 in 2030 without corresponding improvements in maternal health services. CONCLUSIONS: Although substantial reductions in maternal mortality between 1970 and 2017 can be attributed to contraceptive use and further contributions to the year 2030 are probable, smaller contributions are likely due to the already relatively high CPR and the challenges that must be overcome to move the CPR significantly higher. The ability of Indonesia to reach the 2030 SDG maternal mortality target of 70 maternal deaths per 100,000 live births will depend primarily upon health system effectiveness in addressing health risks to women once they are pregnant.

An Application of the Confidante Method to Estimate Induced Abortion Incidence in Java, Indonesia.

CONTEXT: Induced abortion is legally restricted and highly stigmatized in Indonesia, and is thus extremely difficult to measure. Indirect methods leveraging women's social networks, such as the Confidante Method, have shown promise in estimating hidden behaviors, including abortion, in similar settings. METHODS: A community-based survey was conducted among 8,696 women aged 15-49 in Java, Indonesia, in November 2018-January 2019. Data were collected via in-person interviews with respondents about their own abortions and those of up to three of their closest confidantes. One-year induced abortion incidence rates per 1,000 women were estimated using a direct-report approach and the Confidante Method. RESULTS: The direct-report abortion rate was 3.4 per 1,000 women in 2018, compared with the Confidante Method rate of 11.3 per 1,000. Among the confidantes of women who reported an abortion in the past five years, the abortion rate was 42.0 per 1,000. Half of the women reported that they had no confidantes with whom they shared private information. Among women reporting an abortion and at least one confidante, 58% had disclosed their abortion to their confidante, indicating that substantial transmission bias was present. CONCLUSIONS: The Confidante Method relies on several assumptions that did not hold in this study. Although the method performed better than the direct-report approach, it underestimated the incidence of abortion in Java. More research is needed to understand how abortion-related information is shared within social networks and to assess the appropriateness of applying the Confidante Method to estimate abortion in a given context.

RESUMEN Contexto: El aborto inducido está restringido legalmente y sumamente estigmatizado en Indonesia y, por lo tanto, es extremadamente difícil de medir. Los métodos indirectos que aprovechan las redes sociales de mujeres, como el método basado en confidentes, han demostrado ser promisorios para estimar comportamientos que se ocultan, incluido el aborto, en entornos similares. Métodos: Entre noviembre de 2018 y enero de 2019, se llevó a cabo una encuesta basada en la comunidad entre 8,696 mujeres en edades de 15 a 49 años en Java, Indonesia. Se recolectaron datos a través de entrevistas presenciales con personas sobre sus propios abortos y los de hasta tres de sus confidentes más cercanas. Se estimaron tasas anuales de incidencia de aborto inducido por 1,000 mujeres mediante el uso del enfoque de informe directo y del método basado en confidentes. Resultados: La tasa de aborto por informe directo fue de 3.4 por 1,000 mujeres en 2018, en comparación con la tasa del método basado en confidentes de 11.3 por 1,000. Entre las personas confidentes de mujeres que reportaron haber tenido un aborto en los últimos cinco años, la tasa de aborto fue de 42.0 por 1,000. La mitad de las mujeres reportaron que no tenían confidentes con quienes compartir su información privada. Entre las mujeres que reportaron haber tenido un aborto y tener al menos una persona confidente, el 58% habían revelado su aborto a su confidente, lo que indica que hubo un importante sesgo de transmisión. Conclusiones: El método basado en confidentes depende de varias suposiciones que no fueron aplicables en este estudio. Aunque el método funcionó mejor que el enfoque de informe directo, subestimó la incidencia del aborto en Java. Es necesario realizar más investigación para comprender la forma en que la información relacionada con el aborto se comparte dentro de las redes sociales, así como para determinar qué tan apropiado es aplicar el método basado en confidentes para estimar la incidencia del aborto en un contexto determinado.

RÉSUMÉ Contexte: L'avortement provoqué est limité par la loi et fait l'objet d'une forte stigmatisation en Indonésie. Il est par conséquent extrêmement difficile d'en mesurer l'incidence. Les méthodes indirectes tirant parti des réseaux sociaux des femmes, comme celle de la « confidente ¼, se sont révélées prometteuses dans l'estimation de comportements cachés, notamment l'avortement, dans des contextes comparables. Méthodes: Une enquête communautaire a été menée auprès de 8 696 femmes âgées de 15 à 49 ans à Java (Indonésie) entre novembre 2018 et janvier 2019. Les données ont été collectées dans le cadre d'entretiens personnels avec les répondantes, concernant leurs propres avortements et ceux d'un maximum de trois de leurs confidentes les plus proches. Les taux d'incidence de l'avortement provoqué d'une année pour 1 000 femmes ont été estimés selon une approche de déclaration directe et par la méthode de la confidente. Résultats: Le taux d'avortement estimé par déclaration directe s'est avéré de 3,4 pour 1 000 femmes en 2018, par rapport à 11,3 pour 1 000 selon la méthode de la confidente. Parmi les confidentes des femmes ayant déclaré un avortement durant les cinq dernières années, le taux s'élevait à 42,0 pour 1 000. La moitié des femmes ont déclaré ne pas avoir de confidentes avec lesquelles elles partageaient une information privée. Parmi les femmes déclarant un avortement et au moins une confidente, 58% avaient divulgué leur avortement à leur confidente, indiquant un biais de transmission considérable. Conclusions: La méthode de la confidente repose sur plusieurs hypothèses non confirmées dans cette étude. Bien qu'ayant produit de meilleurs résultats que l'approche par déclaration directe, elle sous-estime l'incidence de l'avortement à Java. Il convient d'approfondir la recherche pour comprendre les modalités du partage de l'information relative à l'avortement au sein des réseaux sociaux et pour évaluer la pertinence du recours à la méthode de la confidente pour estimer l'incidence de l'avortement dans un contexte donné.

Online Abortion Drug Sales in Indonesia: A Quality of Care Assessment.

This study sought to understand the experience of buying misoprostol online for pregnancy termination in Indonesia. We conducted a mystery client study August through October, 2019. Interactions were analyzed quantitatively and qualitatively, along with the contents of the packages. One hundred ten sellers were contacted, from whom mystery clients made 76 purchases and received 64 drug packages. Almost all sellers sold "packets" containing multiple drugs; 73 percent of packets contained misoprostol, and 47 percent contained at least 800 mcg of misoprostol. Thirty-four packets contained insufficient drugs to complete an abortion. When compared to WHO standards, 87 percent of sellers imparted incomplete information about potential physical effects; no seller provided information about possible complications. Women buying misoprostol from informal online drugs sellers will be underprepared for understanding potential side effects and complications. Educational activities are needed to increase women's access to information about safe use of misoprostol as a harm reduction strategy.

Estimating the Incidence of Induced Abortion in Java, Indonesia, 2018.

CONTEXT: In Indonesia, maternal mortality is high and abortion is restricted. Reliable information on induced abortion is needed; however, the difficulty of measuring abortion in settings where it is legally restricted and highly stigmatized calls for innovation in approaches to measuring abortion incidence. METHODS: The data were from three original surveys conducted in Java among health facilities, knowledgeable informants and women aged 15-49, fielded in April 2018-January 2019. Two methods were used to estimate the one-year induced abortion incidence rate in Java: the standard Abortion Incidence Complications Method (AICM) and a modified AICM. Each method was evaluated on the basis of data quality, and what is known about sexual and reproductive health indicators related to abortion rates, to determine which performed best in measuring abortion incidence in Java. RESULTS: Estimates of complications resulting from induced abortion from knowledgeable informants and the women differed substantially. The modified AICM produced an estimate of 42.5 abortions per 1,000 women aged 15-49, while the standard AICM estimate was lower (25.8 per 1,000). A comparison of the distribution of abortion methods used revealed that knowledgeable informants believed abortion was less safe than indicated by women's reports of their own experiences. Therefore, the standard AICM likely underestimates abortion. CONCLUSIONS: The modified AICM performed better than the standard AICM and indicates that abortion is common in Java. Increased access to contraceptives and high-quality postabortion care is needed. Future research should investigate the safety of abortion, especially with respect to self-managed abortion.

RESUMEN Contexto: La mortalidad materna en Indonesia es alta y el aborto está restringido. Se necesita información confiable sobre el aborto inducido; sin embargo, la dificultad de medir el aborto en entornos donde está restringido legalmente y es fuertemente estigmatizado, requiere esfuerzos de innovación en los enfoques para medir la incidencia del aborto. Métodos: Los datos se obtuvieron de tres encuestas originales realizadas en Java entre instituciones de salud, informantes conocedores del tema y mujeres en edades de 15 a 49 años y que fueron aplicadas entre abril de 2018 y enero de 2019. Se usaron dos métodos para estimar la tasa de incidencia de aborto inducido en un año en Java: el método estándar de estimación de aborto por complicaciones (AICM, por sus siglas en inglés) y el AICM modificado. Cada método se evaluó con base en la calidad de los datos y en lo que se sabe sobre indicadores de salud sexual y reproductiva relacionados con las tasas de aborto, para determinar cuál método se desempeñó mejor en la medición de la incidencia de aborto en Java. Resultados: Las estimaciones de complicaciones derivadas del aborto inducido según informantes conocedores del tema y según las mujeres, difirieron sustancialmente. El AICM modificado produjo una estimación de 42.5 abortos por 1,000 mujeres en edades de 15 a 49 años, mientras que la estimación del AICM estándar fue más baja (25.8 por 1,000). Una comparación de la distribución de los métodos de aborto usados reveló que los informantes conocedores creían que el aborto era menos seguro que lo indicado en los informes de las mujeres basados en sus propias experiencias. Por lo tanto, es probable que el método AICM estándar subestime la incidencia del aborto. Conclusiones: El método AICM modificado funcionó mejor que el AICM estándar e indica que el aborto es una práctica común en Java. Son necesarios un mayor acceso a los anticonceptivos y a una atención postaborto de alta calidad. Las futuras investigaciones deben investigar la seguridad del aborto, especialmente en relación con el aborto autoadministrado.

RÉSUMÉ Contexte: En Indonésie, la mortalité maternelle est élevée et l'avortement est limité par la loi. Il existe un besoin d'information fiable concernant l'avortement provoqué. La difficulté de mesurer l'avortement dans les contextes où il est strictement limité et fortement stigmatisé demande cependant des approches innovantes. Méthodes: Les données proviennent de trois enquêtes initiales menées à Java auprès de structures de santé, de sources bien informées et de femmes âgées de 15 à 49 ans, entre avril 2018 et janvier 2019. Le taux d'incidence de l'avortement provoqué à l'échelle d'une année à Java a été estimé selon deux méthodes: la méthode AICM standard d'évaluation de l'incidence de l'avortement en fonction des complications traitées et une méthode AICM modifiée. Chaque méthode a été évaluée en fonction de la qualité des données et de l'information connue sur les indicateurs de santé sexuelle et reproductive relatifs aux taux d'avortement, afin de déterminer celle qui avait le mieux mesuré l'incidence de l'avortement à Java. Résultats: Les estimations des complications résultant de l'avortement provoqué obtenues des sources informées et des femmes consultées se sont avérées nettement différentes. La méthode AICM modifiée a produit une estimation de 42,5 avortements pour 1 000 femmes âgées de 15 à 49 ans, tandis que la méthode AICM standard produisait une estimation inférieure (25,8 pour 1 000). En comparant la distribution des méthodes d'avortement pratiquées, on a constaté que les sources informées estimaient l'avortement moins sùr que ne l'indiquaient les déclarations des femmes concernant leur propre expérience. Il est dès lors probable que la méthode AICM standard sous-estime l'avortement. Conclusions: La méthode AICM modifiée, plus efficace que la méthode standard, fait état d'une pratique courante de l'avortement à Java. Un meilleur accès à la contraception et à des soins après avortement de qualité est nécessaire. La recherche future devrait se pencher sur la sécurité de l'avortement, en ce qui concerne en particulier les interventions autogérées.