Contraceptive Method Preference among Conditional Cash Transfer Beneficiaries in Indonesia

Background: Conditional Cash Transfer (CCT) or known as Program Keluarga Harapan (PKH) in Indonesia is a potential program to improve health outcomes, especially reproductive health. This program targeted women from the poor as its beneficiaries. The beneficiaries of this program should visit selected the primary health care to have antenatal care as if they are pregnant. Also, they have to do the growth monitoring regularly if they have children under six. Some studies have found that poor people have a higher risk of unmet need compared to the group with better economies. Could this poor group have a high level of unmet need?. Method: A Cross-sectional study of 172 women which all CCT beneficiaries interviewed using a structured questionnaire. We gathered socio-demographic data and the using of contraception from the respondent. The data were analyzed using descriptive method. Results: Contraceptives practice among CCT beneficiaries is relatively high (89.6%) and unmet need for limiting childbirth was 4.1% higher than Indonesia unmet need in 2017. Most respondents preferred using pills and injection than any other method and procured it from primary healthcare centre and local/village midwife for free. Conclusion: Pills and injection method were mostly chosen by the respondent. The total unmet need (for limiting) was slightly lower than Indonesia unmet need in 2012. It seems that these CCT beneficiaries don’t meet an obstacle to access contraception. The unmet need for spacing somehow needs further investigation.


Introduction
Poverty is a common problem in many countries. The Indonesian government made policies to reduce poverty, one of which is running a Conditional Cash Transfer (CCT). CCT in Indonesia has been started since 2007. This program is widely known as Program Keluarga Harapan (PKH). PKH is a conditional cash transfer program managed by the Indonesian Ministry of Social Affairs which aims to break the inter-generational chain of poverty.(1) Its beneficiaries are poor families and female precedence. Many studies have found that CCT has a positive impact on maternal and child health.(1) Some studies have also mentioned the indirect impact of this program on the number and spacing and family planning. (2) PKH beneficiaries have obligations that must be met, namely Attending Group Meetings or Family Ability Improvement Meetings (P2K2). During the meeting, a variety of materials were provided including health and nutrition materials. The person in charge of delivering the material in P2K2 was the PKH companion. To properly convey the material, some modules can be studied and followed by a companion during the meeting. For health and nutrition material, it is delivered in 3 modules whose contents are: 1. Understanding the health of pregnant women, toddlers, and children; 2. Adequate nutrition of pregnant women; 3. Clean lifestyle; and 4. Pain in children.(1- 3) Family planning is believed to be one of the most cost-effective investment development; It not only contributes to reductions in maternal mortality but also empowers women and makes the gates of prosperity.(4) Unfortunately, there is over 100 million women in the developing world with unmet need for contraception, that is, the woman who want to postpone or avoid childbearing, but neither they or their partner are using contraception. (3) The latest result of Indonesia Demographic and Health Survey (IDHS 2017) shows that 10.6% of married women in Indonesia have unmet need for family planning services; 4.1% for spacing (want to delay the subsequent childbirth for two years or more), and 6.5% for limiting (do not want to have more children). (5) Being the beneficiaries of PKH, these respondents required to always be in contact with health care workers. If they have children under 6 they obligated to monitor the growth every month. If she's she must have antenatal care (ANC) at least 4 times during pregnancy. Thus the need for health services become more and more fulfilled for beneficiaries. Besides ANC and monitoring growth, the researchers wanted to see if this program could also relate to the fulfilment of the need for family planning services. Because this program has great potential for the success of family planning. Results of IDHS 2017 showed that the unmet need for limiting childbirth is 6.5%. The question arises, is the level of unmet need among PKH beneficiaries lower or higher, considering they are very close circuitry health service.
Other research by Khan, M E et al., mentioned that there were three studies showed a positive impact on contraceptive use and four showed a decrease in fertility outcomes. (6) Another study From Peru showed that contraceptive was increased among women exposed to the Junto's CCT program for two years or more. Furthermore, Juntos increased modern methods use by 4 percentage points relative to traditional methods.(7)

Method
Thes study was carried out between March 2017 and July 2018. Samples are CCT beneficiaries in Tanjunganom sub-district who received CCT between 2013 and 2017 and whose infant was 0-5 years old; with a total 172 samples. Data were collected using a structured questionnaire adapted from IDHS 2012. The data were analyzed with STATA software. The result was summarized using descriptive statistic and presented using frequency tables and percentages.

Results
One hundred-two women participated in the study. No respondent younger than 20 years old and we found most respondent (41%) were graduated from middle school level. Most of the respondent (95.3%) are currently married, while a small proportion of the respondent (4.7%) is now a widow. The socioeconomic and demographic data of the respondent were shown Table 1.  (15) We gathered information from 172 respondents about the usage of contraception. As shown in Table 2. One hundred and forty-six (85%) respondents were currently using contraception, only twenty-six did not. Among 26 women who were non-users, seventeen women (10.4%) didn't want more children, and thus met the criteria for unmet need family planning. Eight others are the widow and did not have a sexual partner while the other one state that she was infecund. Those 9 were excluded from the unmet need calculation the reason was the goal of estimating the effect on fertility levels if all unmet need were converted to contraceptive use. Thus, we exclude women for whom contraceptive use would have no demographic impact.
The study found that the most preferred contraceptive method among respondents (50.5%) is a progesterone-only injectable which administered every 3 months, and only one respondent using 5 years implant. Progesterone-only injectable seems to be the most selected contraceptive method among others in every group of age, followed by pills and IUD. Out of 140 woman, only one respondent practised traditional method of contraception (periodic abstinence) to avoid pregnancy. Eighty eight respondents (62.8%) procured their contraception from primary healthcare centre and local/village midwife, only three respondents (10.6%) obtained them from the hospital. This preference was found in any age groups in this study. The contraceptive use base on age data of the respondent were shown Table 3.

Discussion
The contraceptive use in this sub-district has mostly dominated by short-acting methods of contraception, compared to long-acting reversible contraceptives. This is commonly happenes in so many places like in Latin America and Bolivia.(8) Lack of knowledge and time available by health providers to explain the long-term contraceptives provide is the cause of this problem.(9) Woman's preference for contraceptive method choices were complex, as explained by Spagnoletti, et. Al., Women's justifications for their contraceptive choices were complex and manifold: most had concerns about safety and the side effects associated with hormonal and biomedical contraceptives; others were ideologically opposed to fertility control.(10) Unmet need for family planning, defined based on survey data to measure the percentage of women who do not want to become pregnant but are not using contraception. This definition continues revises as it has not been calculated consistently and not calculated the same way in many Demographic and Health Survey through ICF International in 2012. According to DHS, unmet need definition includes 2 cases; limiting and spacing. This study examines the unmet need for limiting birth in the CCT beneficiaries. Contraceptives practice among CCT beneficiaries is relatively high (89.6%) while unmet need for limiting is 10.6% with 4.1% for spacing and 6.5% for limiting. This number is slightly higher compared to Indonesia unmet need in 2017 (11%). (5) There are many factors associated with unmet need. Lack of pregnancy risk understanding, using traditional contraceptive method rather than the modern method, worries of potential side effect, also because of the accessibility (cost and distance). (11) We found that most respondents have used modern methods compared to traditional methods. This result is not much different from earlier research conducted by Gustiana, R. in 2012 about women's preference for contraceptive choice in West Java. The contraceptive method largely dominated by short-term contraceptive especially the use of pills and injection. The research found that woman with higher education preferred long-term contraceptives than short-term contraceptives. The result also indicates that older and more educated women have a greater understanding of contraceptive choice. The PKH beneficiaries are poor and merely has low education. These findings could explain why most PKH beneficiaries mostly choose pills and injection method. The fact that this group has mostly used a modern method of contraceptive is encouraging. But pills have a high dropout rate so there is a greater chance of occurring unmet need when using this method. IDHS 2017 reported dropout rate for the method of pills (46%) and injection (28%) are higher than IUD (9%) and implant (6%) after a year of usage. The contraceptive switching was also higher for the method of pil (22% and 13%, respectively).
Empirical evidence in West Nusa Tenggara showed that unmet need associated with factors age, parity, women's education, husband's education, economic status.(5) Studies by Study by Misniarti have revealed the cost of contraceptive use for poor households has become one of the factors that cause an unmet need for family planning. The most respondent in this group (62.8%) procured their contraceptive from primary healthcare centre and Local/village midwife for free. They have health assurance (JKN) to access contraceptives and make it affordable. (11) This policy surely benefits poor households to meet their need to limit and avoid pregnancy and it seems that these CCT beneficiaries don't have any obstacle to access contraception although there are still some respondents receive family planning service in private sector by paying for contraception (9%).
Unmet need among PKH beneficiaries, not so different from Indonesia's. Although unmet need in Indonesia (11%) not as high as in Africa, Over 82% of family planning users in Sub-Saharan Africa rely on short-acting method, not on long-active reversible and permanent methods (LARC). (12) In Democratic Republic of Congo (DRC), government and

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CARE made a program to address barriers that had been identified specifically to IUD use, such as provider misconceptions and discomfort with method provision, and rumours that existed in the community. This program successfully increased IUD uptake around the region. (12) A program that had been proven to succeed in increasing LARC uptake was shown from a study in Rwanda. Community health worker delivered information about fertility goalbased and couple-focused family planning counselling. This program had doubled the monthly average for IUD insertions from 29 before service implementation to 61 after. (13) PKH is a promising program with a big chance to increase initial of LARC. By focus not only to the woman in the family, but also the man, the program could also reach man to participate in family planning. A study by Mahendra, I Gusti Agung showed that 30.1% woman In Indonesia had made a joint decision with their partner or health care provider on their current contraceptive use. (14) If the partner/husband in this percentage suggests their wife to use LARC, the uptake of IUD might be increased twice. According to the facts of PKH beneficiaries in Nganjuk and earlier study, we recommend an additional program for PKH beneficiaries to provide counselling for family planning acceptor in each primary health sector. (15) We also recommend the program to strengthen woman's health and power in this lower socioeconomic background to improve LARC, because it could improve power decision making to their health, as it's suggested by Bhandari, Rajan, et al. (16)

Conclusion
Unmet need for FP was found to be high in the study area compared to national prevalence. Pills and injection method were mostly chosen by the respondent. It seems that these CCT beneficiaries don't meet obstacle ability in accessing family planning services because family planning services are available at some government's health care providers for free through health insurance. The unmet need for spacing somehow needs further investigation.