Education and Traditional Contraceptive Use

This paper uses Demographic and Health Survey (DHS I) data to investigate the influence of education upon use of traditional contraceptive methods. Traditional methods include periodic abstinence (rhythm), withdrawal, and country-specific folk methods. Bivariate analysis shows that as education increases, so does the use of traditional contraception in all nine countries. However, controlling for contraceptive use by eliminating non-users from the analysis reveals differences in the relationship between education level and the use of traditional contraception. In only four countries did the use of traditional contraception increase over education level. Multivariate logistic regression was employed separately for each country to identify the contributions of additional variables to the use of traditional methods. The results showed that education significantly contributed to the use of traditional contraception in only two of the nine countries. Age, rural residence, and wanting another child were significant in many of the countries examined. These results suggest that education does not affect traditional method use among women contracepting when controlling for other factors. Introduction Contraceptive use has become more common in developing countries and much of this increase has been in the form of modern methods of fertility control (Gille, 1985). These methods include voluntary sterilization, oral contraceptives, intrauterine devices (IUD), condoms, injectables and vaginal methods. The use of these methods has grown more than the use of traditional methods, such as periodic abstinence (rhythm), withdrawal, and folk methods (Robey et al., 1992). The increased use of effective family planning methods is the primary cause of dramatic fertility declines in many developing countries (Rutenberg et al., 1991; Bongaarts et al., 1990). Recent surveys show that modern methods account for much of the increase in contraceptive prevalence (Robey et al., 1992). Past studies document the relationship of female education to the decline in fertility (Singh and Casterline, 1985). According to one study, education can influence women’s reproduction in several ways: by increasing knowledge of fertility, increasing socioeconomic status, and changing attitudes about fertility control (Castro and Juarez, 1994). Education may also affect the distribution of authority within households, whereby women may increase their authority with husbands, and affect fertility and use of family planning (Bertrand et al., 1993). Caldwell (1982) sees education as a vehicle by which people learn more Western views about the family, which leads to a more child centered parenting approach, and to different definitions of acceptable child care. This may lead to a demand for fewer children, and consequently, the use of contraceptives to prevent or to space childbirth. Education is closely linked to the use of contraception: more educated women are more likely to use family planning (Kasarda et al., 1986, Robey et al., 1992). Data from the countries where the Demographic and Health Surveys (DHS) have been conducted demonstrate the relationship between education and the use of family planning (Robey et al., 1992). Modern contraceptive methods are generally more effective in preventing pregnancy than are traditional methods, although effectiveness varies with the quality of practice (Trussel and Kost, 1987). While the use of more effective modern methods has been the trend, users in some countries have shifted toward greater use of other methods, such as rhythm, withdrawal, abstinence and foam (Palmore and Bulatao, 1989). According to one study, use of traditional methods is found among about 10 percent of married couples in developing countries (Donaldson and Tsui, 1990). In developed countries, traditional methods are more popular, where approximately 30 percent of married couples choose these methods (Donaldson and Tsui, 1990). In some African countries included in the DHS, a positive association is seen between traditional method use and women’s educational level (Bertrand et al, 1993). Some studies have shown an increase in the use of rhythm among the more educated (DaVanzo et al., 1989). In an unpublished analysis of survey data from thirty-two countries, twenty-seven countries displayed a positive relationship between female education and traditional contraceptive use, although tests for significance were not performed (Kumar and Tsui, 1990). A study by Bulatao (1985) suggests that the relationship between higher education and higher levels of traditional contraceptive use is a result of better information about or greater sensitivity to side-effects of modern methods among more educated women. Traditional methods may be used with greater confidence by more educated women, who may have more contraceptive competence than less educated women. These relationships could result in different method choices (Palmore and Bulatao, 1989). However, other studies have found a more complex picture of method choice. One study done in Sri Lanka first found that better-educated contraceptors favored traditional methods. However, when controlling for family size, educational level was no longer significant. More educated women had smaller families and women with smaller families tended to use traditional methods more than women with larger families (Gajanayake, 1989). Bivariate results of a Bangladesh study showed the most educated women to use more traditional methods than the least educated women, but education was not statistically significant in multivariate analysis (Ullah and Chakraborty, 1994). While Bertrand et al. (1993) report a positive association between education and use of traditional contraception in some African countries surveyed by the DHS, data from other African countries reveal that the use of modern contraception also increases with educational level. The association between education and the choice of traditional or modern contraception is still poorly understood. This paper will explore one aspect of the issue: how does women’s education influence use of traditional methods? This paper does not examine the decision to contracept, rather it explores the choice between traditional and modern methods once the decision has been made to use contraception. Bivariate analyses are displayed for education level and type of contraception: traditional or modern. Then a multivariate logistic regression technique was used to assess the effects of selected variables on the choice of traditional versus modern methods. Methods The data used were taken from the DHS I in nine developing countries. Three countries were chosen from three continents: Asia, Africa and Latin America. These countries were selected because an earlier unpublished study, using bivariate analysis, found a positive relationship between higher education and traditional method use in each of them (Kumar and Tsui, 1990). Countries selected had a high contraceptive prevalence rate for their region (Asia, Africa, Latin America), and all countries selected had at least 2% of the sample reporting traditional method use. Table 1. Contraceptive Prevalence Rate: All methods and traditional methods, Currently married women age 15-49 Bivariate analysis All analyses were performed with data from currently married women. This selection criteria was necessary because the DHS sampled only ever-married women in five of the nine countries studied. This eliminated the possibility of analysis on all women and required the use of a sample common to all surveys. Bivariate analysis was performed to explore the basic relationship between traditional method use and education levels. Women’s educational attainment was classified categorically as no education, primary education only, secondary education only, and post-secondary education. Method use was categorized as no use, traditional use or modern use. A second correlation was performed with the same variables after non-users were All Methods Traditional Methods Sri Lanka 1987 61.0 20.6 Indonesia 1987 51.4 4.8 Thailand 1987 65.0 2.5 Peru 1986 49.5 23.4 Bolivia 1989 34.3 18.2 Colombia 1986 68.4 13.8 Kenya 1989 26.0 7.0 Morocco 1987 35.8 6.9 Tunisia 1988 49.8 9.4 removed from the analysis. This limited the contraceptive choice variable to two categories: traditional method use or modern method use. Multivariate analysis Logistic regression is used for the dichotomous dependent variable (Y), and gives each regressor a value (bj) which measures the regressor’s independent contribution to Y. (Darlington, 1990) In the analysis, the dependent variable was assigned a value of 1 if the respondent was using a traditional method and a value of 0 if the respondent was using a modern method. Non-users were not considered in this analysis. The independent variables were entered simultaneously into the analysis. Results are presented in a summary table listing the number of countries where the parameter tested was significant, and the range of odds ratios (see Table 4). Each model was run separately by country. In addition to education, three other variables were used as independent control variables in the regression model. These variables: age of respondent in years, urban or rural residence and fertility preference, were chosen to eliminate the potential influences on the dependent variable, choice of method. Prior research has suggested that these variables strongly influence contraceptive method choice (Bertrand et al. 1993; Gajanayake, 1989; Caldwell et al. 1987; Ullah and Chakraborty, 1994, Hamill et al., 1990). Education is the predictor of interest in this paper. Years of education was used as a continuous variable. As stated above, while more educated women are more likely to use family planning (Kasarda et al., 1986; Robey et al., 1992), some DHS country surveys have revealed an association between women’s educational level and an increase in traditional method use (Bertrand et al., 1993). The second variable chosen was place of residence: a dichotomous variable coded as urban or rural. Modern contraceptive use is higher in urban than in rural areas (Bertrand et al., 1993). Urban women may be more likely to use modern methods than rural women because of greater access to modern methods in urban areas. Other reasons may be the desire for smaller families among urban couples, (Hamill et al., 1990) and lower educational levels in rural women (Gajanayake, 1989). Education has also been shown to have an effect on lowering fertility in urban as compared to rural settings (Kasarda et al., 1986). Age was also selected as an independent continuous variable. The contraceptive method mix varies according to age, as women still bearing children use temporary methods for spacing births while women wanting no more children may use more permanent methods to prevent births (Robey et al., 1992). Analysis of surveys conducted in Africa have found that the use of modern contraception generally increases, then decreases with age (Bertrand et al., 1993). Older women may also stop using contraception, believing that they are no longer at risk of becoming pregnant (Robey et al., 1992). The final independent variable selected was fertility preference. This was dummy-coded as two variables: wanting to have more children and undecided. A fertility preference for no more children served as the reference value. Westoff (1991) has reported that the percentage of women who do not want more children is a short-term predictor of fertility rates. McClelland (1983) reports studies in Taiwan and Venezuela which found desire for children, relative to other variables such as education and marriage duration, to be an important predictor of contraceptive use. This may in turn influence the type of contraceptive method chosen. Results Bivariate Analysis In the bivariate results, the use of traditional methods does increase as the level of education increases as displayed in Table 2. The chi square statistic is significant at the .01 level in all nine countries and traditional use is always higher at the highest level of education than at the lowest. Table 2 however may reflect the greater use of contraception overall as education increases. To analyze this possibility, those not using contraception were excluded from the next analysis, as shown in Table 3. This allows Table 2. Traditional method use of currently married women, age 15-49, by educational level in nine countries No Education Primary Education Secondary Education Post Secondary Sri Lanka 10.0 14.9 22.1 31.2 Indonesia 2.2 4.2 8.7 11.1 Thailand 0.6 1.8 5.2 8.8 Peru 11.7 22.8 27.0 31.0 Bolivia 8.8 16.6 23.6 29.1 Colombia 10.3 14.2 13.3 16.5 Kenya 5.8 7.0 8.3 22.2 Morocco 6.0 10.2 11.1 25.0 Tunisia 4.9 12.6 22.1 21.4 assessment of the method preference of those who are using contraception. A different picture emerged. Of the nine countries examined, seven showed a significant (P<.01) chi square value, although only four countries show a definitive increase in the use of traditional contraception over educational levels. These results are the first to indicate that rates of traditional use do not increase with education in all countries. In fact, in three of the countries, Bolivia, Kenya, and Peru, the rates of traditional use were greater at the lowest level of education than at the highest level of education. Table 3. Type of method used by currently married women using contraception, age 15-49, by educational level in nine countries % (n) No Education Primary Education Secondary Education Post Secondary Chisquare Sri Lanka traditional 19.0 (65) 23.8 (241) 35.1 (428) 50.9 (386) 2 =179 df=3 modern 81.0 (277) 76.2 (770) 64.9 (790) 49.1 (372) p=.00 Indonesia traditional 5.8 (50) 8.2 (265) 13.7 (184) 17.8 (27) 2 =61.5 df=3 modern 94.3 (819) 91.9 (2988) 86.3 (1158) 82.2 (125) p=.00 Thailand traditional 1.0 (3) 2.7 (83) 7.7 (37) 13.8 (35) 2 =103 df=3 modern 99.0 (288) 97.3 (2944) 92.3 (441) 86.2 (218) p=.00 Peru traditional 56.7 (34) 54.4 (193) 40.8 (180) 45.3 (62) 2 =16.9 df=3 modern 43.3 (26) 45.6 (162) 59.2 (261) 54.7 (75) p=.00 Bolivia traditional 71.3 (72) 57.9 (271) 47.1 (263) 49.1 (111) 2 =27.2 df=3 modern 28.7 (29) 42.1 (197) 52.9 (295) 50.9 (115) p=.00 Colombia traditional 18.8 (9) 21.6 (144) 18.3 (83) 20.6 (13) 2 =1.9 df=3 modern 81.3 (39) 78.4 (524) 81.7 (371) 79.4 (50) p=.60 Kenya traditional 35.9 (80) 27.8 (162) 19.7 (71) 30.8 (4) 2 =18.9 df=3 modern 64.1 (143) 72.2 (421) 80.3 (289) 69.2 (9) p=.00 Morocco traditional 19.4 (269) 18.0 (55) 17.3 (38) 33.3 (12) 2 =5.5 df=3 modern 80.6 (1118) 82.0 (250) 82.7 (182) 66.7 (24) p=.14 Tunisia traditional 11.6 (111) 22.3 (158) 32.9 (93) 34.9 (15) 2 =82.3 df=3 modern 88.5 (850) 77.8 (552) 67.1 (190) 65.1 (28) p=.00 Multivariate Analysis When controlling for other variables in the multivariate analysis, in only two countries, Indonesia and Tunisia, was the contribution of education significant. In two other countries, Peru and Bolivia, a significant negative effect was found for the use of traditional methods; that is, higher levels of education were negatively related to use of traditional methods. This was consistent with the bivariate analysis of users shown in Table 3, in which both these countries showed less use of traditional methods as education levels increased. Table 4. Resulting odds ratios from logistic regressions: traditional use versus modern use on selected variables, currently married women age 15-49 Education Urban/Rural Age Fertility: Want More Children Fertility: Undecided Bolivia 0.93* 2.17** 1.03** 0.70* 1.07 Colombia 0.98 2.15** 1.08** 1.50* 1.50 Indonesia 1.05* 0.49** 1.07** 2.4** 1.84* Kenya 0.97 2.5** 1.00 2.48** 1.37 Sri Lanka 0.96 1.03 1.09** 1.40** 2.20** Morocco 0.99 0.98 1.05** 1.27 1.30 Peru 0.90* 3.4** 1.07** 1.24 0.45 Thailand 1.00 0.56** 1.07** 1.73** 3.08 Tunisia 1.14** 0.92 1.07** 1.63** 1.15 *significant at 0.05 level **significant at 0.01 level Rural residents were more likely to use traditional contraceptives in four out of the nine countries examined. In contrast, in Indonesia and Thailand, the traditional users were more likely to be urban. Thailand is known for its strong family planning program. One study showed the use of effective methods to be greatest in rural areas of Thailand, and demonstrated the widespread availability of family planning services in rural areas (Chamratrithirong and Stephen, 1989). In Indonesia, a study found that family planning clinics had a greater effect on contraceptive use among the rural poor than among better educated urban women (DaVanzo et al., 1989). In the remaining three countries, there were no significant differences in urban or rural status for traditional method users. Age was a significant determinant of traditional method use in eight countries. In the study countries, it appears that older women use traditional methods to a greater extent than younger women. Since age is a continuous variable, the resulting odds ratios show the relation to the average age of respondents in the sample. One unit change in age will result in one unit change in the likelihood of using traditional methods. The results for fertility preferences were also strong. In six countries, wanting another child was a significant predictor of traditional method use. However, in one country, Bolivia, wanting another child was less likely to lead to traditional use. This result is one example of the many differences among countries with respect to the variables analyzed. Women who stated that they were undecided about their fertility preference did not show a significant relationship with traditional method use except in Sri Lanka and in Indonesia. In these two countries women who were undecided about having more children were 2.2 and 1.8 times more likely to use traditional methods, respectively. Limitations : The DHS are subject to the same limitations that affect other large scale surveys. These include the intimate nature of the questions, poor framing of questions, and the complexity of contraceptive practices (Sardon, 1986). In addition, confining the surveys to women of childbearing age (15-49) may limit the collection of data on traditional methods and their former practice by older women (Caldwell, 1985). There are also potential problems with the operationalization of education. The variable used in this analysis was a continuous variable of years of education. However, the quality of education may vary across countries. It is impossible to capture the quality and the content of schooling, particularly in cross-national analyses (Kasarda, 1986). Since the analysis here included only currently married women, these results may not be generalizable to all women. Kasarda (1986) notes that restricting the analysis to currently married women underestimates both the positive effect education has on the probability of never marrying and on postponing marriage. The higher the education completed, the greater the underestimation of education’s true effects when never-married women are excluded. Discussion The results showed that education significantly contributed to the use of traditional contraception in only two of the nine countries. Age, rural residence, and wanting another child were significant in many of the countries examined. These results suggest that education does not affect traditional method use when controlling for other factors. The most consistent finding was with age, with older women being more likely to use traditional methods of contraception. Older women may be more familiar with traditional methods, or new users may forgo use of traditional methods because modern methods are more readily available than in past years (Donaldson and Tsui, 1990). Reaching women who are older but may still be at risk for pregnancy could be an important component of family planning programs. Family planning workers may overlook older women and neglect to give them new information on modern methods. In six of the nine countries, women who want more children appear more likely to use traditional methods, indicating the use of traditional methods for spacing births rather than using them for terminating childbirth. In a study of couples using the rhythm method, Bulatao (1985) found that only the desire to space births appeared to be related to the choice of rhythm (Palmore and Bulatao, 1989). The fact that rural women were significantly more likely to use traditional methods in four of the nine countries is also interesting. This may reflect a weaker family planning effort in rural areas of these countries, or lack of access to modern methods. Later DHS results may show the situation has improved as family planning programs become more widely available, accepted and utilized. Further analyses should examine other important variables, such as the education of the husband, duration of marriage, the number of living children, and the prior use of modern methods. The wealth of the household may also be important because of its correlation with education and since wealth may have effects on desired family size and contraceptive use effectiveness (Hamill et al., 1990). In addition, analyzing all women, including those not reporting contraceptive use, could show the effect of education on the decision to contracept at all. Examination of these variables should give a better picture of what factors contribute to traditional method use. References: Bertrand J, Bauni E, Lesthaeghe R, Montgomery M, Tambashe O, Wawer, M. Factors Affecting Contraceptive Use in Sub-Saharan Africa. Washington, DC: National Research Council, National Academy Press; 1993. Bongaarts J, Mauldin WP, Phillips J. The demographic impact of family planning programs. Studies in Family Planning, 1990; 21(6): 299-310. Bulatao R. Late marriage and the use of rhythm. Paper presented at the Annual Meeting of the Population Association of America ; 1985. Caldwell J. Theory of Fertility Decline. Chapter 10: Mass education as a determinant of fertility decline. London: Academic Press; 1982. Caldwell J. Marital fertility decline in developing countries: theories and the evidence. In: Reproductive Change in Developing Countries: Insights from the World Fertility Survey. Cleland J, Hobcraft J, Dinesen B, eds. Oxford: Oxford University Press; 1985. Castro Martin T, Juarez F. Women’s education and fertility in Latin America: exploring the significance of education for women’s lives. Demographic and Health Surveys Working Papers No. 10 Maryland: Macro International; 1994. Chamratrithirong A, Stephen E. Determinants of contraceptive method choice in Thailand. In: Choosing a Contraceptive: Method Choice in Asia and the United States . Bulatao R, Palmore J, Ward S. eds. Boulder, Colorado: Westview Press; 1989. Darlington RB. Regression and Linear Models. New York, New York: McGraw Hill; 1990. DaVanzo J, Ann TB, Othman R. Determinants of contraceptive method choice in peninsular Malaysia, 1961-1975. In: Choosing a Contraceptive: Method Choice in Asia and the United States. Bulatao R, Palmore J, Ward S, eds. Boulder, Colorado: Westview Press; 1989. Donaldson P, Tsui AO. The international family planning movement. Population Bulletin, 1990; 45(3): 3-44. Gajanayake I. Traditional contraception in Sri Lanka. In: Choosing a Contraceptive, Method Choice in Asia and the United States. Bulatao R, Palmore J, Ward S, eds. Boulder, Colorado: Westview Press; 1989. Gille H. The World Fertility Survey: policy implications for developing countries. International Family Planning Perspectives. 1985; 11(1): 9-17. Hamill D, Tsui AO, Thapa S. Determinants of contraceptive switching behavior in rural Sri Lanka. Demography . 1990; 27(4): 559-578. Kasarda J, Billy J, West K. Status Enhancement and Fertility. Orlando, Florida: Academic Press; 1986. Kumar A, Tsui AO. Education and contraception: a closer look at traditional method use (unpublished manuscript). Chapel Hill, NC: University of North Carolina Population Center; August 1990. McClelland GH. Family-size desires as measures of demand. In: Determinants of Fertility in Developing Countries, Vol. 1.. Bulatao R, Lee R. eds. New York, New York: Academic Press; 1983. Palmore J, Bulatao R. The contraceptive method mix: an overview. In: Choosing a Contraceptive, Method Choice in Asia and the United States.. Bulatao R, Palmore J, Ward S. eds. Boulder, Colorado: Westview Press; 1989. Robey B, Rutstein SO, Morris L, Blackburn R. The Reproductive Revolution: New Survey Findings. Population Reports, Series M, No.11. Baltimore, Johns Hopkins University, Population Information Program; December 1992. Rutenberg N, Ayad M, Ochoa L, Wilkinson M. Knowledge and use of contraception. Demographic and Health Surveys Comparative Studies No. 6. Columbia, Maryland: Institute for Resource Development/Macro Systems; July 1991. Sardon J. The collection of information on contraceptive practice: results of the survey by INED-INSEE in 1978. Population. 1986; 41(1): 73-91. Singh S, Casterline J. The socioeconomic determinants of fertility. In: Reproductive Change in Developing Countries: Insights from the World Fertility Survey. Cleland J, Hobcraft J, Dinesen B. eds. Oxford: Oxford University Press; 1985. Trussel J, Kost K. Contraceptive failure in the United States: a critical review of the literature. Population Association of America. Annual Meeting Collected Papers. Vol. 9.; 1987. Ullah MS, Chakraborty N. The use of modern and traditional methods of fertility control in Bangladesh: a multivariate analysis. Contraception. 1994; 50: 363-72. Westoff CF. Reproductive preferences: a comparative view. Demographic and Health Surveys Comparative Studies No.3 Columbia, Maryland: Institute for Resource Development/Macro Systems. February 1991.