Unfolding the Mystery of Reliance on Traditional Methods of Birth Control in Assam,India

Abstract

Reliance on traditional methods of birth control causes psychological tension in couples because the fear of unwanted pregnancy bars them from experiencing a healthy sexual life. However, in Assam, half of all contraceptive users depend on traditional methods of birth control. The current study used National Family Health Survey 2005–2006 data. Out of 3840 sample women in the age group 15–49 years, 1286 women are filtered for the present study. Most of the demographic and socioeconomic characteristics of traditional method users fall between those of modern spacing method users and terminal method users. Thus, the burden of unwanted fertility is highest among the traditional method users.

Keywords

Traditional method of contraception birth control family planning Assam

Introduction

Contraceptive methods allow a family to regulate the child bearing process with appropriate spacing and timing. Failure to plan for pregnancy can adversely affect the health of the mother, the child and the entire family in one way or another. However, all contraceptive methods do not share the same level of effectiveness. Some are highly effective, whereas others are moderately effective or even much less effective. Traditional methods of birth control are known to have very low effectiveness, due to how they are used or adopted. Reliance on traditional methods of birth control causes psychological tension in couples because the fear of unwanted pregnancy bars them from experiencing a healthy sexual life. Even so, a fairly high percentage of women/couples in Assam prefer them. Despite such peculiar behavior, studies relating to contraceptive dynamism in Assam are lacking. However, studies conducted in various parts of the globe cite different reasons for adoption of traditional methods of contraception.

According to a study conducted in Turkey (Cindoglu et al., 2008), the factors affecting use of withdrawal (one of the traditional methods) over modern methods are complex. The choice of a traditional method over modern contraceptive methods depends on the accessibility of various contraceptive methods. Similarly, another study (Ross et al., 2001) shows that the absence of complete choice among a variety of contraceptive offerings restricts personal access to each method as well as the use of all methods in the population. It is to that extent that the ability to choose satisfactory contraceptive protection depends on ready access to multiple methods. Increasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services in developing countries (Williamson et al., 2009). Another study (Kamal et al., 2007) argues that users of traditional methods of birth control generally do not strictly confine themselves to one particular method. Couples who adopt periodic abstinence shift to the ‘withdrawal’ method when they are not sure about the safe period or use condoms for the same reason and for increased protection.

Whatever the reason for reliance on traditional methods, large-scale surveys around the world show that some proportion of women/couples rely on traditional methods of birth control, which offer comparatively low effectiveness. Such surveys also show that reliance on less effective traditional methods leads to unwanted pregnancies, abortion and various other complications. In this context, it also is estimated (Cleland et al., 2006) that 90 percent of abortion-related and 20 percent of pregnancy-related morbidity and mortality, along with 32 percent of maternal deaths, could be prevented by use of effective contraception. So, there is a need to investigate why women/couples rely on traditional methods of birth control when other effective modern methods are easily available, and whether the reasons for this dependence on traditional methods in Assam are similar to other parts of the globe.

Objectives

It is a matter of serious concern why such a high percentage of women/couples rely on traditional methods of birth control. Is there any change in contraceptive use dynamism in the last few years? What are the factors that lead to adoption of less effective traditional methods? Are they not aware of modern contraceptive methods? Overall, the present paper aims to investigate and attempts to divulge the dynamism of contraceptive use as a whole.

Hypotheses

It is hypothesized that ‘there is a negative relation between women’s knowledge of the five modern methods of contraception and use of traditional methods’, and ‘women who desire additional children rely on traditional methods’.

Methods

For the purpose of understanding the trends and patterns of contraceptive use between 1992–1993 and 2005–2006, reports from National Family Health Surveys, conducted during the years 1992–1993 (NFHS-1), 1998–1999 (NFHS-2) and 2005–2006 (NFHS-3) are used. However, to address the issue of why such a high proportion of women rely on traditional methods of contraception, NFHS-3 raw data are analyzed. The survey interviewed women in the age group 15–49 years irrespective of marital staus and who are either usual resident or visitor. However, for the present study, only currently married, currently fecund and resident women who are currently using some contraceptive method are retained for the analyses. Thus, 1286 such women are filtered out of the total sample of 3840. To fulfill objectives of the study and to test the formulated hypotheses, the mean, percentage and standard deviation are computed. Data have been cross-tabulated, and the statistical significance of association between the variables has been tested by chi square. Further, multi-nominal logistic regression has been run to find out the relationship between the variables using version 20 of the Statistical Package for Social Sciences (SPSS).

Variables

Contraceptive methods

In the present study, periodic abstinence, withdrawal and other folkloric methods are considered as traditional methods. For the suitability of interpretation, the phrase traditional methods of contraception are used synonymously for traditional ways of birth control. Oral pills, intrauterine devices (IUDs), injections, diaphragms and condoms are included as modern spacing methods. Male and female sterilization are considered as modern permanent or terminal methods.

Constructed indices

The exposure to mass media index was constructed by examining three variables, namely, frequency of reading newspapers or magazines, frequency of listening to the radio, and frequency of watching television. The respondents who were not at all exposed to any of them are considered ‘not exposed’, whereas others are considered ‘exposed’ to mass media. The exposure to family planning message index is created by examining three variables; namely, heard a family planning message on the radio in the last month, heard or saw one on television in the last month, and read it in the newspaper in the last month. If a woman says no to all three, she is considered recently not exposed to family planning messages; otherwise, she is exposed. The wealth index is used as available in the NFHS-3 data set. It is an indicator of the level of wealth, which is constructed by using 33 household assets and housing characteristics (International Institute for Population Sciences and Macro International, 2007). Achieved fertility has been defined as the equal number between living and ideal number of daughters, and the equal number between living and ideal number of sons as that of another study (Narzary and Sharma, 2013). In other words, sex composition of living children is the same as sex composition of ideal number of children.

Ethical considerations

This study does not identify or affect any individual, group or society/community. This research is immensely useful for policy makers and planners. National Family Health Surveys Data used in this study are fully available to the public without restriction.

Results

Levels, trends and patterns of contraceptive use

The level of contraceptive use in the state of Assam at present (2005–2006) is moderate at 56.5 percent (Figure 1). During the study period contraceptive use in the state has increased considerably, but the increase is at slightly lower pace than the national level. In NFHS-1, use of any contraceptive methods was 42.8 percent and it has increased to 56.5 by NFHS-3. But there was no such change in percentage of contraceptive use between NFHS-1 and NFHS-2. However, there is a huge rise between NFHS-2 and NFHS-3.

Figure 1.

Levels and trends of contraceptive use in Assam during 1992–1993 to 2005–2006.

It is apparent from the graph (Figure 1) that during the study period use of modern spacing methods has steadily increased from a mere 5.4 to 13.2 percent. One of the notable features of contraceptive use pattern in Assam is that the use of terminal methods has increased from 14.4 percent in NFHS-1 to 16.7 percent in NFHS-2, but marginally declined to 13.8 percent in NFHS-3. Contrary to this, use of any traditional method dropped from 22.9 percent in NFHS-1 to 15.8 percent in NFHS-2, but it again increased to 29.5 percent in NFHS-3. This pattern is true for both the rhythm and withdrawal methods.

Proportion of different types of contraceptive users

From the graph (Figure 2) it is quite clear that the proportion of traditional method users to total users was about 54 percent in NFHS-1; it declined to a mere 37 percent in NFHS-2, but again increased to 52 percent in NFHS-3. This means that the share of traditional contraceptive method users to total users regained its position by NFHS-3. On the other hand, the share of terminal method to total users increased from 33.6 percent in NFHS-1 to 38.6 percent in NFHS-2, but it reduced steeply in NFHS-3 to 24.4 percent. But, the share of the modern spacing method shows a different pattern. The proportion of modern spacing method users was 12.6 percent in NFHS-1 and it almost doubled to 24.9 percent in NFHS-2, whereas in NFHS-3 it marginally declined to 23.4 percent. Hence, the overall picture of the contraceptive use pattern is that there is a shift in contraceptive users from traditional to terminal and modern spacing methods during NFHS-1 to NFHS-2. But there is a reversal in the share of users from terminal to traditional methods during NFHS-2 to NFHS-3. In other words, the change in proportion of traditional method users leads to a change in the share of terminal method, and vice versa.

Figure 2.

Levels and trends in proportion of different types of contraceptions during 1992–1993 to 2005–2006.

Method-specific contraceptive use

During 2005–2006, among the contraceptive users in Assam, as high as 31 percent relied on periodic abstinences, whereas 23 percent adopted female sterilization, 21 percent resorted to withdrawal and 18 percent to the pill (Table 1). It is quite apparent that users of condoms and IUDs are below five percent, while male sterilization is quite negligible in the state. This implies that among the modern contraceptive methods, female sterilization and the pill are still the most usually adopted methods of contraception in the state. But at the national level, even though female sterilization leads, it is followed by the condom rather than pills. This may be due to the fact that after completion of the family building process or family size, most couples might like to completely get rid of the burden of using any temporary method.

Table 1.

Percentage distribution of respondents by specific methods of contraceptive use (n=1286).

Methods	Frequency	Percentage
Pill	233	18.1
IUD	29	2.3
Condom	49	3.8
Female sterilization	297	23.1
Male sterilization	4	0.3
Periodic abstinence	398	30.9
Withdrawal	263	20.5
Other traditional	13	1.0
Total	1286	100.0

A further look into the pattern of current contraceptive use in Assam reveals that about 24 percent use modern spacing methods, 23.4 percent have adopted the terminal method whereas as high as 52.4 percent rely on traditional methods (Table 1). This means that, among the users, more than half of them depend on traditional methods, which is not a very good sign from an effectiveness point of view. At the national level, use of traditional methods is only 7.8 percent (International Institute for Population Sciences and Macro International, 2007) – a mere 13.85 percent of total users. Such a contrasting contraceptive dynamism among women/couples makes Assam an interesting region in terms of studying contraceptive use.

Comparative demographic characteristics by type of contraceptive use

As different contraceptive methods have different levels of effectiveness, it is good to know the socio-economic and demographic characteristics of different groups of women by method of contraceptive use. In this regard, results (Table 2) show that traditional method users are slightly older than users of modern spacing methods, but younger than permanent method users. The mean age of the traditional method users is 31 years, while for modern spacing method users it is 29 years and for terminal method users 36 years, while overall for women it is 31.97 years with a standard deviation of 7.44 (result not shown). In terms of age at marriage there is no distinct variation among users of traditional methods and modern spacing methods, but permanent method users married at a slightly younger age. Further, traditional method users are married for about 13 years, modern spacing method users for 11 years, but permanent method users are married for as high as 19 years. This signifies that marital duration is one of the leading determinants of contraceptive choice, which may be because it is closely associated with the completion of their family size and desired number of children.

Table 2.

Mean demographic characteristics of women by type of contraceptive use (n=1286).

Demographic characteristics	Modern spacing	Traditional	Permanent	Total
Age of the women	28.74	31.48	36.40	31.97
Age at marriage	18.06	18.41	17.47	18.10
Marital duration	10.69	13.07	18.93	13.86
Ideal number of children	2.12	2.25	2.57	2.29
Ideal number of sons	0.97	1.10	1.28	1.11
Ideal number of daughters	0.78	0.81	0.90	0.83
Total number of children ever born	2.51	2.78	3.57	2.90
Living children	2.32	2.49	3.23	2.62
Living sons	1.21	1.30	1.83	1.40
Living daughters	1.11	1.18	1.39	1.21
Total in percent	24.2	52.4	23.4	100.0
Number of women	(311)	(674)	(301)	(1286)

An attempt to understand the association of ideal number of children with contraceptive use shows (Table 2) that there is no great variation in mean ideal number of children by contraceptive use. Women in all categories desire to have slightly more than two children. Conversely, it is high among users of the terminal method (2.57) followed by traditional method users (2.25). Overall, sample women desire to have 2.29 children with a standard deviation of 0.84 (result not shown). Further, ideal number of sons compared to ideal number of daughters is higher for all categories of women, which indicates a preference towards sons in Assam. It is a fact that the number of children ever born has a great bearing on the choice of contraception. In this context, it is found that traditional method users have borne about 2.78 children; modern spacing method users have 2.51 children, whereas permanent method users have borne 3.57 children per woman. Theoretically, the effect of living children on contraceptive use is stronger than that of children ever born. Its comparison shows that traditional method users have 2.49 living children, modern spacing users have 2.32 children, whereas permanent method users have 3.57 children. Furthermore, it is well established that there is a strong preference towards sons in India. So, number of living children alone may not be able to motivate couples to use effective contraceptive methods, rather the number of living sons may exert more pressure. In this regard, results (Table 2) show that traditional method users have 1.30 living sons and modern spacing method users have 1.21 sons, whereas permanent method users have 1.83 living sons. Irrespective of the number of all children born and the number of living children, the number of living sons plays a greater role in the choosing of contraceptive methods. Son preference is one of the determinants of contraceptive choice in patrilineal societies.

Comparative socio-economic characteristics by type of contraceptive use

Results (Table 3) show that with increase in age, the percentage of traditional and permanent method usage also increases, but modern spacing method usage constantly decreases. The percentage of users of traditional methods is highest among younger women, and remains constant after 25 years of age. This result demonstrates that with increase in age, users of modern spacing methods shift to permanent methods, which is not true in the case of traditional method users. Aside from demographic characteristics, the cost of contraceptive method may also deter a woman from using modern contraception. But from the results (Table 3) it is quite apparent that there is no clear pattern showing a relationship between economic condition (wealth index) and contraceptive use. This signifies that poverty is not the cause of using traditional methods of contraception. Urban areas fare much better in terms of using modern spacing methods, while rural areas dominate in using traditional methods, but there is no significant variation in use of the terminal method. This may be due to the relatively limited access to modern spacing methods in rural areas, because of psychological cost or inhibition.

Table 3.

Demographic and socio-economic characteristics of women by type of contraceptive use (in %).

Characteristics	Modern spacing	Traditional	Permanent	Total cases
Age of the women
Below 25	38.5	57.8	3.7	218
25–29	31.8	51.2	17.0	283
30 and above	17.5	51.3	31.2	785
Wealth index
Poorest quintile	21.4	64.2	14.4	187
Poorer quintile	24.0	54.3	21.7	359
Middle quintile	24.2	43.9	31.8	314
Richer quintile	26.6	51.0	22.4	241
Richest quintile	25.1	51.9	23.0	187
Place of residence
Urban	34.6	44.0	21.4	266
Rural	21.5	54.6	23.9	1021
Religion
Hindu	23.2	50.1	26.7	950
Muslim	31.6	59.9	8.5	272
Others	9.2	53.8	36.9	65
Education of the women
Illiterate	15.7	48.2	36.1	415
Primary	20.8	53.0	26.3	236
Secondary and higher	31.2	54.8	14.0	635
Native language
Assamese	26.8	51.1	22.1	593
Bengali	27.7	60.5	11.8	347
Others	16.4	46.3	37.4	348
Caste/Tribe
Scheduled tribe	23.2	43.5	33.3	138
Scheduled caste	23.8	42.5	33.8	160
Other backward caste	22.2	61.6	16.2	297
Others	25.5	52.4	22.1	691
Total	24.2	52.4	23.4	100.0
Number of women	(311)	(674)	(301)	(1286)

It is found that among Muslim women in Assam, adoption of the terminal method is minimal compared to the adoption of modern spacing and traditional methods. With the increase in level of education, the percentage of traditional and modern spacing method users steadily increases, whereas there is a decline in users of the permanent method, a result which is similar to another study (Kamal et al., 2007). With the increase in education, women are likely to be better aware about modern spacing methods and have decision making power, for which they could choose temporary methods as per their requirement and suitability. Here an attempt is also made to assess the variation in the choice of contraceptive methods across different linguistic groups by considering language as one of the proxy variables of cultural differences. Results show that between two dominant linguistic groups, no apparent difference in the percentage of modern spacing method users is noted. But there is a huge difference in terms of use of traditional and permanent methods. Among speakers of the Assamese language, as high as 22 percent have adopted the terminal method, whereas among speakers of the Bengali language only 11 percent have. Adoption of the terminal method among the women belonging to the ‘others’ group is comparatively higher, whereas use of modern spacing methods among them is much lower. Examining contraceptive use by social status demonstrates that about the same percentage of scheduled tribe and caste women rely on traditional methods, whereas as high as 62 percent of other backward caste women rely on it. The contraceptive use pattern is quite similar among scheduled tribe and caste women.

Crucial factors regarding contraceptive choice

From the bi-variate result (Table 4) it is clear that the percentage of women who do not want any more children is slightly higher among traditional method users than modern spacing method users, and this result is statistically significant. This means the second hypothesis ‘women who desire additional children rely on traditional methods’ may be rejected. Similarly, the percentage of women who did not want the last child/mis-timed is highest among users of traditional methods. This issue points towards the lack of effectiveness and/or the need for effective use of traditional methods.

Table 4.

Contraceptive use pattern by associated crucial factors (in %).

Characteristics	Modern spacing	Traditional	Permanent	Total
Women who want no more children^a	75.3	77.1	N/A	58.6
Did not want last child/mis-timed	14.7	17.5	12.9	16.0
Women exposed to any mass media	83.7	78.6	83.7	81.0
Women exposed to any FP message^a	67.0	60.8	54.0	60.7
Women knowing all modern methods^a	35.6	36.8	26.2	34.0
Recently sexually active^a	92.9	89.0	64.1	84.1
Ideal and living children equal	46.2	40.8	41.2	42.2
Achieved fertility	19.9	18.4	20.9	19.3
Ever had terminated pregnancy^a	34.9	29.0	22.7	28.9
Mainly respondent decides using contraception^a	2.3	7.6	N/A	5.8
Total in percent	24.2	52.4	23.4	100.0
Number of women	(311)	(674)	(301)	(1286)

Significant at the 0.05 level. FP = Family Planning.

Exposure to mass media is considered to have a lot of bearing on the life of every individual. So, it is considered to have a crucial impact on contraceptive use as well. In Assam it is found that exposure to mass media is lower, relatively speaking, among users of traditional methods compared to other groups of women. Furthermore, exposure to the family planning message is more relevant in terms of contraceptive use. In the state, exposure to the family planning message in recent times is better among users of modern spacing methods, whereas it is worse among users of permanent methods. Linking this result to the percentage of women who do not want any more children signifies that lack of exposure to the family planning message may also be the cause of very high, unmet needs for family planning in Assam. Knowledge of all the modern contraceptive methods is essential for informed choice about contraception. Among the users of modern spacing and traditional methods slightly more than one-third of women are aware about all five modern methods of contraception, whereas among terminal method users only one-fourth are aware. Indeed, knowledge of all the five modern methods is highest among traditional method users. This means that knowledge of contraception has a positive relationship with the adoption of traditional ways of birth control. In other words, women who are well aware about positive and negative (actual or perceived) aspects of modern contraceptive methods are inclined towards traditional ways of birth control. Thus, the hypothesis ‘there is a negative relation between women’s knowledge of the five modern methods of contraception and use of traditional methods’ may be rejected.

One of the most striking needs for effective contraceptive method arises if the couple is sexually active. However, it is understood that due to some reasons couples are not always sexually active. Results show that the percentage of sexually active couples is highest among modern spacing method users followed by users of traditional methods. The question arises therefore that if the couple has not been sexually active during the last four weeks then why are they using contraceptive methods? It may be because followers of ‘periodic abstinence’ might have reported themselves as being sexually inactive. Couples who have living children less than the ideal number may not resort to effective methods, for the apparent reason that they want an additional child/children. In Assam, it is found that as high as 46 percent of modern spacing method users have achieved their ideal number of children, whereas only 41 percent of traditional and permanent method users have. Theoretically it is more pertinent to assess the determinants of contraceptive method choice from an ‘achieved fertility’ perspective. Among traditional method users 18 percent have achieved fertility, whereas the remaining 82 percent have not achieved the desired sex composition of children. Thus, it is notable that even after achieving the desired sex composition of children, as high as 18 percent of traditional method users are not resorting to effective methods of contraception. Thus, this result requires the attention of planners and policy makers from a family planning program perspective. In this direction, an attempt is also made to assess the burden of unwanted pregnancy by method of contraceptive use. It is found that among traditional method users 29 percent have experienced termination of a pregnancy, whereas this number is 35 percent among modern spacing method users and 23 percent among terminal method users. This means that the burden of unwanted pregnancy is higher among modern spacing method users followed by users of traditional methods. But this does not imply that modern spacing method users are more likely to experience termination of a pregnancy. Another very interesting finding is that the number of women who mainly decide on contraceptive method is higher among traditional method users, followed by modern spacing methods users. This implies that women are conscious about the associated (possible) side effects of modern contraceptive methods, thus they prefer to rely on traditional methods of birth control, although they need the full cooperation of their husbands in order to use them. About 90 percent of traditional method users, 97 percent of modern temporary and 93 percent of modern permanent method users decide about contraceptive use jointly with their husbands (results not shown). Husbands who mainly decide about contraceptive use is less than 2 percent among all the three categories of women (results not shown).

Determinants of contraceptive choice

Traditional methods, although less effective, are also spacing methods. The reason why women prefer these methods over more effective modern spacing methods cannot be ascertained through bi-variate results alone. However, multi-variate results can present more appropriate and accurate findings regarding the issue under investigation (Foroutan, 2008). In the present study the dependent variable ‘use of contraceptive method’ has three categories (users of modern spacing, users of traditional and users of terminal methods). Hence, multi-nominal logistic regression is applied to discover the determinants of preference for traditional methods over the other methods. Multi-variate analysis shows that education of the women, marital duration, religion, native language, exposure to mass media and economic status of the household are the variables that significantly affect the choice of traditional methods over modern spacing methods. It is found that, compared to women with higher levels of education, illiterate women and those with primary levels of education are more likely to prefer traditional methods over modern spacing methods (Table 5). Compared to women who were married for longer than 20 years, women who were married for shorter durations were less likely to rely on traditional methods. In other words, the reliance on traditional methods increases with the increase in marital duration. It is apparent that compared to the women from ‘other religions’, Hindu women are more likely to adopt traditional methods over modern spacing methods. Results show that speakers of Assamese and Bengali languages and women from poorer economic conditions are less likely to adopt traditional methods.

Table 5.

Result of multi-nominal logistic regression.

Independent variables	Dependant variable codes: Usingmodern spacing method: 0; traditional method: 1; permanent method: 2
	Traditional method			Permanent method
	Odds ratio	Lower bound	Upper bound	Odds ratio	Lower bound	Upper bound
Age (in years)
Below 30	0.691	0.406	1.175	0.626*	0.425	0.923
30 and above^a	1.000
Education
Illiterate	4.337***
Primary	2.914***	2.533	7.429	1.314	0.859	2.010
Secondary and higher^a	1.000	1.712	4.960	1.329	0.883	2.001
Wealth index
Poorer	0.464**	0.265	0.815	0.808	0.530	1.232
Middle	0.880	0.523	1.483	7.17	0.475	1.080
Richer^a	1.000
Place of residence
Urban	0.746	0.455	1.224	0.469***	0.321	0.686
Rural^a	1.000
Exposure to mass media
Not exposed	0.702	0.393	1.252	1.052	0.673	1.645
Exposed^a	1.000
Knowledge of modern methods
Others	1.270			0.869		1.172
Know all methods^a	1.000	0.850	1.896		0.644
Exposure to FP message
Not exposed at all	1.575*	1.013	2.449	1.166	0.822	1.655
Exposed at least one^a	1.000
Religion
Hindu	2.507***	1.510	4.161	1.081	0.745	1.568
Others^a	1.000
Caste
Backward	0.830	0.551	1.251	1.039	0.747	1.444
Forward^a	1.000
Native language
Assamese	0.588*	0.371	0.934	0.751	0.511	1.103
Bengali	0.220***	0.125	0.386	0.870	0.572	1.324
Others^a	1.000
Marital duration
Up to 10 years	0.051***	0.023	0.111	0.404**	0.215	0.760
11–20 years	0.182***	0.102	0.326	0.385**	0.223	0.664
21 and above^a	1.000
Achieved fertility
Not achieved	0.651	0.412	1.028	0.928	0.652	1.320
Achieved^a	1.000

Note: *** = p < 0.001; ** = p < 0.005; * = p < 0.050.

Reference category.

Multi-variate results (Table 5) show that marital duration, place of residence and age are the variables exerting significant impact on women’s preference for terminal methods over modern spacing methods. It is found that, compared to the women who were married for longer than 20 years, women with shorter marital durations were less likely to adopt terminal methods. In other words, with the increase in age, women prefer terminal methods over modern spacing methods. From the results, it is apparent that, compared to rural women, urban women are less likely to resort to terminal methods. Furthermore, younger women are also less likely to choose terminal methods over modern spacing methods. This implies that younger women are in the family-building process, have not attained ‘achieved fertility’ and therefore would not resort to terminal methods.

Discussion

Comparative analysis of demographic characteristics shows that traditional method users are in between users of modern spacing and users of terminal methods. This signifies that users of traditional methods may adopt terminal methods over a period of time, because they may still be in the family-building process. Thus, there is a great opportunity to motivate these women to use (modern) effective contraceptive methods so that they can be free from unwanted pregnancies and other complications. Adoption of effective methods is essential not only in terms of reducing unwanted births, but also for the better reproductive health of women. Exposure to mass media equips women with knowledge on family life and possibly family planning. As with exposure to mass media, exposure to family planning messages has more bearing on choosing an appropriate, suitable and effective contraceptive method. Unless a woman is exposed to the entire range of contraceptive methods, she cannot have a true choice. In general, the use and choice of contraceptive method rely greatly on the relationship between the number of living children and the desire for additional children. However, despite achieving their desired number of children with desired sex composition, many women do not resort to contraception (Narzary and Sharma, 2013).

One of the studies (Kamal et al., 2007) demonstrated that the sex composition of living children has the strongest association with the use of periodic abstinence. With the increase in number of sons, the probability of using periodic abstinence and other methods increases (Kamal et al., 2007). However, in matrilineal societies, the opposite is demonstrated. The absence of daughters accompanied by an increase in total number of sons increases the desire for additional children (Narzary and Sharma, 2013) which ultimately may affect contraceptive use. However, in the present study, no significant relationship in this regard is established.

A study conducted in Bangladesh on the practice of periodic abstinence (Kamal et al., 2007), one of the traditional methods of birth control, reveals that as the women grow older and have at least one son, they either practice periodic abstinence or adopt permanent methods. The reasons for reliance on periodic abstinence are, firstly, women were dissatisfied with the side effects of the modern contraceptives they had used so they resorted to periodic abstinence. Secondly, others thought that, due to older age, their libidos were lower than before, so it was possible to observe periodic abstinence (Kamal et al., 2007). In the present study, no relationship between age and use of traditional methods is found. However, a positive relationship between age and use of terminal methods is noted even in Assam. Such differences in contraceptive use may be due to the differences in socio-economic settings between Bangladesh and Assam.

The question of choice or preference arises only when there is an array of options. The preference for a particular contraceptive method crops up only if a woman is knowledgeable about other available methods. In Vietnam, urban households with experience and better awareness choose traditional methods, such as withdrawal and the menstrual cycle, more than rural households do (Binh, 2012). In Assam, however, the opposite relationship is noted, although the result is statistically not significant. Some women do not use contraception, despite a pressing need, due to the fear of side effects, which might be due more to unfounded rumors relating to the methods and people’s ignorance of the workings of the methods than to actual experiences (Nwachukwu and Obasi, 2008). Further, non-use and ineffective use of modern methods may not only reflect difficulties in obtaining such information and services, but also indicate that they are dissatisfied with current methods (Darroch et al., 2011). Sometimes, due to their ease of use and lack of side effects, traditional methods may appeal even to couples who are not currently using any method, and to those who are dissatisfied with their current or past methods. There is an urgent need for community level programs that address family planning education, especially on safe and effective use of contraceptive methods.

Conclusion

The demographic characteristics of users of traditional methods are in between modern spacing and terminal method users, implying they are still in the family-building process. Traditional methods, although less effective, are also spacing methods, but why women prefer traditional methods over modern spacing methods is assessed in this paper. The present analysis hints that traditional method users are at the waiting stage before adopting more effective methods of contraception – possibly terminal methods. However, during this waiting stage, they suffer from unwanted pregnancies, which naturally raises the fertility level to a higher-than-desired level. Assam makes up about 70 percent of the total population of the north east region. Any change in the state affects the demographic scenario of the entire region. Assam plays a dominant role in bringing the demographic transition of the region to a desired stage. Thus, there is a need to motivate women/couples to adopt more effective methods of contraception. As the results show, the burden of unwanted/mis-timed fertility is highest among users of traditional methods, so there is an urgent need to impart proper knowledge about the effective use of both traditional and modern contraceptive methods. If accurate information regarding traditional methods is imparted, at least their effectiveness can be raised. Further, knowledge of all the modern methods would enable women to choose suitable and affordable methods of contraception.

Footnotes

Authors’ contributions

PN initiated and guided this study and made substantial contributions to conception, acquisition and interpretation of data. BM and SA extensively reviewed and provided valuable inputs in the methods section. All authors read and approved the final manuscript.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Pralip Kumar Narzary worked as Lecturer in the Post-Graduate Department of Population Studies, Fakir Mohan University, India for 10 years. He has recently joined International Institute for Population Sciences, Mumbai, India as Associate Professor in the Department of Development Studies. His areas of interest include forced migration, contraceptive use, public health and issues relating to marginalized groups. His research works have been published in various reputed journals.

Madhusudana Battala, PhD in Population Studies, is working as a Senior Research Officer in Population council at New Delhi, India. His areas of interest include HIV/AIDS, RTI/STI and Public Health.

A Sathiya Susuman is Associate Professor, Faculty of Natural Sciences, Department of Statistics and Population Studies, University of the Western Cape, Bellville 7530, Cape Town, South Africa. His research interests include technical demography, fertility, mortality, gender, reproductive health, vulnerable diseases, HIV/AIDS, health policy and public health. He has published several international accredited journal articles in BMC Reproductive Health, BMC Research Note, International Journal of Equity in Health, Journal of Public Health, SAHARA J: Journal of Social Aspects of HIV/AIDS Research Alliance, Journal of Social Science Research, Journal of Asian and African Studies, Plos One, Clinical Case Report, Iranian Journal of Public Health, and in other journals and edited volumes.

References

Binh

(2012) Contraceptive use in Vietnamese families during the period 2002–2008. International Journal of Humanities and Social Science 2(1): 206–213.

Cindoglu

Sirkeci

(2008) Determinants of choosing withdrawal over modern contraceptive methods in Turkey. The European Journal of Contraception and Reproductive Health Care 13(4): 412–421.

Cleland

Bernstein

Ezeh

et al . (2006) Family planning: The unfinished agenda. Lancet 368: 1810–1827.

Darroch

Sedgh

Ball

(2011) Contraceptive Technologies: Responding to Women’s Needs. New York: Guttmacher Institute.

Foroutan

(2008) Employment differentials of second-generation Muslim immigrants: Assimilation and discrimination hypotheses. Immigrants & Minorities 26(3): 219–241.

International Institute for Population Sciences (IIPS) and Macro International (2007) National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS.

International Institute for Population Sciences (IIPS) and ORC Macro (2000) National Family Health Survey (NFHS-2), 1998–99: India. Mumbai: IIPS.

International Institute for Population Sciences (IIPS) (1995) National Family Health Survey (MCH and Family Planning), India 1992–93. Mumbai: IIPS.

Kamal

Saha

Khan

et al . (2007) Use of periodic abstinence in Bangladesh: Do they really understand? Journal of Biosocial Science 39: 27–40.

10.

Narzary

Sharma

(2013) Daughter preference and contraceptive-use in matrilineal tribal societies in Meghalaya, India. Journal of Health, Population and Nutrition 31(2): 278–289.

11.

Nwachukwu

Obasi

(2008) Use of modern birth control methods among rural communities in Imo State, Nigeria. African Journal of Reproductive Health 12(1): 101–108.

12.

Ross

Hardee

Mumford

et al . (2001) Contraceptive method choice in developing countries. International Family Planning Perspectives 28(1): 32–40.

13.

Williamson

Parkes

Wight

et al . (2009) Limits to modern contraceptive use among young women in developing countries: A systematic review of qualitative research. Reproductive Health 6(3).