Couple’s Pregnancy Ambivalence in Indonesia

1. Couple’s Pregnancy Ambivalence in Indonesia Janine Barden-O’Fallon, PhD Ilene Speizer, PhD University of North Carolina at Chapel Hill October 29, 2008 Session 5183.0 Contextual Factors Influencing Fertility Decisions Annual Meetings of the American Public Health Association

2. Presenter Disclosure Janine Barden-O’Fallon The following personal financial relationship with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose.

3. Working definition of pregnancy ambivalence • The expression of seemingly contrary fertility desires and/or the expression of fertility desires that are contrary to contraceptive behavior • Conventional method of categorizing fertility intentions may not accurately reflect the complex nature of fertility decision-making • In the US, 32% of women who experienced a contraceptive failure did not report the pregnancies as unintended (NSFG 1995)

4. Public health implications • Women with ambivalent pregnancy attitudes are less likely to be current users of contraception, and when using, tend to use less effective methods and to use them less effectively • Pregnancy ambivalence can lead to contraceptive failure and contraceptive discontinuation for reasons other than to become pregnant • Measurement: researchers use of fertility desires may misrepresent women’s actual fertility intentions

5. Study objectives • Explore the issue of ambivalence using a couple’s perspective with recent data from Indonesia: • How do husbands and wives respond to the same questions on fertility desires? • Is there evidence of pregnancy ambivalence in both husbands and wives? What is the correspondence between husband’s and wives ambivalent attitudes? • Does pregnancy ambivalence influence women’s contraceptive use?

6. Data: Indonesia Demographic and Health Survey 2002-2003

7. Methods • Sample includes 5,148 couples who responded to the “problem question” and were not missing any key variables used in the analysis • Problem question categorized as “No problem” vs “Any problem” (Big/Small) • Other variables include: current contraceptive use, fertility desires, age, education, # children ever born and HH wealth • Descriptive comparisons and multivariate analysis with contraceptive use as the outcome • All proportions are weighted for sample design

8. Husband’s and wives’ contraceptive use and fertility desires, IDHS 2002/03; N=5,148

9. Most husbands and wives who want to delay or stop childbearing are using contraception Husband’s and wives contraceptive use by fertility desires; N=5,148 Contraceptive use Husbands (%) Wives (%)

10. Pregnancy ambivalence is high in contraceptive users, especially among men Husband’s and wives' fertility desires by whether a pregnancy in the next few weeks would be no problem, among contraceptive users Wives’ Sample N=3,985 Husband’s Sample N=3,919

11. Similar levels of ambivalence are seen in non-users Husband’s and wives' fertility desires by whether a pregnancy in the next few weeks would be no problem, among non-users Husband’s Sample N=1,229 Wives’ Sample N=1,163

12. Couple’s agreement on ambivalence is relatively low among users Couple’s concordance on pregnancy ambivalence: report of “no problem” among contraceptive users that want to delay or stop childbearing; N=3,085 Husband’s report Kappa value: agreement= 63%; kappa statistic=0.26

13. Couple’s agreement on ambivalence is also relatively low among non-users Couple’s concordance on pregnancy ambivalence: report of “no problem” among non-users that want to delay or stop childbearing; N=750 Husband’s report Kappa value: agreement= 61%; kappa statistic=0.24

14. Multivariate logistic regression of wife’s reported contraceptive use among couples in which at least 1 partner wants to delay or stop childbearing; N=4,914 • Variables • Age: 15-24, 25-34, 35+ (REF) • Education: none, primary, secondary+ (REF) • # Children ever born: 0-1 (REF), 2-3, 4+ • HH wealth: poorest 40%, middle 20% (REF), wealthiest 40% • Couple’s ambivalence: one partner ambivalent, both ambivalent, neither ambivalent (REF) • Couple’s fertility desires: • one partner wants to delay while other wants to stop • one partner wants to delay or stop while other wants another child w/in 2 years or is undecided • both want to delay • both want to stop (REF)

15. Couple’s discordance on pregnancy ambivalence and fertility desires has an effect on contraceptive use MV Regression of wife’s contraceptive use among couples in which at least 1 partner wants to delay or stop childbearing; N=4,914 Adjusted Odds Ratios * * *** • One partner wants to delay other to stop; (2) one partner wants another child soon or is undecided; • *P<0.1; ***p<0.001

16. Conclusions • In Indonesia, more men than women express ambivalence, which may present barriers to contraceptive adoption, effective and/or continuous use • There is not always agreement within the couple: women in couples that were discordant on pregnancy ambivalence were significantly less likely to be using contraception • If pregnancy ambivalence is to be addressed programmatically, both members of a couple should be targeted • Pregnancy ambivalence in non-users indicates that estimates of true “unmet need” may be too high

17. Thank you MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) through Cooperative Agreement GPO-A-00-03-00003-00 and is implemented by the Carolina Population Center at the University of North Carolina in partnership with Futures Group International, John Snow, Inc., Macro International Inc., and Tulane University. The authors’ views expressed in this presentation do not necessarily reflect the views of USAID or the U.S. Government. Visit us online at: http://www.cpc.unc.edu/measure