“Two is Enough”: Rights-based family planning in Indonesia

K4Health Highlights

Sarah V. Harlan

CCP | Learning Director
Young mother and baby

A young mother holds her baby while she waits for a bus in the Kebayoran Baru subdistrict of South Jakarta.

© 2013 Sarah V. Harlan/CCP, Courtesy of Photoshare

During the 1970s and 1980s, Indonesia’s intensive top-down family planning (FP) program helped slash the total fertility rate (TFR) from more than 4 children per woman to 2.6—where it where it remains today—by greatly increasing the contraceptive prevalence rate (CPR). However, since the late 1990s, government decentralization and uneven local FP commitment have resulted in a stagnant CPR (about 58% for modern methods). To address this, President Susilo Bambang Yudhoyono is working to reinvigorate interest in FP and cut the TFR from 2.6 to 2.1 (replacement level) to keep the population from expanding further—and his administration has brought back the “Dua Anak Cukup”—or “Two [Children] is Enough” campaign used during the FP program’s heydey. The Indonesian Government has also committed to FP2020 goals and even hosted its own National Summit for FP last year.

Why the renewed focus on FP in Indonesia? According to government officials, if the TFR remains at 2.6, the population could double by 2060, which would make it increasingly difficult to provide food, education, health care, and infrastructure for its citizens. (Currently, Indonesia is the fourth most populous country in the world—after the United States—with 250 million people.) Indonesia has had one of the fastest growing economies in Asia, but government officials are worried that the country’s population growth is exceeding its economic growth, which could lead to higher levels of unemployment. (For more on population growth and economics in Indonesia, see this Bloomberg News piece published last month.)

While these statistics are alarming—and it is clearly important to examine economic development and employment issues—we also need to look at the situation through a rights-based lens. How can we ensure that FP programs are best meeting the needs of women and girls? For one thing, we should look beyond TFR alone, and examine fertility preferences.

Not only has Indonesia’s TFR been stagnant since the 1990s (as mentioned above), but Indonesia has had a persistent unmet need for FP since the 1990s (around 11 percent). Further, the contraceptive method mix in Indonesia does not adequately reflect the women’s needs. It is heavily skewed towards short-term methods; injectables account for more than half of all modern method use but have lower effectiveness rates and higher discontinuation rates compared to long-acting and permanent methods (LAPMs), such as contraceptive implants and IUDs (now used at less than half of the 1990s rates).

The goal of formulating FP programs around women’s actual contraceptive needs and preferences was the impetus the Improving Contraceptive Method Mix (ICMM) project: a USAID and Australian government-funded project led by K4Health/Johns Hopkins Center for Communication Programs, in partnership with local partners the Cipta Cara Padu Foundation, the Center for Health Research at the University of Indonesia, the National Population and Family Planning Board (BKKBN), and the Indonesian Ministry of Health. ICMM is an evidence-based advocacy project—with the goal of increasing access to and use of LAPMs—and is being conducted in the East Java and West Nusatenggara Provinces of Indonesia.

ICMM’s baseline study—a survey of 13,148 married women of reproductive age and qualitative research with 550 policy makers, health workers, community influentials, and contraceptive users and non-users—shed light on the need to make LAPMs more available. While women in the survey clearly expressed their desire to limit births, the majority reported using spacing methods (that is, shorter-term methods), sometimes for ten or more years, often with high discontinuation rates. However, qualitative results showed that women recognize both the advantages of LAPMs and the disadvantages of short-term methods, but use the latter out of familiarity rather than appropriateness. All of these results suggest that the time may be right to reintroduce LAPMs back into FP programs, especially for women with unmet need for limiting.

Since the Government of Indonesia recognizes the importance of LAPMs in achieving their FP goals, the ICMM project dovetails with their interests nicely. This partnership helps ensure that women are offered a range of contraceptive choices that best meet their needs—and in the process, helps the country achieve its own economic goals.

The final report of the ICMM baseline results will be available soon. Please check back for updates. Click here for more information on the ICMM project.

Comments

We strongly agree with the premise of the article that a greater balance between short-term methods and long-acting and permanent methods (LAPMs) is needed in Indonesia to nudge the CPR off its current plateau. A recent analysis of evidence from 1982-2009 by Ross and Stover (2013) found that "use of contraception may be increased by extending the availability of current methods."  DKT Indonesia, one of the largest social marketing programs in the world, is working hard to do just that. In 2012 and 2013, we sold and distributed a combined 1.4 million IUDs and, in 2013 alone, provided more than 7.1 million couple years of protection to women and men throughout the country, working through the private sector as well as in partnership with the government. We estimate that in 2012 DKT Indonesia contributed 18% of all the couple years of protection delivered in Indonesia.  We will continue to promote vigorously both short-term and long-acting methods as we think that is one of the best ways of shaking Indonesia's CPR out of its doldrums and get it back on a growth trend. - Christopher Purdy, President, DKT International & Todd Callahan, Country Director, DKT Indonesia