Differences in use of family planning in the European Region 1
What can be done and what should be done to live healthier and better? This question is asked by many: parents when their children are born; adults, usually when they or those close to them are sick; and very often by public health experts at public health discussions and health system meetings.
In the WHO European Region health indicators, including those of sexual and reproductive health (SRH) and family planning (FP), have improved during the last decades. However, there are widespread health inequalities between countries and within societies. The economic crisis that started in 2007 has contributed to major challenges leading to in creas ing unemployment and the number of people living in poverty. The search for employment has meant that many individuals need to live and work outside their countries of origin, which has lead to increased migration and a mix of differing levels of health literacy and SRH values all over Europe.
These and many other factors influencing a healthy life are addressed in the new European health policy “Health 2020: A European policy framework supporting action across government and society for health and well -being” approved by all European Union member states in 2012 (1). “Improving health for all and reducing health inequalities” is one of the strategic objectives of this policy and calls all countries to analyze, across the life course, the complex factors contributing to health and well-being, including SRH. The impact of health-related behaviours, such as tobacco and alcohol use, diet and physical activity, has recently been on the agenda of high-level meetings in the region. Yet, even in 2013, the year when many countries and regions are evaluating achievement of the goals set by the International Conference on Population and Development in Cairo in 1994, FP is still on the “waiting list” as an agenda in the WHO European Region. While several countries have prioritized access to infor mation and quality FP services in the bilateral collaboration agreements with the WHO Regional Office for Europe, because FP is not among the direct causes of the loss of disability-adjusted life years, it remains thought of as less of a priority issue for the majority of countries in the Region. As a result, despite its direct link to improved SRH, including maternal and child health, FP data from many countries is lacking and data on contraceptive prevalence in most countries of the Region are not available (2).
Main data sources
What do we know about access to FP and contraceptive prevalence in the region? The best data sources to answer this question come from the Demographic Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) that have been carried out in the region in the 21st century and have included questions on FP and reproductive health. To date, of the 203 DHS carried out globally, 10 countries of the WHO European Region have been involved. In addition, in many of the eastern and central European countries where MICS have been performed, an increasing number of coun tries are also including data from the Roma communities (3, 4). While these surveys are our most reliable data source on contra ception and FP, it is important to realize that questions related to SRH and FP vary from country to coun try and are often adapted to cultural traditions.
This article attempts to present the most recent available data on the subject. DHS data from the 1990’s have not been included since it is felt that these data no longer reflect the current situation as much has changed over the last decade. Data from the 2006 MICS in Turkmenistan is restricted and thus, not available, and data from the Republic of Moldova, Ukraine (both MICS), and Kyrgyzstan and Tajikistan (both DHS) where surveys are ongoing are not yet available.
Information from more than 30 countries on 15-year-olds who used condoms or pills at their last intercourse has been well documented and analyzed (5). Data show large gender differences in rates of condom and pill use among adolescents (see Table 1). The prevalence of condom use was significantly higher among boys in one third of the survey countries, but in some countries (Ireland, Latvia, Lithuania, Poland, Portugal, and Spain) girls report higher condom use. This difference may be related to access to information and condoms or having a partner from a different age group. Some countries, for example Germany, regularly carry out surveys on youth sexuality and can monitor the trends as well as factors influencing contraceptive use. In Germany, the difference between girls and boys who have not used contraception or have used “unsafe methods” during their recent sexual intercourse has decreased since 1980, when the first survey was carried out, from 14 % of girls in 1980 to 3 % in 2009 and from 19 % to 4 % of boys (6). These gender differences can also be seen in older age groups. Data from the 2007 DHS in Ukraine revealed that use of condoms at first sexual intercourse among men and women aged 15–49 was very similar (50.1 % versus 45.4 %) (3). This is in contrast to data from the 2008–2009 DHS in Albania which found that 19.3 % of women aged 15–49 had used a condom at last sexual intercourse, compared to 49.7 % of men (3).
Data on gender differences and FP remain difficult to capture, even from the DHS and MICS. For example, in some countries questions on FP are asked to both women and men aged 15–49, but in others FP questions are asked only to women. While DHS data from select countries (Albania 2008–9; Ukraine 2007; Azerbaijan 2006; Armenia 2005) do include information of having ever used contraception among women and men, men were asked only about use of male-oriented contraceptive methods, making it difficult to interpret or comment on male involvement in FP issues within relationships and to completely understand and/or analyze the gender role in FP (3).
The role of men in FP cannot be neglected, especially as there is strong evidence that male involvement increases uptake and use of FP. Fortunately, in the most recent DHS in Armenia (2010) there is a chapter on men’s attitude toward FP. This chapter highlights the important role men have to play; 73 % of men age 15–49 disagreed with the statement “Contraception is a woman’s business” (3). Increasing male involvement was also found in the 2007 DHS from Ukraine where 93 percent of currently married women aged 15–49 reported that their husband knew about their use of contraception (3). Increasingly national reproductive health surveys (Ireland 2006; Latvia 2011; Germany 2011) are recognizing the importance of including both men and women in their surveys targeting SRH and FP and the inclusion of both sexes in the surveys reveal important similarities and differences among males and females when analyzed.
Place of residence
Analysis of the place of residence of current users of modern, effective methods of contraception is important for further development of the health systems approach to ensure access to information and modern contraceptives to those in need.
In most countries where Reproductive Health Surveys (RHS), DHS and MICS have been carried out recently the difference of use of modern contraception in rural and urban settings is small with some exceptions (see Table 2). In fact, analysis of the trends in FP use in countries where surveys have been carried out more than once over the past 10–15 years illustrates where FP programs have targeted activities at the country level to attempt to decrease inequities that may have been present between rural and urban populations. For example, in Albania the percentage of modern contraceptive users remains small, but has increased in rural areas from 5.5 % to 9.6 % from 2002 to 2008–9, compared to urban settings which demonstrated only marginal changes – 11.3 % versus 11.9 % – during the same time period (3). Interestingly, in Turkmenistan modern contraception use is higher in rural than in urban regions. The same is also true of Uzbekistan where data from 2005 showed the unmet need for contraception was higher in the urban population (3).
The link between education and contraceptive use has also been well documented, with populations who have lower levels of education often having a lower propensity to use contraception.Table 3 presents the difference in current use of modern contraception by educational status across the different countries in the Region. Significant variation is present. The largest difference is seen in Tajikistan where only 13.9 % of women with primary or less education currently use modern contraception compared to 50.7 % of women with higher education – a difference of 35 % (3). The smallest difference is seen in Turkmenistan where 52.6 % of women with primary or lower education use modern contraception, compared to 53.1 % of women with higher education – a gap of less than 1 % (3).
In both the DHS and MICS one can find information on use of contraception in different groups by wealth quintile. Data summarized in Table 4 present the relationship between finances and FP in different countries of the Region. Household income greatly impacts the use of modern contraception in Armenia, Georgia, Republic of Moldova, Montenegro, Romania, Serbia, Turkey and Ukraine, where the difference between the lowest and highest wealth quintile for use of contraception is 15 % and greater (3, 4). In some countries (Albania, Bosnia and Herzegovina and Kyrgyzstan) the difference is very low (3, 4). The relationship between wealth and FP is complex and requires more detailed study as the access to contraceptives in the European Region differs from country to country – from free of charge contraception to a client provided by aid development partners (mainly UNFPA), to reimbursement of contraception by insurance, to free of charge for special population groups (young people, postpartum women, low-socio-economic status), all factors that influence the contraceptive prevalence and method mix.
FP is linked with cultural traditions and norms. Given the diversity of cultures that exist in Europe it is not surprising that variation in use of contraception would also be seen among different ethnicities in the Region.
The Federal Centre for Health Education (BZgA) in Cologne, Germany carried out a study “Women’s Lives - Family Planning and Migration Throughout Life” that compared the current contraceptive practice of German, Turkish, eastern and south-eastern European women living in Germany. The study clearly demonstrated that ethnic background influences the choice of contraceptive method. For example pills were more often used by German women, the intra uterine device (IUD) by women from eastern and south-eastern Europe and Turkish women more often used surgical con traception (7).
According to the 2011 MICS in the former Yugoslav Republic of Macedonia, the percentage of women aged 15–49 years who use a modern contraceptive method differs depend ing on the ethnicity of household head: 14.9 % if the household head is Macedonian, 9.7 % if Albanian and 8.8 % if another nationality (4). In Montenegro, the difference between modern contraceptive use according to the ethnicity of the household head is also present, with the biggest difference being among BosnianMuslim (19.3 %) and Albanian (14.6 %) women (4).
The Roma population represents one of the most marginalized ethnic minorities in Europe, but comparable data on their SRH and FP needs has been lacking. The MICS in Bosnia and Herzegovina (2011/12) and in Serbia (2011) specifically included a section for the Roma, which is providing useful information about FP and this population. For example, in Bosnia and Herzegovina the language spoken in the household influences the use of modern contraception (5.1 % Romani language vs. 12.2 % other languages) (4). When looking at other social determinants of health and their re la tionship with contraceptive use among Roma women, similar trends to those of non-Roma women are seen, with lower use among those who are less educated and less wealthy (see Table 5) (4). In Serbia, while patterns of use may follow simi lar trends, access to FP differs, with a greater percentage of Roma women reporting unmet need for FP compared to non Roma women (10 % versus 7 %) (4).
More and more policy makers are focusing on strengthening high-quality people-centred health systems and tackling persisting health system barriers that continue to limit health promotion and availability of high quality services. Member States of the WHO European Region are starting this process by developing a “Framework for Action towards Coordinated/Integrated Health Services Delivery” (8). The WHO Regional Office for Europe and other partners are supporting countries with policy options and specific recommendations for change, through an action-oriented approach to target areas for strengthening the coordination/integration of care. It is important to ensure that the Frame work for Action includes FP, an important area of public health with impact on the health and well-being not only of the woman or couple, but also the health of the future generations.
In order to help shape the strategies and actions and track progress, it is essential that data on FP is available and comparable throughout the Region. Standardized questionnaires and indicators should be used when any survey on SRH and FP is taking place. These surveys should also involve both sexes, with questions targeted to men as well.
Furthermore, the role of social determinants of health such as place of residence, education, wealth and ethnic background differs from country to country and needs to be studied and monitored to ensure that developed SRH strategies, action plans and activities are targeting those most in need.
1 Dieser Artikel ist erstmals in der Zeitschrift “Entre Nous” Nr. 79-2013 (S. 6–9) erschienen (www.euro.who.int/entrenous). Wir veröffentlichen ihn mit freundlicher Zustimmung der Autorin.
1 Health 2012. A European policy framework supporting action across government and society for health and well -being. Copenhagen: WHO Regional Office for Europe, 2013
2 Social determinants of sexual and reproductive health. Informing future research and programme implementa tion. Geneva: WHO, 2010
3 Measure DHS [website]. (http://measuredhs.com/What-We-Do/Survey-Search.cfm, accessed 20 October 2013)
4 Monitoring the Situation of Children and Women [website]. UNICEF (http://www.childinfo.org/mics4_surveys.html , accessed 20 October 2013)
5 Currie C./Zanotti C./Morgan A. et al., editors. Social determinants of health and well -being among young people. Health behaviour in schoolaged children (HBSC) study: International report from the 2009/2010 survey. Copenhagen: WHO Regional Office for Europe; 2012
6 Youth Sexuality. Repeat survey of 14 to 17-year- olds and their parents current focus: migration – 2010. Bundeszentrale für gesundheitliche Aufklärung; 2010 (http://publikationen.sexualaufklaerung.de/index.php?docid=2132, accessed 19 October 2013)
7 women’s lives – Family Planning and Migration Throughout Life. Interim results of a town- based study involv ing women with a Turkish, Eastern European or Southeastern European migration background. Cologne: BZgA, 2008–2009
8 Roadmap. Strengthening people -centred health systems in the WHO European Region. Copenhagen: WHO
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