32 International Family Planning Perspectives

The report of the International Conference on Population

and Development issued the following directive:
ecogni!e that appropriate methods for couples and
individuals vary according to their age" parity" family si!e#
preference and other factors" and ensure that women and
men have information and access to the widest possi$le
range of safe and effective family planning methods in order
to ena$le them to e%ercise free and informed choice&'
(
The reality in most countries" however" is far different&
)ost countries offer only a limited choice of contraceptive
methods" and couples cannot easily choose the method that
$est suits their reproductive needs& In fact" international
2
program effort scores for (**+ showed that large propor#
tions of people in most developing countries did not have
ready access to a
variety
of contraceptive methods& Cou#
3
ples had essentially no access to the I,D in 3- countries"
no access to female sterili!ation in 3. and no access to va#
sectomy in /(& )any 0frican countries had low access scores
on almost every method& Five years later" in the (*** rat#
ings for 11 countries" only /23 of countries offered the pill
to at least half their population" 2+3 the I,D" +23 female
sterili!ation" 2/3 male sterili!ation and .33 the condom&
+
4u$stantial evidence indicates that a restricted choice
of contraceptive methods has constrained the opportuni#
ty of individual couples to o$tain a method that suits their
needs" resulting in lower levels of contraceptive prevalence&
5ne study noted that in Taiwan" each new method seemed
to add another layer of use to e%isting prevalence6 similar
increases were evident in 4outh 7orea" Thailand and 8ong
7ong& 0 second study found that $roadening the choice
2
of contraceptive methods increased overall contraceptive
prevalence in )atla$" 9angladesh" where household pro#
vision of in:ecta$les in early (*.. helped raise contracep#
tive prevalence from .3 to 2-3" the introduction of tu$ec#
tomy services in (*.1 helped increase prevalence $y an
additional (- percentage points" and household insertion
of I,Ds in (*1( elevated prevalence yet further& ;ain has
/
estimated that the widespread addition of one method to
Contraceptive Method Choice in Developing Countries
John Ross is senior
fellow, Karen Hardee
is director of research
of the POLICY Project
and Sherrine Eid is
cororate research
analyst, all with !he
"#t#res $ro# Inter%
national, $laston%
&#ry, C!' Eli(a&eth
)#*ford is an inde%
endent cons#ltant'
C5<T=>T: For all persons to en:oy a choice among contraceptive options" a range of methods must $e readily avail#
a$le& ?et measures of access show serious de@cits that depress use of each method& Countries differ $oth in the num$er
of methods offered and the e%tent to which each is made availa$le& Information is needed on how these factors have
changed over time and how they have affected contraceptive use overall and use of individual methods&
)=T85D4: Patterns of contraceptive use are derived from data from national surveys" and levels of access to four
methods Afemale sterili!ation" the I,D" the pill and the condomB are measured $y estimates from cycles of a program
effort study of the proportion of couples for whom each method is availa$le" as of (*12" (*1*" (**+ and (***& The
analysis focuses on the relationship $etween access to contraceptives and patterns of use&
=4,CT4: In all four cycles of the program effort study" the mean prevalence of the four methods rises with mean ac#
cess& For e%ample" mean prevalence in (**+ and (*** was close to (23 in countries with very low access" compared
with ++3 in those with high access& Prevalence is highest in countries where access to all methods is uniformly high& In
(**+" for e%ample" mean prevalence was (23 in countries where mean availa$ility was high and diversity in the avail#
a$ility of individual methods was low" compared with *3 in countries where mean availa$ility was high and access to
individual methods varied considera$ly& 9etween (*12 and (**+" the num$er of countries with uniformly high access
rose from nine to 23" while the num$er with uniformly low access declined from 23 to nine& 0t the lowest level of mean
availa$ility" the condom and the pill contri$ute most to availa$ility A+-3 and 3/3" respectivelyB" $ut at the highest
level" the contri$utions of the four methods eDuali!e at 22E2.3 each& The situation for prevalence is similar: The pillFs
share at the lowest level of availa$ility is /.3" compared with 3(3 at the highest level" where it is surpassed $y female
sterili!ation A3/3B&
C5<CC,4I5<4: Full choice among a variety of contraceptive offerings is yet to $e attained in many countries& Its a$#
sence restricts personal access to each method as well as the use of all methods in the population& To the e%tent that
the a$ility to choose satisfactory contraceptive protection depends on ready access to multiple methods" a clear man#
date e%ists for greater programmatic attention to the provision of a full range of methods&
International Family Planning Perspectives" 2--(" 21A(B:32E+-
9y ;ohn oss"
7aren 8ardee"
=li!a$eth )umford
and 4herrine =id

33 Golume 21" <um$er (" )arch 2--2
)ethod availa$ility is measured through the program
effort scores as the percentage of the population having
ready and easy access to each contraceptive method& The
H
percentage for each method comes from respondentsF es#
timates for the ur$an and rural sectors" which we com$ined
with population weights to o$tain the national @gure&
)ethod availa$ility is distinct from method use: The con#
dom" for e%ample" may $e easily availa$le $ut little used6
in fact" its level of use for family planning has usually $een
Duite low& The proportion of women relying on sterili!a#
tion" on the other hand" can rise to a su$stantial @gure over
time" although its availa$ility at any one time may $e mod#
est& espondents to the program effort Duestionnaire were
cautioned not to confuse availa$ility with actual use" $ut
to estimate the percentage of the population having access
without reference to the percentage that might $e using it&
Analytic Approach
In the following sections" we e%amine the association $e#
tween method access and prevalence $y @rst summari!ing
improvements in availa$ility and prevalence over time" $y
region6 $y using all methods to relate mean prevalence to
mean availa$ility6 $y relating availa$ility and prevalence
for each method alone6 $y relating prevalence simultane#
ously to $oth the level and the diversity of method avail#
a$ility6 and $y documenting the relative contri$ution of each
method to $oth availa$ility and prevalence over time" su$#
:ect to the overall availa$ility level&
=4,CT4
Access and Prevalence Improvements
5ver the period (*12E(***" the average availa$ility score
for the group of four methods included here rose from (&2
to 2&/" the eDuivalent of access for 3-E223 of the popula#
tion& The availa$ility of each individual method also rose
su$stantially" from 223 to 323 for female sterili!ation" from
3+3 to /(3 for the pill" from 2/3 to 2-3 for the I,D and
from 3+3 to /33 for the condom&
egional differences are considera$le" with availa$ility great#
est in =ast 0sia and least in 4u$#4aharan 0fricaIespecially
the francophone countries& The other regions are clustered
in a middle range& =ast 0sia attained a high level of availa$ility
early in the study period and e%perienced little change there#
after6 on the other hand" 4u$#4aharan 0frica shows recent
improvements" although at fairly low levels& Condom avail#
a$ility seems to have increased more sharply in 0frica and
0sia than in Catin 0merica" while the availa$ility of female
sterili!ation appears to have risen most in Catin 0merica&
Ci@e availa$ility" the prevalence of contraceptive use has
risen mar@edly over the decades& The latest ,nited <ations
the options availa$le in a country would $e associated with
an increase of (2 percentage points in contraceptive preva#
lence& 9ehind these @gures lie increased num$ers of sat#
.
is@ed couples" as well as fewer unplanned pregnancies" in#
duced a$ortions and unwanted $irths&
This article is devoted to the issue of choice" which in
part depends on the widespread availa$ility of a variety of
contraceptive methods& Je e%amine the overall level of use
and the diversity of use of contraceptive methods in rela#
tion to their measured availa$ility& 0lthough it is $eyond
the scope of this article to deal with important issues of client
treatment" policyma@ers and planners should consider them
along with the issues of method availa$ility addressed here&
D0T0 0<D )=T85D5C5K?
Availability of Contraceptive Methods
This article uses the ratings of method availa$ility o$tained
in studies of national family planning programs conduct#
ed in (*12" (*1*" (**+ and (***& In each cycle" 3- fea#
1
tures of program effort were measured" including some that
focused speci@cally on the availa$ility of contraceptive meth#
ods to the general population& Four modern methods that
are provided through large#scale programsIthe condom"
the pill" the I,D and female sterili!ationIare included here&
5thers" such as the implant" the in:ecta$le and male ster#
ili!ation" are omitted either $ecause separate estimates are
unavaila$le in the effort ratings or $ecause" li@e the implant
and male sterili!ation" the methods e%hi$it very low levels
of use and availa$ility&L
Contraceptive Use
Data on contraceptive use are ta@en from national surveys"
including the Jorld Fertility 4urveys AJF4B" Contracep#
tive Prevalence 4urveys ACP4B and Demographic and 8ealth
4urveys AD84B& The @ey indicator is the percentage of cou#
ples using each method at the time of the survey" $ased on
responses $y married or coha$iting women of reproduc#
tive age Ausually those aged (2E+*B& 8aving data from mul#
tiple surveys over time for a given country allows us to es#
timate contraceptive use" $y method" at appro%imately the
same dates as the effort scores" $y interpolating $etween
survey dates or" in some cases" $y e%trapolating from his#
torical trends& The prevalence information relates to use
for family planning purposes6 thus" condom use for pro#
tection against se%ually transmitted diseases is very li@ely
underestimated&
Availability Measures
4i%ty#four countries had information on program effort
scores for all three years A(*12" (*1* and (**+B" and also
had survey estimates for contraceptive prevalence& AThese
/+ countries are home to *(3 of all women aged (2E+*
who live in the ((- developing countries with populations
of more than one million each& 5nly +. countries had $oth
program effort estimates and recent survey estimates for
(***6 for certain analyses" we com$ine the (**+ and (***
scores and use the total of /+ units of o$servation&
LIncluding these methods would tend to strengthen the association $e#
tween limited choice and low prevalence" $ut it is already evident that the
literal a$sence of methods means nonuse" and the presence of many near#
!ero values would o$scure the correlations for the more common methods&
espondents were instructed that ready and easy access' means spend#
ing no more than an average of two hours per month to o$tain the service
or supply and that the cost of one monthFs supply of the service or supply
should $e less than (3 of a monthFs wages&









3+ International Family Planning Perspectives
review" using surveys that cover 123 of the developing
worldFs population" shows that almost all of the less de#
veloped countries with trend data e%perienced an increase
in the level of contraceptive use&' 5ver an average period
*
of *&2 years" use increased $y at least one percentage point
per year" or (- points per decade" in more than two#thirds
of the countries and $y two points or more annually in ((3
of the countries& 9y region" the ,<Fs medium estimate is
highest for =ast 0sia A133 of couples using a methodB" fol#
lowed $y Catin 0merica and the Cari$$ean A//3B" other
0sian regions A++3B" northern 0frica A+23B and 4u$#4a#
haran 0frica A(+3B&
Mean Availability and Mean Prevalence
In all four cycles of the program effort study A(*12E(***B"
mean prevalence and mean availa$ility are closely and pos#
itively related AFigure (B& The relationship persists as coun#
tries improve in $oth varia$les over the four yearsIthat is"
as they shift upward and to the right& This @nding is con#
sistent with the hypothesis that $etter choice" via easier ac#
cess to methods" leads to use $y more couples" which may
imply greater satisfaction and fewer unwanted pregnancies&
The /+ countries in the study are shown in Figure 2"
which classifies them :ointly $y average availa$ility and
prevalence& The overall prevalence in the /+ countries was
323" rising from /3 in the very low prevalence countries
to 2*3 in the high#prevalence nations& AThese @gures are
for only the four modern methods included in the study"
so they are lower than totals for all methods" including tra#
ditional methods&B )ean prevalence increased with access6
it was only (23 in countries with very low access" compared
with ++3 in countries with high access&
The data for +. countries pertain to (*** and those for
(. countries pertain to (**+6 $ecause patterns in (**+ and
(*** were similar" we used all /+ units of o$servation& Je
divided the /+ countries into four availa$ility groupings of
eDual si!e" as well as four prevalence groupings of eDual
si!e6 the two sets of groups were then cross#classi@ed& This
procedure places (/ countries in each row and in each col#
umn6 if there were no association $etween availa$ility and
prevalence" the countries would $e evenly distri$uted across
the cells&
In fact" most countries cluster along the diagonal in the
ta$le" from very low values to high values on $oth charac#
teristics& Fifty#three of the /+ countries either lie in cells di#
rectly on the diagonal or in ad:oining ones6 only (( are in
cells that are further away& <ot une%pectedly" most coun#
tries in the upper#left cell Ai&e&" those with very low preva#
lence and very low availa$ilityB are in 4u$#4aharan 0frica"
whereas most of the countries in the lower#right cells Athose
with high prevalence and high availa$ilityB are in Catin 0mer#
ica and 0sia& Jhen the original values for average availa$ility
and prevalence are used" the correlation is -&+(& For each
country" the average prevalence for the four modern meth#
ods in the study appears in the cells& 0s one would e%pect"
it is lower than pu$lished @gures for all methods Ainclud#
ing traditional methodsB&
(-
5ne Duestion is whether the respondents who rated the
availa$ility of each method might have $een in@uenced $y
their impressions of prevalence levels6 if so" the assump#
tion of independent measurements might $e compromised
and the correlation $etween availa$ility and prevalence
Contraceptive )ethod Choice in Developing Countries
(- 2- 3- +- 2- /- .- 1-
-
2
(-
(2
2-
22
(- 2- 3- +- 2- /- .- 1-
-
2
(-
(2
2-
22
(- 2- 3- +- 2- /- .- 1-
-
2
(-
(2
2-
22
3 availa$ility
(*12
3 prevalence
(*1*
(**+
(- 2- 3- +- 2- /- .- 1-
-
2
(-
(2
2-
22
(***
FIK,= (& )ean contraceptive prevalence of four methods"
$y mean availa$ility" (*12E(***


32 Golume 21" <um$er (" )arch 2--2
methods are highly signi@cant" at -&3* for female sterili!a#
tion and the pill and -&+. for the I,D $ut only -&(- for the
condom& =ach correlation is higher when the (*1* avail#
a$ility data are used A-&+3" -&+/" -&/2 and -&(.B& These pat#
terns" in $oth years" give partial support to the usefulness
of the availa$ility ratings& esults from one study cycle to
the ne%t have shown a consistency in the associations" even
as the levels of program effort have risen&
(2
The correlations in Duestion necessarily re@ect reality to
some e%tent" $ecause use cannot e%ist without access& The
use level sets a minimum level for what access must $e6
moreover" access to a contraceptive method always e%ceeds
its use" $ecause many couples who could use the method
prefer" and use" other methods& The true degree of associ#
ation $etween access and use is as li@ely to $e o$scured as
heightened $y any nonindependence $etween the measures&
The data for different countries are reported $y different
respondents" who would vary in the access rating they
might $e affected& 8owever" e%plicit instructions are given
in the program effort Duestionnaire that access measures
are not the same as actual use and that the two are not to
$e confused& The respondent is as@ed to estimate the per#
centage of the population with access to each method" with#
out regard to the level of use& =ach method is listed indi#
vidually" with separate entries for the rural and ur$an
sectors&
5ne chec@ on the accuracy of the availa$ility informa#
tion is afforded $y D84 survey information on the per#
centage of women who @now of a source for a given method&
That measure is a more o$:ective indicator" and @nowledge
of a source for a particular method should correspond gen#
erally to the actual availa$ility of the method& 4ome D84
country reports do not include source information" $ut it
is availa$le from data tapes for 2- country surveys con#
ducted $etween (**- and (**3&
((
Correlations for (**+
$etween availa$ility and @nowledge of a source for the four
FIK,= 2& Prevalence of use of four modern contraceptive methods Athe pill" condom" I,D and female sterili!ationB" $y mean
overall level of method availa$ility and overall level of prevalence" /+ countries" (**+ or (***
)ean availa$ility )ean prevalence )ean
prevalence
Gery low A<M(/B Cow A<M(/B )edium A<M(/B 8igh A<M(/B A<M/+B
Country 3 Country 3 Country 3 Country 3
0ll /&2 22&+ 3*&2 21&/ 3(&.
Gery low )ean 2&/ )ean (1&1 )ean +/&- )ean -&- ((&2
9enin 2&+ IraDL (1&1 PanamaL +/&-
=thiopia 2&1 KuyanaL +/&-
<iger 3&2
<igeriaL 3&/
)ali +&-
)adagascar +&1
,ganda 2&2
)auritaniaL 2&/
Cameroon /&+
4udan .&2
)alawi 1&-
Tan!ania 1&1
CesothoL (-&+
C o w ) e a n 1 & 1 )ean (1&* )ean +-&1 )ean 2*&/ 32&2
8aiti ((&/ 4yriaL 23&/ ;ordan 3/&+ =gypt +.&/
4enegal /&- Nam$ia (3&2 =l 4alvador ++&1 Cu$aL 1-&1
<epal (2&/ Nim$a$we +-&1 ;amaica 2-&+
7enya (1&1 8onduras 31&+
Kuatemala 2/&+ =cuador ++&+
Pa@istan (2&/
)edium )ean 1&1 )ean 2-&1 )ean 3.&2 )ean 21&+ 3*&2
Khana 1&1 9olivia (/&- IranL 3*&2 7uwaitL +1&+
5man (2&2 India 32&1 Costa ica /2&-
Philippines 22&/ )orocco +2&+ Gietnam 22&2
Indonesia 2.&2 Tur@ey 32&2 ep& of 7orea 22&2
4ri Can@a 3.&2 China .3&2
Dom& ep& 2.&/
8igh )ean -&- )ean 21&+ )ean 3.&2 )ean 21&( +3&/
Peru 32&- )auritiusL 32&2 Colom$ia 2+&-
)alaysiaL 2+&- Paraguay 3+&+ Thailand 2-&-
9angladesh 32&- 0lgeria 31&1 9ra!il //&+
Trinidad O To$agoL 3(&2 Gene!uelaL +-&- )e%ico 2+&+
9otswanaL 22&1 4ingaporeL /2&1
Taiwan .2&-
TunisiaL +/&1
LData are for (**+&









3/ International Family Planning Perspectives
assumption throughout is one of an independent estimate
of access" Duite apart from the level of use" and any wea@#
ening of this assumption is thought to $e small in com#
parison with the overriding dependence of use on access&
Availability and Prevalence of Methods
=%cept for the condom" the use of each method is highest
where the availa$ility of that method is high& For e%ample"
in the countries with greatest use of the pill A3/E++3B" the
level of availa$ility is ./E1-3& Ci@ewise" the highest preva#
lence of female sterili!ation A32E+(3B is found in countries
where .(E1-3 of the population have access to the method&
The patterns shown in Figure 3 re@ect a crowding of some
countries at the ma%imum value" which as noted is
1-E(--3 of the population& Figure 3 is restricted to (***6
in earlier years" the patterns were similar" $ut countries were
clustered at lower values of $oth availa$ility and prevalence&L
=%cept for the results for the condom" this method#specif#
ic e%amination of availa$ility and prevalence supports the
results shown in Figure ( for the means of availa$ility and
prevalence of the four methods together&
Prevalence Related to Availability
Jhen the mean level of availa$ility is in the middle range"
the diversity AvariationB among methods can $e either great
or small& That is" the same mean can result from all four
methods $eing eDually availa$le or from variation among
themIe&g&" with two at high levels and two at low levels& In
the @rst case" some of the population has $asic access to
all four methods6 in the second case" the population has
more access to two methods" $ut less to two others& 0lso"
depending on how the various methods are geographical#
ly distri$uted" access to individual methods may vary across
su$groups" as when ur$an residents live near facilities that
offer the I,D and sterili!ation and rural residents are served
$y programs that distri$ute the pill and the condom&
8ere we e%plore how prevalence relates to the interplay
of the level and diversity of availa$ility" with diversity mea#
sured $y the standard deviation across the four methods&
Je $egin $y comparing countries that have a low mean for
the availa$ility of all four contraceptive methods with coun#
tries that have a high mean& The preferred situation is rela#
tively high mean availa$ility and a low standard deviation"
meaning that all methods are easily and uniformly accessi#
$le& The reverse case is the unfortunate com$ination of a low
mean and a low standard deviation" indicating that all meth#
ods are uniformly unavaila$le& Contraceptive prevalence is
e%pected to $e Duite high in the @rst instance and Duite low
in the second& A<ote that a very high or a very low mean can
occur only with a very low standard deviation" $ecause di#
versity among methods precludes e%treme averages&B
For couples to en:oy a good choice" they need ready ac#
cess to a variety of methods6 in that case" each method will
Contraceptive )ethod Choice in Developing Countries
LFemale sterili!ation is different" in the sense that a country can attain high
prevalence over the years even though availa$ility is modest in each year&
0 low annual adoption rate still tends to produce high prevalence in the
long run $ecause continuation is so prolonged&
(- 2- 3- +- 2- /- .- 1-
-
(-
2-
3-
+-
2-
(- 2- 3- +- 2- /- .- 1-
-
(-
2-
3-
+-
2-
Condom
Pill
(- 2- 3- +- 2- /- .- 1-
-
(-
2-
3-
+-
2-
I,D
(- 2- 3- +- 2- /- .- 1-
-
(-
2-
3-
+-
2-
Female sterili!ation
3 prevalence
3 availa$ility
FIK,= 3& Contraceptive prevalence" $y availa$ility" accord#
ing to method" +. countries" (***
would give for any @nown level of use" with variations in
the gap $etween use and access& This process would add
confusion to the data" attenuating the true association6 fur#
ther" any in@uence of partially outdated survey materials
would o$scure the association rather than in@ate it& The





3. Golume 21" <um$er (" )arch 2--2
total availa$ility is a more important determinant of preva#
lence than the standard deviation6 however" high total avail#
a$ility automatically incorporates a low standard deviation
$ecause values for all methods must $e uniformly high&L
@nd its own su$group of users in the population& That sit#
uation should in turn lead to su$stantial prevalence values
for each method" and therefore a high total" $ecause most
couples would $e a$le to choose a method that @ts their
stage of life and their reproductive health status and re@ects
their e%perience with other methods&
To test this concept" we constructed a two#$y#two ta$le
in which mean contraceptive availa$ility in a country is clas#
si@ed as either low or high" and the standard deviation is
also classi@ed as low or high ATa$le (B& Je used data for
(*12" (*1* and (**+ $ecause the greater num$er of coun#
tries A/+B provides more sta$ility than the num$er for (***
A+.B& For each year" the /+ countries are divided evenly
a$ove and $elow the median for availa$ility6 the procedure
is repeated using the median for the standard deviation"
so that the num$ers of o$servations for analysis are $al#
anced& This places 32 countries in each row" $y year" and
32 countries in each column" $y year& Je e%pect that preva#
lence will $e highest where mean availa$ility is high and
the standard deviation is low Aupper#right DuadrantB and
that prevalence will $e lowest where $oth the mean and
the standard deviation are low Alower#right DuadrantB& In
fact" prevalence values correspond to these e%pectations
in all three years& In addition" as e%pected" the prevalence
values rise over time&
The ta$le also reveals trends over time in levels of and
diversity in availa$ility& In the top half of Ta$le (" the dis#
tri$ution of countries shifts: In (*12" 23 of the 32 coun#
tries with high mean availa$ility had a high standard de#
viation" $ut $y (*1*" 22 had a low standard deviation& This
trend implies that availa$ility $ecame more uniform across
methods as access to the less readily o$tained methods rose
to match the already high level of access to the others& 0lso"
the favora$le upper#right Duadrant gained mem$ers $e#
tween (*12 and (*1*" while the unfavora$le lower#right
Duadrant lost mem$ers" re@ecting a movement toward uni#
formly high access" a pattern that held in (**+&
Ta$le ( isolates the various com$inations of high and low
values" $ut the limited sample si!e ma@es it necessary to use
$road categories& )ultiple regression analyses indicate that
(--
1-
/-
+-
2-
-
FIK,= +& Percentage distri$ution of contraceptive avail#
a$ility and prevalence" $y method" according to mean level
of availa$ility" (**+
0vaila$ility A3B
(--
1-
/-
+-
2-
-
Prevalence A3B
-E(* 2-E3* +-E2* /-
)ean level of availa$ility A3B
Female I,D Pill Condom
sterili!ation
T09C= (& )ean contraceptive prevalence in /+ countries" $y
mean availa$ility and year" according to standard deviation
of availa$ility
)ean availa$ility 4tandard deviation
and year
8igh Cow
)ean <o& of )ean <o& of
prev& countries prev& countries
8igh
(*12 1&3 23 (-&* *
(*1* *&3 (- ((&2 22
(**+ *&( * ((&1 23
Cow
(*12 +&- * (&* 23
(*1* +&( 22 2&3 (-
(**+ /&2 23 3&/ *
<ote: Data pertain to only four methodsIfemale sterili!ation" the I,D" the
pill and the condom&
LIn addition" the role of the standard deviation is mas@ed $y the assump#
tion of linearity in the regressions& The standard deviation is low at $oth
high and low values of the mean" and the interaction is an important ele#
ment& The standard deviation is large only at intermediate values of the
mean& 4cattergrams con@rm a mar@ed ,#shaped Aupside downB relation
$etween the mean and the standard deviation for each of the four con#
traceptive methods&





31 International Family Planning Perspectives
In summary" Ta$le ( captures the essence of the situa#
tion" that the special com$ination of high availa$ility and
low standard deviation $est predicts high prevalence of use&
Ci@ewise" personal choice is ma%imi!ed in an environment
that gives uniformly high access to several contraceptive
methods&
Contribution of Individual Methods
+,vaila&ility'
To analy!e the relative contri$ution of the
various methods to the availa$ility score" we divided the
(**+ data set with /+ countries into four access groupings:
Cevel ( Athose where mean availa$ility is less than 2-3B"
Cevel 2 Athose where it is 2-E3*3B" Cevel 3 Awhere it is
+-E2*3B and Cevel + Awhere it is /-3 or greaterB& The con#
tri$ution of each method is simply its share of the totalI
that is" each methodFs access ta@en as a percentage of the
total access for all methods AFigure +" page 3.B&
For Cevel ( countries" the pill and the condomI$oth sup#
ply methodsIcontri$ute most to the mean availa$ility score
A3/3 and +-3 of the total" respectivelyB& The I,D and fe#
male sterili!ation together contri$ute only a$out 2+3 to
the score& 0t Cevel 2" the relative contri$utions of the pill
and the condom parallel those seen at Cevel (" while the
contri$ution of the I,D decreases and that of female ster#
ili!ation increases Afrom 33 to (+3 of the totalB& 0t Cevel
3" the contri$utions of female sterili!ation and the I,D $oth
increase& Finally" at Cevel +" the four methods reach a fair#
ly even $alance" at 22E2.3 for each& This $alance re@ects
an improved set of choices for couples in countries at Cevel
+" and it shows the dependence of total availa$ility on the
presence of multiple methods&
+Prevalence'
Figure + also shows the contri$ution of each
method to total prevalence at each availa$ility level& It is in#
teresting to compare the two patterns: The contri$utions
of each method to availa$ility and prevalence agree more
closely as mean availa$ility increases& The pill contri$utes
disproportionately to prevalence at the lowest level of avail#
a$ility A/.3 of the totalB" and loses share with each increase
in level& The condomFs contri$ution remains a$out the same"
so the contri$ution of the two resupply methods com$ined
diminishes proportionately as overall availa$ility rises across
levels& The relative contri$utions of the I,D and sterili!a#
tion increase" so at the highest level of access" sterili!ation
accounts for 3/3 of users" the pill 3(3" the I,D 2(3 and
the condom (23&L
0lthough Figure + is concerned with proportionate con#
tri$utions of the four methods" the a$solute values for avail#
a$ility far e%ceed those for prevalence of use& 0t every level
of mean availa$ility" the proportion of the population with
access to a given method is greater than the proportion using
it& That is a necessary result6 if each of the four methods were
availa$le to half of the population" total use could still $e
only a$out 123 of all couples" an appro%imate ceiling level
in high#prevalence countries& Cevels of use may also $e de#
pressed $elow availa$ility levels $ecause of a variety of $ar#
riers that interfere with the adoption of contraceptives&
Finally" we merged data for three yearsI(*12" (*1* and
(**+Ito study the movement toward an even method mi%
as overall access improves AFigure 2B& In countries with poor
overall availa$ility Aon the lefthand side of the @gureB" the
pill and the condom dominate6 in countries with $etter ac#
cess Aon the rightB" the methods have similar shares cen#
tered on 223& Total prevalence is higher in such countries"
as couples with differing needs are a$le to @nd a satisfac#
tory method and continue its use&
DI4C,44I5< 0<D =C5))=<D0TI5<4
The freedom to choose from a range of contraceptive meth#
ods" according to oneFs needs and preferences" rests part#
ly on the sheer availa$ility of those methods& Jhile it is cer#
tainly true that family opposition" fear" cost and uncongenial
supply sources also affect choice" our data show that the
availa$ility of methods and the prevalence of their use are
intimately related& In general" the prevalence of use of each
method follows its availa$ility" the mean prevalence of all
methods follows mean availa$ility and total prevalence fol#
lows the availa$ility of several methods that are each easi#
ly availa$le&
Intermediate mean levels of availa$ility and prevalence
sometimes hide im$alances in the method mi%& The same
mean can re@ect either unevenness or uniformity" with only
two methods dominating Aas in ChinaB or with a mi% of sev#
eral methods Aas in ThailandB& The very highest means" how#
ever" reDuire uniformly high levels of availa$ility for every
method involved" the optimum situation for full freedom
of choice for individual couples&
0n e%amination of availa$ility data over time suggests
an historical trend in program development that countries
usually do not improve access to all methods at the same
time& ather" they tend to improve access to one or two meth#
ods and only later attend to the others: 0t low average lev#
els of availa$ility" supply methods Apills and condomsB are
most readily availa$le6 as the average level of availa$ility
Contraceptive )ethod Choice in Developing Countries
LThe prevalence of every method can increase in the general population
even during a shift in the shares of use& The changing shares re@ect only
the relative growth rates among the methods&
-
&-2
&(-
&(2
&2-
&22
&3-
&32
&+-
/- +-E2* 2-E3* -E(*
Proportion
Condom
Pill
I,D
4terili!ation
FIK,= 2& Proportion of total contraceptive prevalence
accounted for $y each method" $y mean level of availa$ility
<ote: Galues shown are averages of (*12" (*1* and (**+ data&
)ean level of availa$ility A3B

3* Golume 21" <um$er (" )arch 2--2
=4,)=<
Contexto:
Para -#e todas las ersonas #edan disfr#tar del #so
del anticoncetivo de s# elecci.n, se de&e tener a disosici.n #na
a*lia /a*a de *0todos' !odav1a las *edidas de acceso re%
sentan serias li*itaciones -#e li*itan el #so de cada *0todo'
Los a1ses di2eren tanto con resecto al n3*ero de *0todos -#e
se ofrecen co*o la disoni&ilidad de cada #no' Se necesita in%
for*aci.n acerca de la for*a en -#e estos factores han ca*&ia%
do a trav0s del tie*o y so&re la *anera en -#e han afectado el
#so de anticoncetivos en /eneral y de al/#nos en artic#lar'
Mtodos:
Las a#tas de #so de anticoncetivos se deter*inan
en &ase a los datos o&tenidos en las enc#estas nacionales y los
niveles de acceso a c#atro *0todos 4esterili(aci.n fe*enina, el
5I6, la 1ldora y el cond.n7 son *edidos de ac#erdo con el or%
centaje esti*ado de arejas ara las c#ales cada *0todo se en%
contra&a disoni&le en 89:;, 89:9, 899< y 8999' El an=lisis
se centra en la relaci.n -#e e>iste entre el acceso a los anticon%
cetivos y las a#tas de #so'
Resultados:
En los c#atro ciclos del est#dio de esf#er(o del ro%
/ra*a, la revalencia *edia de los c#atro *0todos a#*enta
de ac#erdo con el ro*edio de acceso' Por eje*lo, la reva%
lencia *edia en 899< y 8999 f#e de cerca del 8;? en los a1ses
donde el acceso era *#y &ajo, en co*araci.n con el <<? en
a-#ellos -#e ofrec1an #n acceso elevado' La revalencia re%
sent. s# *=s alto nivel en los a1ses donde el acceso a todos los
*0todos era #nifor*e*ente elevado' En 899<, or eje*lo, la
revalencia *edia f#e del 8;? en a1ses donde la disoni&ili%
dad *edia era elevada ero la diversidad en la disoni&ilidad
de deter*inados *0todos era &aja, en co*araci.n con #na
revalencia del 9? en los a1ses donde la disoni&ilidad *edia
era elevada y el acceso a deter*inados *0todos varia&a consi%
dera&le*ente' Entre 89:; y 899<, el n3*ero de a1ses con #n
acceso elevado #nifor*e a#*ent. de n#eve a ;@, en tanto -#e
el n3*ero con acceso #nifor*e*ente &ajo dis*in#y. de ;@ a
n#eve' En los *=s &ajos niveles de disoni&ilidad *edia, el con%
d.n y la 1ldora contri&#yeron en *ayor *edida a la disoni%
&ilidad 4<A? y @B?, resectiva*ente7, a#n-#e al *=s eleva%
do nivel, las contri&#ciones de los c#atro *0todos se i/#alaron
en ;;C;D? cada #no' La sit#aci.n con resecto a la revalen%
cia es si*ilarE el orcentaje -#e le corresonde a la 1ldora al
*=s &ajo nivel es del BD?, en co*araci.n con el @8? al *=s
alto nivel, donde lo s#era la esterili(aci.n fe*enina 4@B?7'
Conclusiones:
En *#chos a1ses a3n no se ha lo/rado dis%
oner de #na a*lia /a*a de anticoncetivos' Esta carencia
restrin/e el acceso ersonal a cada *0todo, as1 co*o el #so de
anticoncetivos en /eneral' Hasta el #nto -#e la osi&ilidad
de otar or #na rotecci.n anticoncetiva satisfactoria deende
del f=cil acceso a *0todos *3ltiles, e>iste #n claro *andato
de restar #na *ayor atenci.n ro/ra*=tica a contar con #na
a*lia /a*a de *0todos'
P4,)P
Contexte:
Po#r -#e chac#n #isse &0n02cier dF#n choi> dFo%
tions contracetives, #ne /a**e de *0thodes doit Gtre ais0*ent
accessi&le' Les *es#res dFaccHs d0*ontrent ceendant de /raves
lac#nes, a# d0tri*ent de la rati-#e de cha-#e *0thode' Le
no*&re de *0thodes roos0es et la *es#re de le#r disoni&i%
rises" access to the I,D and female sterili!ation increases&
Jhile concentrating on one or two methods may $e sim#
pler administratively at the start and provide couples with
early access to at least something" it also restricts full choice
in the middle phase of program development&
The large difference $etween method availa$ility and use
in low#prevalence countries indicates that other factors act
as $ra@es on use& This suggests a continuing need to e%#
amine nonaccess $arriers" encompassing the whole range
of implicit and e%plicit policies& These o$stacles
(3
include
e%cessive medical $arriers" unneeded eligi$ility criteria" poor
pu$lic information" and lac@ of training or $iases among
program staff regarding certain methods& In some cases"
an entrenched program su$culture limits clientsF choices
to only one or two favored methods" leaving unserved the
persons for whom these methods do not wor@& Clearly" pu$#
lic policy needs to address not only the variety of contra#
ceptive methods that are present in the environment" $ut
also the many $arriers that impede their use&
=F==<C=4
1. ,nited <ations Population Fund A,<FP0B"
Pro/ra**e of ,ction ,dot%
ed at the International Conference on Po#lation and 5evelo*ent, Cairo,
<ew ?or@: ,<FP0" (**/" p& 23&
2. ;ohnson ;T et al&" Contraceptive method mi%: what determines pro#
gram and individual user perspectivesQ paper presented at the annu#
al meeting of the Population 0ssociation of 0merica" )inneapolis" )<"
,40" )ay 3E2" (*1+6 4now C and Chen CC" Towards an appropriate
contraceptive method mi%: policy analyses in three 0sian countries"
Jor@ing Paper <o& 2" Cam$ridge" )0" ,40: 8arvard ,niversity Cen#
ter for Population and Development 4tudies" (**(6 and Jorld 8ealth
5rgani!ation AJ85B"
Contracetive )ethod )i>E $#idelines for Policy
and Service 5elivery,
Keneva: J85" (**+&
3. oss ;0 and )auldin JP" Family planning programs: efforts and re#
sults" (*.2E*+"
St#dies in "a*ily Plannin/,
(**/" 2.A3B:(3.E(+.&
4. oss ;0" 4tover ; and Jillard 0"
Profiles for "a*ily Plannin/ and
Rerod#ctive Health Pro/ra*sE 88B Co#ntries,
Klaston$ury" CT" ,40:
Futures Kroup International" (***" p& /*&
5. Freedman and 9erelson 9" The record of family planning programs"
St#dies in "a*ily Plannin/,
(*./" .A(B:(E+-&
6. Phillips ;F et al&" Determinants of reproductive change in a traditional
society: evidence from )atla$" 9angladesh"
St#dies in "a*ily Plannin/,
(*11" (*A/B:3(3E33+6 and Phillips ;F et al&" 0 case study of contracep#
tive introduction: domiciliary depot medro%yprogesterone acetate ser#
vices in rural 9angladesh" in: 4egal 4;" Tsui 05 and ogers 4)" eds&"
5e*o/rahic and Pro/ra**atic Conse-#ences of Contracetive Innova%
tions,
<ew ?or@: Plenum Press" (*1*" pp& 22.E2+1&
7. ;ain 07" Fertility reduction and the Duality of family planning ser#
vices"
St#dies in "a*ily Plannin/,
(*1*" 2-A(B:(E(/&
8. oss ;0 and 4tover ;" The family planning program effort inde%: (***
cycle"
International "a*ily Plannin/ Persectives,
2--(" 2.A3B:((*E(2*&
9. ,nited <ations"
Levels and !rends of Contracetive 6se as ,ssessed in
899:,
4TR=40R4=&0R(*-" <ew ?or@: ,nited <ations" 2---" p& (+-&
10. I$id&
11. Curtis 4C and <eit!el 7"
Contracetive Knowled/e, 6se, and So#rces,
D84 Comparative 4tudies" Calverton" )D" ,40: )acro International"
(**/" <o& (*&
12. oss ;0 and 4tover ;" 2--(" op& cit& Asee reference 1B&
13. ,padhyay ,D" Informed choice in family planning: helping peo#
ple decide"
Po#lation Reorts,
4eries ;" <o& 2-" 2--(&


Deadline: November ! "##
+- International Family Planning Perspectives
lit0 diffHrent dF#n ays I lFa#tre' LF0vol#tion de ces facte#rs a#
2l d# te*s et le#rs effets s#r la contracetion en /0n0ral et s#r
la rati-#e de *0thodes individ#elles doivent Gtre doc#*ent0s'
Mthodes:
Les tendances de la rati-#e contracetive sont d0%
riv0es des donn0es dFen-#Gtes nationales, et les nivea#> dFaccHs
I -#atre *0thodes 4la st0rilisation f0*inine, le st0rilet, la i%
l#le et le r0servatif7 sont *es#r0s ar esti*ation de la ro%
ortion des co#les o#r les-#els cha-#e *0thode est disoni&le,
I co*ter de 89:;, 89:9, 899< et 8999' LFanalyse se concentre
s#r le raort entre lFaccHs a#> contracetifs et les tendances
dF#sa/e'
Rsultats:
,#> -#atre cycles de lF0t#de dFeffort ro/ra**a%
ti-#e, la r0valence *oyenne des -#atre *0thodes a#/*ente
en *G*e te*s -#e lFaccHs *oyen' ,insi, la r0valence, en 899<
et 8999, 0tait roche de 8;? dans les ays caract0ris0s ar #n
accHs trHs li*it0, ar raort I <<? dans ce#> offrant #n accHs
trHs 0lev0' La r0valence atteint les l#s ha#t nivea#> dans les
ays oJ lFaccHs I to#tes les *0thodes est #nifor*0*ent 0lev0'
En 899<, ar e>e*le, la r0valence *oyenne 0tait de 8;? dans
les ays I disoni&ilit0 *oyenne 0lev0e et fai&le diversit0 de *0%
thodes individ#elles, ar raort I 9? dans ce#> oJ la diso%
ni&ilit0 *oyenne 0tait 0lev0e *ais oJ lFaccHs a#> *0thodes in%
divid#elles 0tait lar/e*ent varia&le' Entre 89:; et 899<, le
no*&re de ays offrant #n accHs #nifor*0*ent 0lev0 est ass0
de ne#f I ;@, tandis -#e le no*&re de ce#> r0sentant #n accHs
#nifor*0*ent fai&le &aissait, de ;@ I ne#f' ,# l#s fai&le ni%
vea# de disoni&ilit0 *oyenne, le r0servatif et la il#le contri%
&#ent le l#s I la disoni&ilit0 4<A? et @B?, resective*ent7,
*ais a# nivea# s#0rie#r, la contri&#tion des -#atre *0thodes
sF0/alise, entre ;; et ;D? chac#ne' On o&serve #ne sit#ation
se*&la&le o#r la r0valenceE la art de la il#le a# l#s fai&le
nivea# de disoni&ilit0 est de BD?, ar raort I @8? a# l#s
ha#t nivea#, oJ la st0rilisation f0*inine la s#rasse 4@B?7'
Conclusions:
LFoffre dF#n choi> co*let de contracetifs va%
ri0s nFest as encore atteinte dans de no*&re#> ays' Cette a&%
sence li*ite lFaccHs ersonnel I cha-#e *0thode a#ssi &ien -#e
la rati-#e /lo&ale des *0thodes a# sein de la o#lation' 5ans
la *es#re oJ la caacit0 de choisir #ne rotection contrace%
tive satisfaisante d0end dF#n accHs ais0 I #ne *#ltilicit0 de
*0thodes, les ro/ra**es se doivent claire*ent dFaccorder #ne
l#s /rande attention I la fo#rnit#re dF#ne /a**e co*lHte
de *0thodes'
Ac$no%ledgments
!his research was cond#cted #nder the POLICY I and POLICY II
rojects of !he "#t#res $ro# International, f#nded &y the 6'S'
,/ency for International 5evelo*ent, contract HRK%C%AA%AA%
AAAAB%AA' !he a#thors are /ratef#l to Lillia* L' Linfrey for sta%
tistical advice and than2 Ratha Lo/anathan for assistance with the
data analysis'
Author contact:
j'rossMtf/i'co*
Contraceptive )ethod Choice in Developing Countries
The legal status of a$ortion varies widely around the world" $ut health care providers in all
countries share a need for information on treatment for complications from spontaneous or
induced a$ortion& In response to this need" the 4eptem$er 2--3 issue of International Family
Planning Perspectives will include a special section on posta$ortion care as part of the :ournalFs
Issues in Perspective' series& Je are see@ing papers on provision of posta$ortion care6 integration
of family planning counseling and services with posta$ortion care6 the technology" training and
costs involved in initiating services6 Duality of care6 and access issues& Je will consider commen#
taries as well as Dualitative and Duantitative research&
To $e eligi$le for the special section" papers should $e no more than 3"--- words and must $e
received $y <ovem$er (" 2--2& 0uthors should follow the :ournalFs style" as detailed in the Kuide#
lines for 0uthors" which can $e found in this issue and on our Je$ site" www&guttmacher&orgR
guidelines&
Please send su$missions to Patricia Donovan" =ditor in Chief" International Family Planning Per#
spectives" The 0lan Kuttmacher Institute" (2- Jall 4treet" <ew ?or@" <? (---2& Suestions a$out the
special section should $e addressed to Patricia Donovan at pdonovanTguttmacher&org&
C ALL FOR PAPERS