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Family Planning and Contraception

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Suchira Suranga Indralal De Silva

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Chapter 9
Family Planning and
Contraception
M. Suchira Suranga, W. Indralal De Silva & Malith Kumarasinghe

9.1 Introduction

Contraception can be defined as the deliberate use of artificial methods or other techniques to prevent
pregnancy as a consequence of sexual intercourse. The major forms of artificial contraception are: natural
methods such as withdrawal or standard days method, barrier methods, of which the commonest is the
condom or sheath; the contraceptive pill, which contains synthetic sex hormones which prevent ovulation
in the female; long acting and reversible methods such as implants and intrauterine devices, which prevent
the fertilized ovum from implanting in the uterus; and male or female sterilization (Oxford Dictionary,
2017). Use of contraceptive methods in the context of planning a family is referred to as family planning.
Use of contraceptive methods by unmarried women or girls is not normally considered as family planning.
Family planning allows people to attain their desired number of children and determine the spacing of
pregnancies. It is achieved through use of contraceptive methods and the treatment of infertility (World
Health Organization, 2018).

Globally, there are 1.8 billion adolescents and youth, composing 25 per cent of the world’s population
(United Nations Population Fund, 2014). While many adolescents and youth choose to delay sexual
initiation, a significant number is sexually active and want to prevent or delay a pregnancy for multiple
years - until finishing school, gaining employment, getting married, or to space their children. At the same
time, one third of girls in developing countries are married or in union before the age of 18 (United Nations
Population Fund, 2012).

Global efforts to prevent unintended pregnancies and improve pregnancy spacing among adolescents and
youth will reduce maternal and infant morbidity and mortality, decrease rates of unsafe abortion, reduce
HIV/STI incidence, improve nutritional status, keep girls in school, improve economic opportunities, and
contribute towards reaching the Sustainable Development Goals. Paragraph 7.44 of the ICPD1 Program of
Action urged governments to address adolescent sexual and reproductive health issues, including unwanted
pregnancy, unsafe abortion, and sexually transmitted infection including HIV/ AIDS. It also called for the
reduction in adolescent pregnancies (Silva, 2015).

This chapter discusses the knowledge, attitudes and practices of Sri Lankan women with special focus to
female youth in relation to the use and practice of contraception.

1 International Conference on Population and Development which happened in Cairo in 1994, diverse views on human rights, population,
sexual and reproductive health, gender equality and sustainable development merged into a remarkable global consensus that placed
individual dignity and human rights, including the right to plan one’s family, at the very heart of development.

Chapter 9 161
Family Planning and Contraception
9.2 Current status and evolution of family planning in Sri Lanka

Family planning efforts in Sri Lanka date back to the 1950s, with The Government formally launched the
the establishment of the Family Planning Association; the pioneer family planning programme in 1965. Well
organization in the field of Family Planning in Sri Lanka. The first before the Program of Action under the
state run family planning clinic was opened in 1937, however, it International Conference on Population
was discontinued. A survey conducted in 1958 by the Government and Development was initiated, family
of Sri Lanka, with the support of the Government of Sweden, planning was integrated into maternal
revealed that there was no religious opposition to family planning and child health programme of the
and a high latent demand existed for contraception among married Ministry of Health in Sri Lanka.
couples (De Silva, 1996). These findings, coupled with rising
rates of youth unemployment due to the population increase, led
the Government to formally launch the family planning programme in 1965. Even 30 years before ICPD,
this programme was integrated into the maternal and child health programme of the Ministry of Health
(World Health Organization, 2017). In 1968, the Family Health Bureau (FHB) was established to coordinate
family planning under the Ministry of Health. Table 9.1 demonstrates the trend in contraceptive use among
currently married women from 1975 to 2016.

Table 9.1: Trends in current contraceptive use among currently married women, 1975 to 2016

Contraceptive Methods Percentage of currently married women currently using contraceptives

WFS CPS DHS DHS DHS DHS DHS
19752 19822 19871 19931 20001 2006/071 20162
All Modern Methods 20.2 31.9 40.6 43.7 49.5 53.1 53.6
All Traditional Methods 14.2 26.0 21.1 22.4 20.5 17.0 11.0
All Methods (CPR) 34.4 57.8 61.7 66.1 70.0 70.2 64.6
Notes: - WFS – World Fertility Survey; CPS – Contraceptive Prevalence Survey; DHS- Demographic and Health Survey.
1
Northern and Eastern provinces were excluded; 2All provinces are included.
Source: Various sources of Department of Census and Statistics

Almost 5 per cent of the pregnancies in 2016 were reported among

The review of the national family
teenage mothers (less than 20 years). However, the number and
planning programme conducted in
percentage of teenage pregnancies reported in the country shows
2016 pointed out that a considerable
a declining trend from 6 per cent in 2012 to 4.8 per cent in 2016.
proportion of unmarried young persons
Recent information reveals that the sub national disparities in Sri Lanka are sexually active. The
of teenage pregnancies are higher in Sri Lanka ranging from National Youth Health Survey 2012/2013
8.6 per cent in Trincomalee to 2.6 per cent in Mannar (Family found that around 15 per cent of
Health Bureau, 2018a). The results of latest demographic and respondents declared they had sexual
health surveys show that 3.0 per cent of ever married women intercourse during the preceding year,
begun childbearing in their teen ages (Department of Census and of them 5.3 per cent were unmarried.
Statistics, 2009). It is important to note that this is a significant
decline compared to percentage of teenage married women (6.2 per cent) reported in 2006 (Department of
Census and Statistics, 2009). The national family planning programme review conducted in 2016 pointed
out that a considerable proportion of unmarried young persons in Sri Lanka are sexually active. The National
Youth Health Survey 2012/2013 found that around 15 per cent of respondents declared they had sexual
intercourse during the preceding year, of them 5.3 per cent were unmarried (Family Health Bureau, 2015;
2017). A Needs Assessment Survey on Sexual and Reproductive Health for youth in Technical and Vocational
Education and Training Sector in Sri Lanka in 2015 showed that one third of the respondents aged 15-29
had engaged in sexual intercourse (Family Health Bureau, 2017). This situation is further complicated with
irregularities within the legal system of Sri Lanka as reported in a newspaper evidencing that 50 registrars
had been interdicted for falsifying marriage registers and solemnizing under age marriages (De Silva, 2006).

Studies have highlighted the existence of “child marriage” in which either male or female partner is under-
aged i.e., less than 18 years of age. These unions are either legal in some ethnic groups and in others they are
considered as “living together”. A study on “Lost Childhoods in War: Addressing early marriage as a human
rights violation in war-affected districts of Sri Lanka” conducted by the Centre for Equality and Justice

162 Sri Lankan Youth : sexual and reproductive health

Profile, Knowledge, Attitudes, Behaviour & Vulnerability
in 10 districts including Jaffna, Kilinochchi, Mannar, Mullaitivu and Vavuniya in the Northern Province;
Ampara, Batticaloa and Trincomalee in the Eastern Province; and Anuradhapura and Polonnaruwa in the
North Central Province shed insight on some of the issues of unmarried youth “in union” in these districts.
Female youth were more at risk to marrying young with 21 per cent of young females married below the
age of 15 years, whereas only 11.1 per cent of male youth went into marriage. In the age-group of 16-18
years, it was 78.4 per cent and 55.5 per cent of females and males respectively who got into these marriages
were underage. Furthermore, among these underage marriages, sexual intercourse commence early in the
relationship with 19.5 per cent of the couples were ‘living together’ at the age of 15 years which significantly
increased to 70.2 per cent by the age of 17 (Center for Equity & Justice, 2019

9.3 Family planning - 2020 commitments

As an outcome of the 2012 London Summit on Family Planning, Family Planning-2020 (FP 2020)
commitments were formulated and accepted. FP 2020 is based on the principle that all women, no matter
where they live, should have access to lifesaving contraceptives. Achieving the FP 2020 goal is a critical
milestone for ensuring universal access to sexual and reproductive health services and rights by 2030, as laid
out in Sustainable Development Goals 3 and 5. FP 2020 is in support of the UN Secretary-General’s Global
Strategy for health of Women, Children and Adolescent. FP 2020 works with governments, civil society,
multilateral organizations, donors, the private sector, and the research and development community to
enable 120 million more women and girls to use contraceptives by 2020 (FP 2020, 2017).

Sri Lanka became a new FP 2020 commitment making country in July 2018. In Sri Lanka, the Family
Planning Program has been integrated into maternal and child health services since the 1960s. A national
family planning strategy is being developed to improve family planning programs and to address newly
emerging issues and challenges. Government of Sri Lanka commits to include a budget-line for reproductive
health in 2019 and to engage the education sector to address the accessibility of adolescents and youth to
family planning services and information. Recognizing that the causes of maternal mortality are associated
with the unmet need for family planning, Sri Lanka commits to promoting rights-based family planning,
increasing service delivery points, capacity building of health workforce, and strengthening postpartum and
post abortion care, with a goal to increase modern contraceptive prevalence rate (mCPR) from 53.6 per cent
to 57.2 per cent by 2025 (FP 2020, 2018; Sugathadasa, 2018). At the programmatic level, the government
of Sri Lanka committed to particularly focus on special groups such as teenagers, women in higher age
groups, working female etc. Further, the government committed to make service delivery points youth
friendly to ensure availability of temporary methods to youth (Sugathadasa, 2018). Table 9.2 represent
FP 2020 targets with baseline values captured from 2016 DHS survey (Sugathadasa, 2018; Department of
Census and Statistics, 2017).

Table 9.2: Sri Lanka’s national targets for 2025 in comparison with 2016 achievements

No Indicator DHS 2016 FP 2020 targets for 2025

01 Percentage of ever married women with unmet need for family 7.5 per cent 5.7 per cent
planning
02 Contraceptive Prevalence Rate (CPR) 64.6 per cent 66.4 per cent
03 Prevalence Rate of Modern Methods (mCPR) 53.6 per cent 57.2 per cent
04 Percentage of eligible families who have their need for family 74.2 per cent 79.0 per cent
planning satisfied with modern methods
Source: Adopted from Family Planning 2020; Sri Lanka Commitment Pledge.

Since the premarital and extramarital sexual activities are highly stigmatized in the Sri Lankan society, data
on the use of contraception among unmarried young people is not widely available and gathering such data
in desired quality is extremely difficult.

Chapter 9 163
Family Planning and Contraception
9.4 Currently married youth and adult women

9.4.1 Knowledge on family planning

One of the key determinants to increase the use of contraceptive methods is knowledge on available methods
of contraception in the country. As per the findings of recent demographic and health survey, almost all ever
married and currently married women of 15-19 age group knew at least a single contraceptive/ modern
contraceptive method and on average nine methods were known by the respondents. The most widely
known modern methods are injectables and pills. Among the currently married women in reproductive
ages, only 4 per cent of women did not know of female sterilization as a family planning method and
33 per cent were not familiar with male sterilization. There was no significant difference in the level of
knowledge among married young people (age below 25) and married adults (Department of Census and
Statistics, 2017). However, currently married youth of 15-19 years exhibited in excess of 3 percentage
point reduction in knowledge of contraceptive with regards to awareness of at least a single contraceptive/
modern contraceptive method compared to currently married women of reproductive age (96.4 vs. 99.7 per
cent). These results do not exhibit a significant difference from the results of previous DHS held in 2006/07
(Department of Census and Statistics, 2009).

Table 9.3: Currently married women aged 15-49 who received a family planning message from radio,
television, newspaper or internet by age group: Comparison of data from DHS 2006/07* and 2016

New-paper /
Radio Television Internet None of these
Magazine
Age
DHS DHS DHS DHS DHS DHS DHS DHS DHS DHS
2006/07 2016 2006/07 2016 2006/07 2016 2006/07 2016 2006/07 2016

15-19 35.0 16.4 46.4 25.6 36.4 26.6 n.a. 5.2 40.0 58.9
20-24 32.2 21.3 52.4 40.9 36.7 35.6 n.a. 6.7 35.8 45.7
15-24 33.5 21.1 52.5 39.8 37.5 35.2 n.a. 6.7 37.5 48.8
25-29 33.7 24.2 54 45.9 38.1 40.6 n.a. 11.2 34.6 41.4
30-34 32.5 25.3 52.7 45.5 36.0 39.8 n.a. 9.6 37.0 43.1
35-39 32.3 24.1 46.7 43.1 32.8 37.8 n.a. 5.6 41.9 45.9
40-44 29.1 24.0 44.7 41.0 29.9 35.5 n.a. 4.6 45.2 49.2
45-49 26.9 21.6 41.0 37.5 26.0 32.0 n.a. 2.7 50.7 53.9
25-49 30.9 23.9 47.8 42.6 32.5 37.1 n.a. 6.6 41.9 46.8
All 31.1 23.6 48.1 42.2 33.0 36.9 n.a. 6.6 41.3 46.8
Note: *In DHS 2006/07, Northern province was excluded.
Source: Department of Census and Statistics, 2006/07 & 2016/17. Data for age group 15-24 and 25-49 were calculated by the author using
available data in the report. DHS 2006/07 has not gathered data on the usage of internet.

Family planning clinics are the primary source of primarily provide

key information for women visiting them. The field health workers There is a reduction of access to
also inform married women on family planning. However, we family planning messages from young
cannot ignore the role of mass media in building knowledge of married women (and all married
general public on family planning. Table 9.3 describes percentages women in general) from 2006/07 to
of currently married women aged 15-49 who received a family 2016. This may be a reflection of the
fall of contraceptive prevalence rate
planning message on radio, television or in a newspaper or
(CPR) in Sri Lanka from 2006/07 to
internet by age group. As per the results of 2016 DHS, the most
2016. However, there is no significant
common media for family planning messages for young married
difference in access to family planning
women is the television (40 per cent), followed by newspaper / messages among youth, married women
magazine (35 per cent) and radio (21 per cent). Internet has not and adult married women.
played yet a critical role in creating awareness on family planning
among young married women in Sri Lanka. Almost half of the
young married women (49 per cent) have not received any family
planning related message from any of those sources.

164 Sri Lankan Youth : sexual and reproductive health

Profile, Knowledge, Attitudes, Behaviour & Vulnerability
As described in figure 9.1 there is a reduction of access to family planning messages among young married
women (and all married women in general) from 2006/07 to 2016. This may be reflected in the reduction
of contraceptive prevalence rate (CPR) in Sri Lanka from 2006/07 to 2016. Overall, there is no significant
difference in access to family planning messages among youth, married women and adult married women
(Department of Census and Statistics, 2009; 2017).

Figure 9.1: Access to family planning messages through different sources by youth and adult married
women in 2006/07 and 2016*
60%

50%

40%
15-24
30%
25-49
20%

10%

0%
DHS DHS DHS DHS DHS DHS DHS DHS DHS DHS
2006 2016 2006 2016 2006 2016 2006 2016 2006 2016
Radio Television News-paper/ Internet None of these
Magazine four media
sources
Note: *In DHS 2006/07, Northern province was excluded.
Source: Department of Census and Statistics, 2009; 2017.

9.4.2 Practice of contraception

As per the results of recent demographic and health survey (2016),
The contraceptive prevalence rate
the median age at first marriage is 24 years. Contraceptive behavior
(CPR) and the modern contraceptive
of married young women is expected to be different from unmarried
prevalence (mCPR) rate of the young
sexually active girls. As described in table 9.4, the contraceptive
married women is significantly
prevalence rate (CPR) and the modern contraceptive prevalence lower than the general contraceptive
(mCPR) rate of the young married women is significantly prevalence rate and the modern
lower than general contraceptive prevalence rate and modern contraceptive prevalence rate of Sri
contraceptive prevalence rate of Sri Lanka (Department of Census Lanka. This pattern is common in both
and Statistics, 2017). This observed pattern common in both 2006/07 and 2016 DHS surveys. These
2006/07 and 2016 DHS surveys. These results suggest restrictions results suggest restrictions to access
to access contraceptive services for young people even they are contraceptive services for young people
married compared to their older counterparts. Unexpectedly, CPR even they are married compared to their
of married women of 15-49 has reduced significantly from 2006 older counterparts.
to 2016 (68.4 vs 64.6 per cent). In the contrary, mCPR of married
women of 15-49 has increased slightly during the decade between
the surveys (52.5 vs 53.6 per cent). This pattern of mCPR was reversed among female youth (15- 24 yrs.)
with reported rates of 44.9 vs 37.5 per cent and 50.2 vs 47.8 per cent for 15-19 and 20-24 age groups
respectively. Interestingly, 2006 survey excluded the Northern Province. When the Northern Province is
excluded in 2016 survey, the CPR rate increased to 65.5 per cent. For modern methods (mCPR), it was 54.1
per cent. However, CPR is still lower in 2016 compared with 2006 survey despite the exclusion of Northern
province (68.4 vs 65.5 per cent).

Chapter 9 165
Family Planning and Contraception
 Table 9.4: Percentage of currently married women aged 15-49 currently using contraceptives;
comparison of DHS 2006/07* and 2016

Any contraceptive
Any traditional method Any Modern Method Number of women
method
Age
DHS DHS DHS DHS DHS DHS DHS DHS
2006/07 2016 2006/07 2016 2006/07 2016 2006/07 2016
15-19 53.7 43.5 8.9 6.0 44.9 37.5 314 225
20-24 58.6 56.0 8.4 8.2 50.2 47.8 1,332 1,373
15-24 57.7 54.2 8.5 7.9 49.2 46.3 1,646 1,598
25-29 64.2 58.6 10.7 7.2 53.4 51.3 2,356 2,559
30-34 69.8 63.6 13.3 9.7 56.6 54.0 2,549 3,481
35-39 74.4 71.1 18.4 10.9 56.0 60.2 2,589 3,757
40-44 75.5 72.0 22.2 14.6 53.3 57.4 2,456 3,033
45-49 64.3 60.6 20.2 14.3 44.1 46.3 2,152 2,851
25-49 69.9 65.7 16.9 11.4 53.0 54.3 12,102 15,659
All 68.4 64.6 15.9 11.0 52.5 53.6 13,748 17,257
Note:*In DHS 2006/07, Northern Province was excluded.
Source: Department of Census and Statistics, 2009; 2017. Data for age group 15-24 and 25-49 were calculated by using available data in the report.

Figure 9.2: Contraceptive prevalence rate and modern contraceptive prevalence rate of currently
married youth and adult women in 2006/07* and 2016
80%

70%

60%

50% 15-24
40%
25-49
30%

20%

10%

0%
DHS 2006 DHS 2016 DHS 2006 DHS 2016 DHS 2006 DHS 2016
Any contrceptive method Any modern method Any traditional method

Note: *In DHS 2006/07, Northern Province was excluded.

Source: Department of Census and Statistics, 2009; 2017.

Around 8 per cent of married young women were using traditional

methods in 2016 which was not significantly different from the The most common modern method of
findings of previous DHS survey (2006/07). Percentages of contraception among young married
married young women who are using traditional methods were women is injectable (12 per cent),
significantly lower than their adult counterparts (De Silva 1994). followed by implant (10 per cent),
IUD (9 per cent) and OCP (9 per cent).
As illustrated in table 9.5, the most common modern method of
Less than 5 per cent of married young
contraception among young married women is injectable (12 per
women use male condoms which is the
cent), followed by implant (10 per cent), IUD (9 per cent) and
only contraceptive method with dual
OCP (9 per cent). Less than 5 per cent of married young women protection. Percentages of married
are using male condoms which is the only contraceptive method young women who use traditional
with dual protection (Department of Census and Statistics, 2017). methods were significantly lower than
Young (15-24) married women are using Implant, injectable and their adult counterparts.
OCP than their adult (25-49) counterparts. Sterilization, IUD and

166 Sri Lankan Youth : sexual and reproductive health

Profile, Knowledge, Attitudes, Behaviour & Vulnerability
condoms are more common methods among adult married women (Department of Census and Statistics,
2017). As illustrated in figure 9.3, percentages of young married women who are using implants, IUD and
male condoms have increased from 2006/07 to 2016. The highest increase from less than 01 per cent in
2006/07 to 10 per cent in 2016 is seen in implant as a method of contraception, an increase of more than
10 folds.

Comparatively, percentages of young married women (15-24) who are using injectable and male condoms
show a reduction during the past decade. Use of injectables recorded a remarkable reduction from 26 per
cent in 2006 to 12 per cent in 2016 (Department of Census and Statistics, 2009; 2017). This may be due
to the shift of preference from injectables to 5 year implant (Jadelle), extensive media coverage of death of
a woman following injectables due to severe reactions and unavailability due to shortages despite for brief
time periods.

There are some incidences where young women, especially the married young women have used OCP for
self-poisoning. In a retrospective hospital-based study conducted from 2011 to 2014 it was revealed that
fifty-four patients (52 women and two men) admitted with an overdose of OCP as a means of intentional self-
poisoning to one of the two hospitals surveyed. The median age of the patients was 19 with the interquartile
range of 5 years. Information available for a subset of female patients indicated that many cases (13 of
23, or 56.5 per cent) were in their first year of marriage. The author concludes that although the toxicity
of OCPs is low and the public health significance of OCP poisoning remains minor, reproductive health
service providers should be attentive to OCP overdose, monitor the development of this problem, and ensure
appropriate information to OCP users (Weerasinghe and others, 2016).

Table 9.5: Use of modern contraceptive methods by currently married women aged 15-49, comparison of
DHS 2006/07* and 2016

Age Male Condoms OCP Injectable Implants IUD

DHS DHS DHS DHS DHS DHS DHS DHS DHS DHS
2006/07 2016 2006/07 2016 2006/07 2016 2006/07 2016 2006/07 2016

15-19 3.4 2.7 12.4 9.2 23.5 8.2 0.3 14.0 5.2 3.4
20-24 4.5 5.0 11.2 9.3 27.1 12.9 0.7 9.4 6.5 10.4
15-24 4.3 4.7 11.4 9.3 26.4 12.2 0.6 10.0 6.3 9.4
25-29 6.9 8.9 9.5 10.1 25.9 12.8 0.4 7.2 7.7 10.9
30-34 7.7 8.4 11.4 10.6 20.1 1.09 0.5 5.9 8.4 11.2
35-39 6.6 7.5 9.3 9.5 11.7 9.2 0.3 4.1 7.7 13.3
40-44 5.2 6.5 5.2 7.4 5.9 6.1 0.1 2.2 5.9 10.4
45-49 2.4 4.9 2.1 4.4 1.7 2.0 0.0 0.7 2.1 6.9
25-49 5.9 7.3 7.7 8.5 13.3 6.1 0.3 4.0 6.5 10.7
All 5.7 7.0 8.1 8.6 14.8 8.6 0.3 4.6 6.5 10.6
Note: *In DHS 2006/07, Northern Province was excluded.
Source: Department of Census and Statistics, 2009; 2017. Data for age group 15-24 and 25-49 were calculated by using available data in the report.

Chapter 9 167
Family Planning and Contraception
Figure 9.3: Type of modern contraceptive methods used by currently married young and adult women in
2006/07 and 2016
30%

25%

20%
15-24
15%
25-49

10%

5%

0%
DHS DHS DHS DHS DHS DHS DHS DHS DHS DHS
2006 2016 2006 2016 2006 2016 2006 2016 2006 2016
Injectable OCP Implants IUD Condoms
Note: In DHS 2006/07, Northern Province was excluded. Source: Department of Census and Statistics, 2009; 2017.

In 1988, the Sri Lankan government imposed restrictions on the minimum age at which a woman can
undergo sterilization. Before 1988, a significant proportion of women who underwent the sterilization
procedure were either under 25 years of age or had two children with the second child being very young.
Following the introduction of the new guidelines, a woman under age 26 can get sterilized only if she has
a minimum of 3 living children and her spouse insists on a sterilization. Those who are over 26 years of
age should have at least two living children, the youngest of whom should be over two years of age. Hence,
after 1988, sterilization is not considered as a common contraceptive method among young people. With
reference to 2016 DHS survey, only 16.7 Per cent of women underwent sterilization before the age of 25
(Department of Census and Statistics, 2009). As expectedly, this percentage was further reduced to 7.4 per
cent by 2016. The median age of sterilization in 2016 was 32.2 years. Out of the women who had sterilized
before 25 years of age the majority has performed the procedure before 10 years (Department of Census
and Statistics, 2017).

9.4.3 Unmet need for family planning

Proportion of women (1) who are not pregnant and not postpartum amenorrhoeic, are considered fecund,
and want to postpone their next birth for 02 more years or stop childbearing altogether but are not using
a contraceptive method OR (2) those have a mistimed or unwanted current pregnancy, OR (3) who are
postpartum amenorrhoeic and their last birth in the last 2 years was mistimed or unwanted are considered
as unmet need for family planning.

Almost 13 per cent of currently married young women was recorded as having unmet need for family
planning. This is a significantly high proportion compared to the unmet need for family planning in Sri
Lanka (7.5 per cent) (Department of Census and Statistics, 2017). As described in table 9.6, the unmet
need for family planning is higher among young (age 15-24) married women compared to their adult
counterparts. However, as expected unmet need for limiting number of children is higher among adults
than young married women (Department of Census and Statistics, 2009; 2017). It is important to note that
in line with the reduction of CPR, unmet need for family planning has increased during the past decade.
(Figure 9.4)

However, the sub national disparity for unmet need in family planning is apparent ranging from 2 per cent
in Kilinochchi to 9.7 per cent in Vavuniya (Family Health Bureau, 2018a). In a context where unmet need for
family planning is recognized as an attributing factor of maternal mortality, it is well documented that the
reduction or stagnation of the unmet need becomes a priority policy concern (Silva, 2015).

168 Sri Lankan Youth : sexual and reproductive health

Profile, Knowledge, Attitudes, Behaviour & Vulnerability
 Table 9.6: Percentage of women who were identified as unmet need for family, comparison of DHS
2006/07* and 2016

Unmet need for family Unmet need for family Total unmet need for
Number of women
planning for spacing planning for limiting family planning
Age
DHS DHS DHS DHS DHS DHS DHS DHS
2006/07 2016 2006/07 2016 2006/07 2016 2006/07 2016

15-19 12.9 19.3 1.0 2.1 13.9 21.4 314 225

20-24 9.7 9.6 1.7 1.5 11.4 11.2 1,332 1,373
15-24 10.3 11.0 1.6 1.6 11.9 12.6 1,646 1,598
25-29 6.8 6.7 2.4 3.3 9.2 9.9 2,356 2,559
30-34 3.3 3.4 3.4 5.3 6.7 8.7 2,549 3,481
35-39 2.1 1.4 6.1 5.6 8.2 7.1 2,589 3,757
40-44 0.5 0.5 4.7 4.9 5.3 5.4 2,456 3,033
45-49 0.1 0.2 3.7 3.7 3.9 3.9 2,152 2,851
25-49 2.0 2.3 3.2 4.7 5.2 7.0 12,102 15,659
All 3.5 3.1 3.8 4.4 7.3 7.5 13,748 17,257
Note: *In DHS 2006/07, Northern Province was excluded.
Source: Department of Census and Statistics, 2009; 2017. Data for age group 15-24 and 25-49 were calculated by using available data in the report.

Figure 9.4: Unmet need for family planning among youth and adult married women,
a comparison of DHS 2006/07* and 2016.
14%

12%

10%

8% 15-24

6% 25-49

4%

2%

0%
DHS 2006 DHS 2016 DHS 2006 DHS 2016 DHS 2006 DHS 2016
Unmet need for family Unmet need for family Total unmet need for
planning for limiting planning for specing family planning

Note: *In DHS 2006/07, Northern Province was excluded.

Source: Department of Census and Statistics, 2009; 2017.

The results from the demographic and health survey 2016 indicate that a large majority of non-users of
contraception (86 per cent) have not discussed family planning matters with a field worker or during a visit
to a health facility. The age breakdown indicates that 82 per cent and 78 per cent of ever married youth in
15-19 and 20-24 age groups respectively did not discuss the family planning related matters either with a
field worker or at a health facility (Department of Census and Statistics, 2016).

Chapter 9 169
Family Planning and Contraception
9.5 Practice of contraception by unmarried adolescents

South Asian cultural norms promotes entering to nuptial bonds at an early age. For many years, the
average age of entry into marriage in Sri Lanka was more than 25 years and 28 years for women and
men respectively (De Silva and others , 2010). The gap between puberty and marriage had widened in the
last century, prolonging sexual activity and sexual behaviour before marriage. In 1901, the age of puberty
was 14 years while the age of marriage was 18. In 2000 this was 12 years (age of puberty) and 26 years
(age of marriage). The four-year gap had increased to 12 years (De Silva , 2015). However, the age at first
marriage has reduced up to 24 years in 2016, still the girls in Sri Lanka do not marry at the puberty but a
decade later (Department of Census and Statistics, 2017). While the risk-taking period has expanded, the
safety net provided by families/relatives who protect young girls is fragmented. Socio-economic changes in
a conservative culture has resulted in premarital sexual interactions being more acceptable; opposition to
sexual activity from all sectors including the family/authorities are weakening. Pre-marital sexual behaviour
without proper awareness about reproductive health can result in unwanted pregnancies and induced
abortions. In conclusion, the age at first marriage and age at first sexual intercourse may not necessarily
occur at the same time. The age at which women initiate sexual intercourse usually marks the beginning of
their exposure to risk of pregnancy. However, DHS-2016 does not show a significant difference between the
age at first marriage and age at first sexual intercourse (23.7 years) (Department of Census and Statistics,
2017).

In the present study, a 17 year old male Muslim student from Hambantota revealed following experience on
use of contraception by a fellow school going male adolescent.

“I heard about male condoms and its use from my friend for the first time. He told me that he
had sexual intercourse with his girlfriend, and he was 100 per cent sure that his girlfriend would
not get pregnant. I asked him how he was so sure. He replied that he used condoms and then he
described how to use them” (Findings of Focus Group Discussion).

In a study conducted among school going adolescents in the Badulla district; out of the adolescents who had
the experience of sexual intercourse, among male adolescents, only 60 per cent reported using a contraceptive
method at first sexual intercourse whereas the same was lower among females at 56.7 per cent. However,
among male respondents, all had used contraceptive methods at least once in their life while it was still low
among female school going adolescents with less than 60 per cent (Figure 9.5). As respondents were school
going unmarried adolescents these findings are cause for concern. However, specific information on wider
representation of school going youth in Sri Lanka is required as above study was limited to Badulla district.
(Rajapaksa-Hewageegana, 2010).

Figure 9.5: Use of contraceptives by school going adolescents with experience

of sexual intercourse in Badulla district
100%
90%

80%

70% Used onthe first

Sexual intercourse
60%
Had ever used
50%
a method
40%

30%

20%

10%
0%
Male Female
Source: Rajapaksa-Hewageegana, 2010.

170 Sri Lankan Youth : sexual and reproductive health

Profile, Knowledge, Attitudes, Behaviour & Vulnerability
Same study revealed that among school going adolescents, knowledge on contraception was very poor. Only
9.8 per cent of male adolescents were able to name correctly a method of contraception whereas among
female adolescents the rate was 11.7 per cent out of 2020 respondents (Rajapaksa-Hewageegana, 2010).

9.6 Knowledge and use of emergency contraception

Emergency Contraception (EC) is a method of preventing pregnancy following either an unprotected sexual
intercourse or if concerns exists about possible contraceptive failure or after incorrect use of contraceptives
or following sexual assault if without contraception coverage. It can prevent up to over 95 per cent of
pregnancies when taken within 5 days after intercourse. Methods of emergency contraception are the copper-
bearing intrauterine devices (IUDs) and the emergency contraceptive pills (ECPs). Emergency Contraceptive
pills (ECP) have been available for more than 30 years globally, and for more than 10 years in Sri Lanka.
ECP is not a family planning method. It can be taken to prevent pregnancy within 72 hours of unprotected
sexual intercourse (Byamugisha and others, 2006).

In September 1997, the Sri Lanka Consortium, coordinated by the Family Planning Association of Sri Lanka
(FPASL), initiated a project to make a dedicated emergency contraception product (Postinor-2) available
through pharmacists, general practitioners, youth groups, and community health workers. After Consortium
members met with local regulatory authorities, Postinor-2 received final approval in April 1998 for sale in
both the private and public sectors. By 2001, FPASL reported sales of 120,109 packages of Postinor-2, an 80
per cent increase over the previous year’s sales. Over 800 pharmacies were selling Postinor-2 (International
Consortium for Emergency Contraception, 2006). As per the latest information available in International
Consortium for Emergency Contraception web site, by 2012 more than 1 million ECP distributed by the IPPF
outlets per year (International Consortium for Emergency Contraception, 2016). This information highlight
that the use of emergency contraception has increased almost by 10 times during the first decade after
introduction. As per the latest data available in the FPASL website 401,124 CYP (Couple Years of Protection)
generated in 2018 of which 27.0 per cent of CYP was generated from EC (The Family Planning Association
of Sri Lanka, 2018). When factored this figure with USAID standard CYP conversion factor for ECP (20
doses per CYP), it can be estimated that FPASL has distributed more than 2 million ECP in 2018 (USAID,
2011). Again, the volume has doubled within the five years of 2013-2018. Population Service Lanka (PSL)
also sell two emergency contraceptive brands called EMCON and FEMNYL but the volume considered to be
relatively low.

Apart from above stated NGOs, other private sector pharmaceutical companies are also engaged in selling
emergency contraceptives (International Consortium for Emergency Contraception, 2016). The National
Family Planning Programme Review conducted in 2016 revealed that the Emergency contraceptive pills
(ECP) are currently only available through the private and NGO sector (Family Planning Association of Sri
Lanka and Population Service Lanka). Though the government also introduced the ECP into the national
programme there was no demand from clients and ECP is no longer available through the national programme
(Family Health Bureau, 2017). Therefore, public sector contribution for emergency contraception assumed
to be negligible. In summary, it can be assumed that around 3 million Emergency Contraceptive Pills are
used by the women in Sri Lanka annually.

The level of knowledge on emergency contraception among married women is remarkably low compared to
that of the routine knowledge on contraception. It is important to highlight that only half (53.7 per cent) of
currently married women have heard of emergency contraceptive pills (Department of Census and Statistics,
2017). This is a significant increase in the level of knowledge on emergency contraception from 2006 DHS
which concluded that only 34.5 per cent currently married women are aware of emergency contraceptives
(Department of Census and Statistics, 2009). However, according to some unrecorded data, ECP known to
be a popular and is used as a routine contraceptive method in Sri Lanka. Even though, ECP is very popular
in the community setting, malpractices and misconceptions still remain.

Research evidence and data on the use of emergency contraception among young people in Sri Lanka is
very limited. Numerous barriers exist which prevent planning and conducting such studies. Demographic
and Health Surveys conducted in 2006/07 and before did not gathered data on the use of emergency
contraceptives (Department of Census and Statistics, 2009). As per the DHS-2016 only 0.3 per cent of
married women between 20 and 24 of age were currently using emergency contraception. There were no
records on the use of emergency contraception among teenage (15-19) married women (Department of
Census and Statistics, 2017). This may be due to under reporting when considered the nature of EC behavior
and current trend in sales of Emergency Contraceptives. However, it is important to note that proportion of

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young married women (20-24) who are currently using emergency contraceptives (0.3 per cent) is higher
than the proportion of same among adults married women (0.1 per cent). In reality, the number of young
married women who have ever used an ECP would be much higher.

Data on the use of emergency contraceptives among unmarried youth is limited but it is assumed to be
higher than among the married youth based on available data. According to the National Youth Health
Survey 2012/2013, almost one tenth (9 per cent) of sexually active youth or their partners had used ECP
during the preceding month (Family Health Bureau, 2015). During a focus group discussion of the national
family planning review (2016), a pharmacist in Colombo district expressed that “Our sales of ECP are the
highest on the Valentine’s day. It’s the children going to international schools who come and buy them”. In
the same study an unmarried woman (age 20-29 years) in the Monaragala district had complained that “the
pharmacy asks for a prescription to give Postinor”.

Findings of the Focus Group Discussions of the current study among unmarried youth provided following
qualitative evidences on the use of Postinor by school students. “I have some idea of Postinor as well… I got
to know of Postinor by one of friends. This is the same female friend who helped me to start my affair. She
used to massage me through Messenger app whenever she is down… following fight with her boyfriend…
Once… when she was in grade 13, she massaged me saying she had sexual intercourse with her boyfriend
who was 5 years older than her. She said she took 2 pills after that named “Postinor” which prevented her
getting pregnant. A 18 year Sinhalese male school going adolescent in the Hambantota district stated that
some pharmacies refuse to provide emergency contraceptive pills to adolescents without any valid proof
that they are above 18 years. “Some of my friends told me that pharmacies in the town sometimes ask for
the identity card before issuing Postinor” (Findings of the Focus Group Discussions of the current study).”

Further, the national family planning programme review report (2016) pointed out that the knowledge about
ECP was poor, especially among unmarried women (Family Health Bureau, 2017). As per the findings of the
national youth health survey, 45 per cent of the respondents (85 per cent of them are unmarried) had heard
of emergency contraceptive pills. However, a significant variability was observed between estate, Northern
and Eastern provinces’ youth who were reporting a significantly lower level of awareness compared with
urban and rural youth. Of the school going youth, around one third (35 per cent) have heard about ECP.
The majority of the respondents (71 per cent) were unaware of the time interval within which ECP should
be taken after a sexual act. However, the married youth had a significantly higher knowledge of the time
interval compared to the unmarried that the ECP should be taken after sex.

Confirming the findings of the national youth survey (2016), in a study conducted among 395 undergraduate
students in the Kothalawala Defense University in Sri Lanka, only 69.1 per cent had heard of ECP. Most of
the students, 42.5 per cent knew that more effective way to take ECP was soon after the unprotected sexual
intercourse. Majority of the students, 57.5 per cent, has not received information regarding side effects or
problems that might result-in from ECP. Around one fifth (20.2 per cent) of the respondents were of the view
that it was important as a preferred contraceptive method. Around 13.4 per cent has stated that ECP might
prevent STI’s and HIV. Among the total participants, only 25 (6.5 per cent) had used ECP (Boteju and others,
2016). Another community-based study conducted among 267 girls and residents in the Colombo city of Sri
Lanka reveals that only 40 per cent of the respondents had correct knowledge on emergency contraception
(Suranga and others, 2016). A public seminar presentation on access to Sexual & Reproductive Health
(SRH) information and counselling to youth via Information communication tools in the Happy Life Contact
Centre of FPA Sri Lanka revealed that the majority of the young people (31 per cent of 1083) has contacted
the center through telephone in 2015 to receive information on Emergency Contraceptives. Most of the
clients who had requested information on ECP were recorded as boys who were aged below 25 years
(Tissera and others, 2016).

9.7 Family planning services for adolescents and youth

Health services for adolescents are not a discrete entity in Sri Lanka. A person below 12 years of age is entitled
to outpatient and in-ward care in paediatric services while those above 12 years have to seek these services
as for adults. This may be due to the common perception that adolescents are healthy and the overwhelming
focus on the mother and child in the orientation and establishment of sexual and reproductive health
services. Nevertheless, in recent years, more attention was paid for adolescent health with the establishment

172 Sri Lankan Youth : sexual and reproductive health

Profile, Knowledge, Attitudes, Behaviour & Vulnerability
of separate Adolescent Health Unit at Family Health Bureau in addition to the services provided by Young,
Elderly, Disabled and Displaced Unit in Ministry of Health. Furthermore, Sri Lanka have a School Health
Promotion Policy and School Health unit at Family Health Bureau conducts school health inspections at
Years 1, 4 and 7 and collaborates closely with the Health Unit of the Ministry of Education in the delivery of
the Life Skills Program. The Life skills Programme in Government secondary schools is the vehicle through
which inputs on sexual health are expected to be provided to students (Silva, 2015). The recently released
National Youth Policy of Sri Lanka 2014 by the Ministry of Youth Affairs and Skills Development is heavily
orientated to the role of youth in development and its focus on the health of youth is relatively low. It
acknowledge the importance of integrating comprehensive sexuality education (CSE) into school curricula
(Ministry of Youth Affairs and Skill Development, 2014). In reality, however, teachers are reluctant to discuss
these topics in the classroom due to cultural inhibitions (Silva, 2015).

While there are no judiciary restrictions for mechanism to restrict adolescents from accessing the desired
sexual and reproductive health services, many barriers exist, including the behaviour and attitudes of the
adolescents themselves and that of the service providers. The situation of unmarried and married adolescents
differs significantly, yet both groups are neglected when it comes to reproductive health services (De Silva,
1998). Sri Lanka national strategic master plan on health (2016-2025) recognizes the importance of youth
friendly health services to young people. It proposed to combine underutilized clinics operated in hospitals
with youth friendly services (Ministry of Health, 2015).

Going forward, the Family Health Bureau recently developed the standards for quality health services for
adolescents and youth in Sri Lanka which include 08 quality standards of youth friendly services (Family
Health Bureau, 2018c). Adolescent and Youth Friendly Health Service (AYFHS) concept was introduced in
Sri Lanka in 2005. Although around 50 AYFHS centers were established by late 2008, there were only nine
AYFHS centers functioning by 2015. Meanwhile “Youth” component was incorporated into the family health
programme of the Family Health Bureau in the latter half of 2015. Following that, revamping of the AYFHS
was initiated under the concept of “Yowun Piyasa” with three models; as hospital based, MOH office based
and separate independent youth centers. The newly developed “Yowun Piyasa” protocol acknowledges the
requirement for availability of pregnancy test strips, Condoms and other temporary contraceptive items such
as Oral Contraceptive Pills and injectables along with Emergency Contraceptive Pills (Family Health Bureau,
2018b).

Research on use of contraception by adolescents and young people has been identified as one of the
priority areas that would contribute for the improvement of SRH of adolescent and young people. Given
the current momentum for family planning, it is even more critical to streamline research and prioritize
reaching adolescents with high quality contraceptive services. Researchers should focus on filling existing
gaps, including testing programs that expand the method mix for adolescents and figuring out what works
to reach vulnerable populations (Gottschalk & Ortayli, 2014).

Acknowledgement

Authors’ gratitude to Mr. Duminda Rajakaruna and Ranjith de Silva for their supports and efforts for
improvement of the paper.

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