C´ alculo de Secadores

Abstract

The Republic of Moldova exhibits a fertility rate below the replacement level, similar to the patterns observed in other Eastern-European post socialist countries. Natural method use is widespread in Moldova and is often associated with high failure rates and termination of pregnancies. This study evaluates contraceptive failure rates in Moldova to determine whether seemingly conflicting contraceptive use and fertility patterns could result from unusually effective traditional method use or from other influences such as high abortion rates. Data are drawn from the 5-year contraceptive calendar of the 2005 Moldovan Demographic and Health Survey, which provides monthly information on contraception, pregnancy, births and terminations. A multilevel competing hazard model is used to estimate the monthly probability of contraceptive failure, while accounting for contraceptive switching and

abandonment. The model compares contraceptive failure rates for natural and modern method users, while controlling for selected proximate determinants of fertility and relevant socio-economic variables. The model also accounts for repeated spells of contraceptive use and clustering of women within communities. There is a significantly higher hazard of contraceptive failure among natural method users when compared to modern reversible and modern clinical methods, which, in the case of Moldova, is often followed by the use of abortion. Users of modern

reversible methods exhibit a high hazard of contraceptive abandonment, suggesting the likelihood of subsequent abortion. The findings suggest that encouraging modern method use could reduce the likelihood of unwanted pregnancies and abortions in Moldova. It is imperative to develop policy strategies to dissuade women from using natural methods and monitor consistency in modern method use. Emphasis should be placed on improving access to modern methods and ensuring adequate quality of care in family planning delivery, and where appropriate educating and providing informed method choices to women and couples.

5.1 Introduction

Over the last 20 years Moldova has experienced low fertility levels. Following independence in 1991, Moldovan fertility fell significantly reaching a Total Fertility Rate (TFR) of 1.3 in 2000, representing the lowest fertility rate ever recorded in Moldova (NCPM and ORC Macro 2006). Since then fertility increased slightly to a TFR of 1.7 in 2005 - which is still below replacement level (NCPM and ORC Macro 2006). Moldova has a high proportion of traditional contraceptive method users: 24% of married women use natural contraceptives. Such methods, however, are generally assumed to be ineffective. For example, Trussell (2008) estimates that the Pearl index failure rate of coitus interruptus is in the region of 27 per 100 woman-years of use. The combination of low fertility and ineffective contraception is

demographically inconsistent. Theoretically, widespread use of ineffective contraception should be associated with a higher fertility rate.

Previous research shows that widespread natural contraceptive use can be effective in reducing population level fertility rates (Fisher and Szreter 2003, Szreter et al. 2003, Fisher 2000). Further, diligent use of natural methods can be more effective than the inconsistent use of modern contraceptives (Potter et al. 1996, Goldburg and Toros 1994). This study aims to evaluate contraceptive failure rates in Moldova to determine whether the low fertility rate could potentially result from unusually effective traditional method use. The theoretical motivation for this analysis is that if low fertility rates are explained by natural method use – after controlling for other proximate determinants then it is plausible that natural method use in Moldova is highly effective. Understanding the effectiveness of natural method use is important, as natural methods can potentially meet women’s reproductive health needs more effectively than modern methods (Gribble 2003). More generally, the study analyses the determinants of contraceptive method continuation, abandonment, switching and failure over time. The analysis contributes not only to a deeper understanding of the dynamics of natural contraceptive use but also to reformulating existing policy strategies.

High failure rates of natural methods can often lead to increased use of abortion (Agadjanian 2003, Sobotka 2003, Westoff 2000; 2005). This, in turn, can have serious maternal health implications. Westoff (2005) estimates that the abortion rate in Moldova could be reduced by 33% if natural method users switched to a modern method. Determining the correlates of method abandonment and switching will help to inform policy decisions on how best to focus family planning efforts to ensure that modern method use is maximised - a public health priority of the Moldovan

government (NCPM and ORC Macro 2006). In particular, there is a need for correctly orientating policy efforts in a country where family planning funding is reliant on limited financial resources and international aid (Comendant 2005).

A multilevel competing hazard model is used to estimate the monthly probability of contraceptive failure, while accounting for contraceptive switching and

abandonment. The model controls for proximate determinants of fertility (e.g. sexual activity, lactation, fecundity) and socio-economic variables (e.g. education,

ethnicity), as well as accounting for repeated spells of contraceptive use by some women and clustering of women within communities. Data are drawn from the 5- year contraceptive calendar of the 2005 Moldovan Demographic and Health Survey (MDHS), which provides monthly information on contraception, pregnancy, births and terminations.

The remainder of this paper is structured as follows. The research hypotheses are outlined in Section 5.2. The contraceptive calendar data and the analysis sample are described in Section 5.3. Important explanatory variables are outlined in Section 5.4. Section 5.5 considers the model employed in this analysis and the modelling

strategy. The results are presented in Section 5.6. The conclusions as well as implications for policy and practice are discussed in 5.7.

5.2 Background and Research hypotheses

Moldova exhibits a sub-replacement fertility rate - TFR 1.7 in 2005 (NCPM and ORC Macro 2006) - despite high use of natural methods and high prevalence of abortion

as observed elsewhere in eastern European countries (Sobotka 2003, Avdeev et al. 1995, Westoff 2005, 2000). Indeed, in the majority of post-Socialist countries,

fertility has been very low since the collapse of Soviet Union, due to macro-economic instability and rapid social change (Witte and Wagner 1995, Sobotka 2003). Before proceeding with a hypothesis linking contraceptive failure rates and fertility, it is worth examining the current low fertility situation in Moldova.

Fertility is determined by proximate determinants including prevalence of marriage, lactational amenorrhea, spontaneous abortion, durability of spermatozoa and ova, and fecundability (Bongaarts 1978). Variation in any of these determinants presents a potential explanation for low fertility in Moldova.

Marriage rates in Moldova are persistently high, and marriage remains an important prerequisite for fertility (Sobotka 2003, Anderson et al. 1994). It is therefore

implausible that low fertility could be caused by low rates of union formation as observed in northern European countries. Considering the role of lactational infecundability, only 31% of parity 1 women are aware that breastfeeding can prevent further births (author’s calculations from MDHS 2005 2005). Further, of those parity 1 women who gave birth within the past year, 59% report

discontinuation of breastfeeding before 6 months post-partum (author’s calculation, MDHS 2005). This suggests that the influence of lactational infecundability on

Moldovan fertility is likely to be small. The other proximate determinants of fertility (spontaneous abortion, durability of spermatozoa and ova, and fecundability) do not vary at a population levels (Bongaarts 1978) and cannot explain cross-national variation in fertility rates. Therefore, the most plausible explanations for low Moldovan fertility seem to be contraception or abortion use.

It is therefore necessary to determine how the observed TFR in Moldova compares with the expected value in the post-Socialist context, given the level of contraceptive use and abortion. If Moldovan fertility is unusually low after controlling for

contraceptive and abortion behaviour, this adds weight to the hypothesis that contraceptive use is unusually effective. Poisson regression was used to determine