Abstract
Although many studies have examined the influence of women's fertility preferences on subsequent fertility behavior and the role of contraceptive use intentions on unmet need, very few have explored their concurrent effects on contraceptive use dynamics. This study examines the independent concurrent effects of women's fertility preferences and contraceptive intentions on subsequent adoption and discontinuation, treating pregnancy as a competing risk factor that may alter contraceptive need. The data are derived from a 2018 follow-up survey of a 2014 national sample of 3,800 Ugandan female respondents of childbearing age. The survey included a contraceptive calendar that recorded pregnancy, birth, and contraceptive event episodes, including reasons for discontinuation. We use competing risk regression to estimate the effect of fertility preferences and contraceptive intentions on the cumulative incidence function of contraceptive behaviors, accounting for intervening pregnancy, female background covariates, loss to follow-up, and complex survey design. We find that women's contraceptive intentions significantly increase the rate of contraceptive adoption. After having adopted, women's contraceptive intentions have been realized and do not prolong use. The risk of discontinuation among women who adopted after baseline was significantly higher than for those using at baseline, irrespective of their initial intentions. The effectiveness of the type of contraceptive method chosen significantly lowered discontinuation risk. Fertility preferences were not significantly associated with either time to adoption or discontinuation. The pace of the fertility transition in this sub-Saharan African setting is likely being shaped by reproductive regulation through the intentional use of contraception that enables spacing births.
Highlights
The fertility preferences of women, as measured by their desired family size and intention to limit or delay childbearing, have been the subject of continuous study since the 1970s for their pred ictive validity of subsequent childbearing (Bankole and ELECTRONIC SUPPLEMENTARY MATERIAL The online version of this article contains supplementary material.Westoff 1998; Cleland et al 2020; Hayford and Agadjanian 2017; Morgan 1982; Vlassoff 1990; Westoff 1990; Westoff and Ryder 1977)
With transitions from high to low fertility nearly complete in all reg ions of the world outside of sub-Saharan Africa (SSA), research is increasingly foc used on understanding how fertility prefer ences are temporally related to the pace of fertility dec line, as either a determinant or a precursor (Bongaarts and Casterline 2018)
The authors speculated that the strength of the association is related to how well preferences are implemented by contraceptive use
Summary
In high-income countries, researchers have used data from national longitudinal surveys of women and men (e.g., Rackin and Morgan [2018] for the United States; Iacovou and Tavares [2011] for the United Kingdom) to study fertility expectations and their achievem ent across birth cohorts, but elsewhere such insights are constrained by a reliance on cross-sectional survey data (e.g., Westoff and Bankole 2002). A recent review of longitudinal studies of fer tility preferences and subsequent childbearing in Asia and Africa by Cleland et al (2020) found coverage of only 28 populations since 1967, many of them subnational (23), more of them in Asia (19) than in Africa (9), and taking place over intervals ranging from 2 to 12 years. The authors speculated that the strength of the association is related to how well preferences are implemented by contraceptive use
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