University of Southampton Research Repository Eprints Soton

University of Southampton Research Repository Eprints Soton

University of Southampton Research Repository ePrints Soton Copyright © and Moral Rights for this thesis are retained by the author and/or other copyright owners. A copy can be downloaded for personal non-commercial research or study, without prior permission or charge. This thesis cannot be reproduced or quoted extensively from without first obtaining permission in writing from the copyright holder/s. The content must not be changed in any way or sold commercially in any format or medium without the formal permission of the copyright holders. When referring to this work, full bibliographic details including the author, title, awarding institution and date of the thesis must be given e.g. AUTHOR (year of submission) "Full thesis title", University of Southampton, name of the University School or Department, PhD Thesis, pagination http://eprints.soton.ac.uk UNIVERSITY OF SOUTHAMPTON Faculty of Social and Human Sciences School of Social Sciences NATURAL CONTRACEPTIVE USE IN A MODERN POPULATION: CORRELATES, FERTILITY TIMING AND EFFICACY AMONG USERS IN MOLDOVA Mark James Lyons-Amos Thesis for the degree of Doctor of Philosophy April 2012 i Abstract This thesis investigates the dynamics of natural contraceptive method use in a low fertility setting in contemporary Eastern Europe. Natural contraception was one of the key drivers of European fertility transition and still accounts for a large proportion of current method use in the developing world as well as in the Eastern Europe. Nonetheless, little systematic research on natural method use exists in contemporary demographic literature. This thesis focuses on the post-Socialist republic of Moldova- the poorest country in Europe. The Moldovan contraceptive regime, as observed elsewhere in Eastern Europe, is characterised by limited uptake of modern contraception and widespread use of induced abortion. Under the Moldovan Socialist government, social pressures including the requirement of children to obtain housing led to an almost homogenous pattern of early low fertility. In examining natural method use in the Moldova, this thesis addresses not only the limited understanding of natural method use in contemporary societies, but also contributes to unravelling the potential interaction between contraception and abortion in a low fertility setting. The main aims of this thesis are to: (i) provide a quantitative evaluation of the dynamics of natural contraceptive use in a low fertility setting and (ii) explore the changing fertility situation in Moldova. These aims are accomplished using data from the first ever Demographic and Health Survey (DHS) conducted in Moldova during 2005. The thesis comprises four research chapters as well as an introduction and conclusion. The introduction chapter examines the significance of natural methods in historical and contemporary societies, and provides context on the Moldovan demographic and socio-economic context. The second chapter examines the factors influencing the use of natural contraceptive methods. Specifically, the effect of economic hardship on the persistence of natural contraceptive use is examined. The analysis also evaluates the impact of FP programmes designed to reduce reliance on natural methods at a regional level. It contributes direct policy relevance by improving understanding of the efficacy of reproductive health interventions. In particular, the ii chapter identifies an impact of uneven coverage of health infrastructure on contraceptive choice and switching patterns. The second and third chapters evaluate the fertility timing patterns associated with natural method use – specifically the effect of contraceptive confidence on the interval between marriage and first birth and all subsequent birth intervals. These analyses also expand the understanding of contraceptive confidence by examining the interaction between natural method use and induced abortion. The fourth chapter tests the hypothesis that natural method use is in fact less effective than modern method use. This is pertinent to the peculiar demographic situation in Moldova, where low fertility occurs concurrently with a high prevalence of natural method use. The analysis evaluates the determinants of contraceptive discontinuation using the contraceptive histories recorded in the DHS contraceptive calendar. Key results are the high failure rates of natural contraceptives, and the high propensity of modern reversible method users to abandon use- hence exposing them to unwanted pregnancy. The final chapter summarises the key findings from each paper and addresses the policy implications as well as limitations of the thesis. Areas for future research are also identified. iii Table of contents Chapter 1: Introduction …………... 1 1.1 Motivation and research problem …………... 1 1.2 Research objectives …………... 2 1.3 Research questions …………... 3 1.4 Natural contraception in historical and contemporary societies …………... 4 1.5 The Moldovan demographic and socioeconomic context …………... 6 1.6 Policy relevance …………... 11 1.7 Structure of the thesis …………... 12 …………... 14 Chapter 2: The correlates of natural method use in Moldova 2.1 Aims and introduction …………... 15 2.2 Conceptual framework and research hypotheses …………... 19 2.2.1 The effect of economic disadvantage …………... 20 2.2.2 The effect of Moldovan FP programmes – NPRH and NPAIDS …………... 22 2.2.3 Confounding factors: demographic effects and the desire and ability to have children …………... 24 2.2.4 Contraceptive network effects …………... 26 2.3 Analysis sample …………... 27 2.4 Variable operationalization …………... 30 2.4.1 Response variable …………... 30 2.4.2 Measurement of market cost barriers …………... 31 2.4.3 Measurement of FP impact; variables measuring the effect of NPRH and NPAIDS …………... 36 2.4.4 Confounding factors …………... 37 2.4.5 Data limitations …………... 40 2.5 Methodology …………... 43 2.5.1 Regression model …………... 43 2.5.2 Modelling strategy …………... 44 2.6 Results and interpretation …………... 46 2.6.1 Descriptive results …………... 46 2.6.2 Results from regression modelling …………... 51 2.7 Conclusion, evaluation and policy recommendations …………... 75 iv Chapter 3: Contraceptive confidence and the timing of first birth in transitional Moldova …………… 79 3.1 Introduction and motivation …………... 80 3.2 Theoretical motivation and research hypotheses …………... 81 3.2.1 The effect of contraceptive confidence on birth timings …………... 82 3.2.2 The role of induced abortion in Moldovan fertility control regime …………... 82 3.2.3 Temporal effects: crisis and adjustment …………... 84 3.3 Data …………... 86 3.3.1 Moldovan Demographic and Health Survey …………... 86 3.3.2 Analysis sample …………... 87 3.4 Definition of explanatory variables …………... 88 3.4.1 Contraceptive confidence: Current contraceptive method …………... 88 3.4.2 Propensity to use induced abortion …………... 89 3.4.3 Temporal effects …………... 90 3.4.4 Control variables …………... 92 3.5 Methodology …………... 93 3.5.1 Piecewise constant hazard model …………... 93 3.5.2 Modelling strategy …………... 95 3.6 Results …………... 96 3.6.1 Descriptive analysis …………... 96 3.6.2 Regression modelling results …………... 104 3.7 Summary and conclusions …………... 124 Chapter 4: The effect of contraceptive confidence on inter-birth intervals in a setting with high levels of induced abortion ………………. 129 4.1: Introduction ………………. 130 4.2: Theoretical motivation and research hypotheses …………... 131 4.2.1 he effect of contraceptive confidence on birth timings …………... 131 4.2.2 The role of induced abortion in the Moldovan fertility control regime …………... 136 4.3 Data …………... 138 4.4 Explanatory variables …………... 141 4.4.1 Current contraceptive method …………... 141 4.4.2 Abortion ratio …………... 142 4.4.3 Control variables …………... 143 4.5 Methodology …………... 145 4.5.1 Regression model …………... 145 4.5.2 Model selection strategy …………... 147 4.6 Results …………... 148 4.6.1 …………... 148 v 4.6.2 Regression analysis …………... 156 4.7 Summary and discussion …………... 178 Chapter 5: Evaluating natural contraceptive failure and contraceptive discontinuation in Moldova …………... 181 5.1 Introduction …………... 182 5.2 Background and Research hypotheses …………... 183 5.2.1 Effectiveness of natural method use: an historical review …………... 185 5.2.2 Evidence for ineffective modern method use …………... 187 5.3 Data …………... 190 5.3.1 Contraceptive calendar data in the MDHS …………... 190 5.3.2 Analysis sample …………... 194 5.4 Explanatory variables …………... 195 5.4.1 Contraceptive type …………... 195 5.4.2 Controls for proximate determinants of fertility …………... 196 5.4.3 Socio-economic controls …………... 198 5.5 Methodology …………... 202 5.5.1 Regression model …………... 202 5.5.2 Modelling strategy …………... 204 5.6 Results …………... 206 5.6.1 Descriptive analysis …………... 206 5.6.2 Regression model …………... 211 5.6 Conclusions …………... 223 …………... Chapter 6: Conclusions …………... 226 6.1 Summary and research questions …………... 226 6.2 Further research …………... 229 6.3 Policy implications …………... 230 …………... References …………... 233 Appendix A: Correlation matrix and scoring factors for PCA of asset ownership …………... 241 Appendix B: Correlation matrix and scoring factors for PCA of FP media exposure …………... 242 Appendix C: Estimated hazard plots by previous method discontinued given a) modern reversible method use (moderate contraceptive confidence, b) non-use (unobserved), c) natural method use (low) and d) permanent method use (high) …………... 243 vi Appendix D: Estimated survival curves by previous method discontinued given a) modern reversible method use (moderate contraceptive confidence, b) non-use

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