This paper discusses the family planning survey components of a multi-indicator cluster survey conducted in the Province of Samar in late 1998. The Samar survey was part of a national survey under the Local Government Unit Performance Program (LPP) of the Department of Health (DOH). LPP is a component of the Integrated Family Planning and Maternal Health Program (IFPMHP), a project assisted by the U.S. Agency for International Development (USAID). It aims to improve the health of the mothers and children through family planning and selected child survival interventions. The maternal and child health survey component is discussed in a separate paper.

The survey covered 62 barangay clusters in 24 municipalities and one city of Samar Province. The barangay clusters were randomly chosen using the probability proportionate to size (PPS) method. Fifteen women per cluster were chosen for a total of 930 respondents per indicator.

RESULTS AND DISCUSSION

This section discusses the family planning component of the Samar multi-indicator cluster survey, the data for which were derived from the Contraceptive Prevalence Questionnaire. The respondents were women of reproductive age (15-49 years old) regardless of marital status, pregnant or not, physically present, may have undergone unilateral salphingo-oophorectomy (surgical removal of one ovary and one fallopian tube, which still allows for pregnancy to occur), and a permanent resident of the area.

The data were presented in required output tables found in the field interviewer’s manual. Two other tables (Tables 3 and 4) were added to present data for related analysis and interpretation.

Table 1 presents the percentage of currently married women aged 15-49 years using modern contraceptive methods and traditional methods. By definition, "currently married women" in this study include both legally married women and those living with their men in consensual union. "Contraceptive method" or "family planning method," whichever term is conveniently used is the succeeding texts, both refer to any method used by the women to prevent or delay pregnancy and limit the number of their children.

The table shows country (Philippine) data derived from the 1995, 1996, and 1997 Family Surveys. For Samar, provincial data from the 1996 Family Planning Report were provided for comparison with the findings of this study.

The finding of this survey, which did not allow for multiple responses on the use of contraceptives among the currently married women, shows a total user rate of 38.1 percent for Samar Province. The figure on the use of modern methods for Samar (17.4 percent) is nearly half the national figure (30.9 percent) in the 1997 Family Planning Survey. Still, the provincial figure in this study shows an increase of 3.4 percentage points over the figure (14 percent) for the province in the 1996 Family Planning Report. An increase of 12 percentage points over the 1996 provincial figure was also noted for the use of traditional methods (i.e., 20.7 percent for 1998; 8.7 percent for 1996). Overall, the data show a 15.4 percentage points increment for the combined use of both modern and traditional methods in Samar between 1996 and 1998.

However, the comparative provincial data on contraceptive use in Samar might not mean a lot. Two related researches conducted in other provinces of Region VIII (the Leyte-Samar Region) over the past decade have shown that high rates of use of family planning methods did not often mean lower fertility and birth rates in the same area. A UNFPA-supported population, health and nutrition survey in Leyte in 1988 showed that a high rate of use of family planning methods and a high fertility rate among the mothers could in fact co-exist in the same study area (Abilar and Borrinaga; 1988). On the other extreme, a low rate of use of family planning methods could be found in an area with comparatively low fertility rate among the mothers.

Incidentally, similar data patterns in the above study also showed in the district level of this 1998 Samar LPP-MICS Study, as detailed in Annex "C". This annex contains municipal, district, and provincial data for the LGU Performance Program (LPP) coverage benchmarks for the province, as required by the specific objectives of this study.

A UNICEF-supported maternal and child health survey in Eastern Samar in 1994 (hereafter known as the 1994 Eastern Samar MCH Study) provides more recent, same-island data for comparison with the findings of the present study (Borrinaga; 1994). Eastern Samar data pertaining to the use of specific family planning methods (multiple responses) showed that 10.6 percent of the respondent mothers were using modern methods (pill, IUD, ligation, condom, injectable), while 24.9 percent were using traditional methods (withdrawal, rhythm, abstinence, etc.). The total user rate among the mothers was 34.8 percent.

However, the 1996 Family Planning Report also presented deflated family planning figures for Eastern Samar, which were in fact much lower than the figures from the 1994 Eastern Samar MCH Study. It shows that only 4.8 percent of the mothers were using modern methods and 14.1 percent were using traditional methods, for a total user rate of 18.9 percent. Yet there had been no major demographic events in Eastern Samar between 1994 and 1996 that could possibly explain the sudden drop in the use of family planning methods by 1996.

We do not know the reason for the great disparity between the provincial figures for family planning in the 1996 Family Planning Report and the comparable figures in the 1994 Eastern Samar MCH Study and this 1998 Samar LPP-MICS Study . What we know is that the studies in the two provinces of Samar Island, though separated by four years, have statistics that closely match each other. These include the 38.1 percent total user rate for family planning methods among currently married women in Samar and 34.8 percent total user rate in Eastern Samar, an average of 4.2 children per mother in Samar and 4.3 children per mother in Eastern Samar, and a similar average educational attainment - completed first year high school - among the respondent women in both provinces.

Table 2 presents the percentage of use of contraception by currently married women of reproductive age (15-49 years). Comparing with specific data about the use of modern methods from the 1994 Eastern Samar MCH Study (i.e., pill, 7.5 percent; IUD, one percent; ligation, one percent; injectable, 0.1 percent) show incremental increases in use of three methods in the present study (i.e., pill, 9.9 percent; ligation, 4 percent; injectable, 1.4 percent). The percentage reduction of IUD use in the present study (to just 0.2 percent) might have been caused by a shift to a more convenient method (i.e., injectable) among former IUD users. An addition to the modern methods category, lactational amenorrhea method (LAM), under which 1.5 percent of the respondents are classified, was not among the family planning methods monitored in previous studies.

Considering their limited number of users (162 or 17.4 percent) in this study, it is doubtful that the use of modern contraceptive methods had some impact on both fertility and birth rates in Samar among currently married women aged 15-49 years over the past few years. Indeed, as had been cited earlier, it seems not much change had happened in the family planning sector in the province over the past four years, if we use applicable findings from the 1994 Eastern Samar MCH Study as basis for comparison. The statistics for two critical variables of progress in family planning work - average number of children and average educational attainment of mothers - remain essentially the same.

Still, the succeeding analysis seeks to determine patterns and possibilities for the use of both modern and traditional family planning methods in the years ahead.

Table 3 presents the number and percentage of non-pregnant, currently married women according to their use/non-use of any method (i.e., contraceptives) to delay pregnancy and educational attainment. The data show that almost half (360 or 48.4 percent) of these women were users of a method to delay their pregnancy. More than three-fifths (94 or 61.4 percent) of college-educated women, nearly half (104 or 48.8 percent) of high-school-educated women, and more than two-fifths (162 or 43 percent) of elementary-educated women use a method to delay pregnancy. (Note: "Elementary-educated" in this report include the seven respondent women who are unschooled.)

The pattern presented by the data shows that educational attainment is an important independent variable of the tendency among mothers to use any method to delay pregnancy. Thus, mothers with higher educational attainment have greater tendency to use pregnancy-delaying methods than those mothers with lower educational attainment. The result of a chi-square test provides statistical proof of this thesis.

Table 4 presents the number of non-single women (currently married, living together with their men, separated, or widowed) according to educational attainment and average number of children. The data show that the non-single women in the Samar sample gave birth to an average of 4.2 children (ranging from 0 to 14 children). College-educated women gave birth to an average of 3.1 children, high-school-educated women gave birth to an average of 3.6 children, and elementary-educated women gave birth to an average of 5.0 children.

T-test results show significant differences in number of children among college-educated mothers and high-school-educated mothers, respectively, compared to elementary-educated mothers. There is no significant difference in average number of children between college-educated mothers and high-school-educated mothers.

Among the non-single women in the sample were 30 who did not bear children of their own, and two elementary-educated women who gave birth to 13 and 14 children, respectively. A total of 53 women (5.9 percent) gave birth to 10 or more children.

The pattern presented by the data also shows that educational attainment, rather than contraceptive use, is the more reliable predictor variable of the number of children that mothers would likely raise. Thus, mothers with higher educational attainment are likely to raise fewer children than those mothers with lower educational attainment, irrespective of their rates of contraceptive use.

For instance, using contraceptive prevalence rate as variable, high-school-educated mothers surpass the elementary-educated mothers by only 5.8 percentage points (48.8 percent versus 43 percent). But in terms of number of children, both groups are separated from each other by an average of 1.4 children per mother. In contrast, college-educated mothers surpass the high-school-educated mothers by as much as 12.6 percentage points (61.4 percent versus 48.8 percent) in terms of contraceptive use. But in terms of number of children, both groups are separated from each other by a mere average of 0.5 child per mother.

A challenge for health policy makers and administrators is to design and implement a relevant and appropriate front-line family planning programs that would effectively curb child-bearing, particularly among women with lower educational attainment. The elementary-educated women constitute almost half (455 or 48.9 percent) of the Samar sample.

Age Group	Method Mix (%)
	Pill	IUD	Injec- table	Con- dom	Female Steri- lization	Male Steri- lization	Dia- phragm/ Foam/ Jelly/ Cream	Mucus/ Billing/ Ovula- tion	Tempe- rature	LAM	Calendar/ Rhythm	With- drawal	Others
15 - 19 yrs.	-	-	-	-	-	-	-	-	-	-	-	0.8	-
20 - 24 yrs	20.6	-	15.4	-	-	100.0	-	-	-	28.6	13.6	16.0	11.1
25 - 29 yrs.	22.8	-	30.7	-	2.7	-	-	-	-	35.7	13.6	15.2	22.2
30 - 34 yrs.	28.3	100.0	15.4	100.0	29.7	-	-	100.0	-	14.3	28.8	21.6	33.3
35 - 39 yrs.	21.7	-	23.1	-	29.7	-	-	-	-	14.3	18.6	20.0	33.3
40 - 44 yrs.	4.3	-	15.4	-	29.7	-	-	-	-	7.1	15.2	22.4	-
45 - 49 yrs.	2.2	-	-	-	8.1	-	-	-	-	-	10.2	4.0	-
Total (15-49 yrs)	25.9	0.6	3.7	0.6	10.4	0.3	-	0.3	-	3.9	16.6	35.2	2.5

Table 5 presents the percentage on the method mix among currently married women using contraceptives aged 15-49 years by age group. The data show that withdrawal, a traditional method, is used by more than one-third (35.2 percent) of the women acceptors. The pill, a modern method, is used by one-fourth (25.9 percent) of them. Both withdrawal-users and pill-users already constitute three-fifths (61.1 percent) of the users of family planning methods.

Calendar/Rhythm/Periodic Abstinence are being used of by one-sixth (16.6 percent) of the acceptors, while one-tenth (10.4 percent) had undergone female sterilization (ligation). Taken together, only four methods - withdrawal, pill, calendar/rhythm/periodic abstinence, and female sterilization - are being used by most (88.1 percent) currently married women acceptors in this study.

The pattern under age groups shows virtually no users of modern methods in the 15-19 age group and few users of both modern and traditional methods in the 45-49 age group. The widest array of contraceptive methods (10 types) are availed of by women acceptors in the 30-34 age group, presumably the age range when many women become very much concerned about controlling their fertility .

The use of the pill rises and peaks in the 30-34 age group and declines abruptly in the higher age groups. The use of injectable shows a rise-and-fall wave pattern from the 20-24 age group to the 40-44 age group. And most of the women acceptors who had undergone female sterilization (ligation) belong to higher age groups starting at the 30-34 age group.

Nearly two-thirds (64.3 percent) of the women classified as using the lactational amenorrhea method (LAM) are lumped in the 20-24 and 25-29 age groups, probably the most active child-bearing years among the women. The use of calendar/rhythm/periodic abstinence and withdrawal methods rises and peaks in the 30-34 age group and gradually drops in the older age groups.

Table 6 presents the number of all women and currently married women by contraceptive use and five-year age group. Among the 875 currently married women, more than one-fourth (248 or 28.3 percent) were living with their men in consensual union (i.e., not legally married). The rest of the respondent women include 33 single women, 13 women separated from their husbands, and nine widows.

Table 7 presents the percentage for all women and currently married women by contraceptive use and five-year group itemized in the previous table. The pattern of the percentages for the use of any method by all women acceptors shows an abrupt rise in the 20-24 age group, which eventually peaks in the 40-44 age group and then abruptly drops in the 45-49 age group. Except for a slight dip in the 25-29 age group, the same pattern applies for the currently married women. This pattern suggests the continuing determination of the women, particularly from the 30-34 to the 40-44 age groups, to prevent new pregnancies until menopause catches up with them.

The pattern for currently married women (i.e., with a slight dip in the 25-29 age group) also characterizes the use of any traditional method by all women and currently married women. And as had been noted earlier, the widest array of methods (10 types) are availed of by the women in the 30-34 age group.

However, the same patterns noted above could not be sustained among users of any modern method. After reaching the peak in the 30-34 and 35-39 age groups, the use of any modern method abruptly drops in the older age groups.

The use of the pill is almost level (12+ percent) from the 20-24 age group to the 35-39 age group, but drops in the older age groups. Female sterilization (ligation) no longer seems popular among the younger women. Almost all ligated women in the sample are aged 30 and above. The potential acceptors of female sterilization might have shifted to the injectable, a more convenient method.

As for lactational amenorrhea method (LAM), this newly-recognized method is perhaps better known to the health workers than the respondent women themselves. It was the field interviewers who classified some respondent mothers as using LAM based on the qualification criteria provided in the field interviewer’s manual. Thus, a mother may be classified as using LAM if all three of the following conditions are true:

1. She has a baby less than six months old and
2. She is amenorrheic (not menstruating) and
3. She is breastfeeding the baby day and night without supplementation.

If at least one of the three conditions is not met, the mother cannot be classified as using LAM.

		Modern Method
Back- ground Charac- teristics	Any Method	Any Modern Method	Pill	IUD	Injec- tion	Con- dom	Female Steri- lization	Male Steri- lization	Mucus/ Bil- lings/ Ovu- lation	Tempe- rature	Lacta- tional Amenor- rhea Method	Any Tradi- tional Method	Not Using	Total
Total	38.1	17.4	9.9	0.2	1.4	0.2	4.0	0.1	0.1	-	1.5	20.7	55.9	100.0
Number of Children
None	-	-	-	-	-	-	-	-	-	-	-	-	100.0	100.0
1	28.2	14.6	10.7	-	-	-	1.0	1.0	-	-	1.9	13.6	71.8	100.0
2	46.8	19.4	11.5	-	-	0.7	3.6	-	-	-	3.6	27.3	53.2	100.0
3	38.9	20.8	11.1	-	2.8	0.7	4.8	-	-	-	1.4	18.1	61.1	100.0
4	49.6	27.4	14.5	0.8	2.6	-	7.7	-	0.8	-	0.8	22.2	50.4	100.0
5	48.5	20.2	10.1	1.0	1.0	-	7.1	-	-	-	1.0	28.3	51.5	100.0
6	51.4	20.0	14.3	-	1.4	-	2.9	-	-	-	1.4	31.4	48.6	100.0
7 or more	36.6	13.9	6.9	-	2.3	-	3.5	-	-	-	1.2	22.7	63.4	100.0

Table 8 presents the percentage of currentld women by modern contraceptive method used and number of children. There are no contraceptive users among women who do not have children.

The pattern presented by the data shows that, except for a significant dip in the three-children level, there is continuing increase of contraceptive use until the six-children level, when more than half (51.4 percent) of the mothers have become users. A spurt of contraceptive use every other two children is also noticeable in the data. This pattern suggests that the mothers tend to be watchful about any addition to every pair of children.

The use of any modern method rises in percentage and peaks in the four-children level, and then drops after the fourth child. The use of the pill is almost even, except for some rise in the four-children and six-children levels, respectively, which then abruptly drops at the seven-or-more-children level. The pill is also the most popular modern method among mothers with one or two children. This method allows the mothers flexibility to continue or discontinue its use, depending on whether they want another child or not.

The injectable is availed of by the acceptors starting at the three-children level.

Female sterilization was availed of by the acceptors right after the first child, with the peak after the fourth child. The fact that there is greater percentage of acceptance of female sterilization in the four-children and five-children levels, respectively, seems to indicate that the mothers in the study seek to limit their children to about these numbers.

Overall, the use of contraceptives among the mothers in the study drops abruptly after the sixth child. This finding is very critical, because two-fifths (40.3 percent) of the children (i.e., 1,161 out of 3,767) in the sample were born after the sixth child. For both health and economic reasons, extra efforts must be exerted to promote fertility control among those seemingly demoralized mothers who already have six children. This study has revealed their tendency to bear more children.

Table 9 presents the number and percentage of current contraceptive use by method and source of supply of service. The data show that more than four-fifths (83.9 percent) of the contraceptive users get their supply and service from the government public health system, a great majority of which from the poblacion-based Rural Health Unit. The pill is distributed mainly at the RHUs, although some mothers get their supply from the government hospital, the rural health midwife (RHM) at the nearest Barangay Health Station (BHW), and even from the barangay health worker (BHW) in the neighborhood.

Most female sterilization procedures were performed in the government hospital, although a few mothers reported that they were operated in the RHU.

The private sector has entered the rural family planning scene, and has reached about one-seventh (13.4 percent) of the contraceptive users in Samar. Private hospitals/clinics and several Tacloban-based non-government organizations (NGOs) have provided female sterilization services and pills. But these services and the pill supply seemed to have been provided free. Apart from a few pill users who went to the pharmacy to buy their pills, there seems to be no significant indication yet of a growing market of clients who are willing to pay for family planning services and supply.

Table 10 presents the reasons for not using any contraceptive method among currently married women aged 15-49 years. "Amenorrheic," the non-return of menstruation for some period after birthing (child delivery), was the leading reason given by more than one-fifth (22.3 percent) of the non-users of contraceptives. Many mothers seem to believe they are safe from getting pregnant again before the return of their menstrual cycle after birthing. Unfortunately, a few mothers got pregnant again even before their menstruation returned. This belief seems false and shaky and must be clarified by appropriate information, education, and communication (IEC) efforts.

Several leading reasons such as "want to have a child," "old or difficult to get pregnant," "single or not sexually active," "menopausal," and "husband away or infrequent sex" have defensible logic of their own. But "afraid of side effects," "husband does not want," "lack of knowledge," and "health concerns" could be clarified by proper counseling and IEC efforts.

Five coded reasons almost ignored by the respondents underscore the low cost (if any) and virtual acceptability and accessibility of contraceptive methods for the women in the study. "Inconvenient to use," cited by only three respondents, suggests that contraceptives are not that difficult to use. "Against religious belief," also with three responses, suggests that religion is not a key factor influencing non-use of contraceptives among the respondents. "Hard to get method," with only one response, suggests that family methods are accessible to the women. "Too costly or expensive" and "opposed to family planning," which were never mentioned by any respondent, negates cost and perceptual barriers against family planning.

Yet, despite the virtual absence of restraints, the use of contraceptives remains low among the women in the study. Why? The answer to this question can be probed further by focus group discussions (FGDs) with representative groups of mothers around the province.

Table 11 presents the percent distribution of the 38 sterilized women by age at time of sterilization according to number of years since operation. The data show that most women-acceptors of this method were evenly distributed in the 30-34, 35-39, and 40-44 age groups. At least two-fifths (42.1 percent) of the female surgical operations were performed within the past five years. More than one-fourth (28.9 percent) of the operations were performed 10 or more years ago.

Table 12 presents the percent distribution of women using IUD by age at time of IUD insertion according to number of years since insertion. The data show that the IUDs in two women-users were inserted within the past two years. These women belong to the 30-34 age group. As cited earlier, a comparison with the finding of the 1994 Eastern Samar MCH Study shows a significant drop in the percentage of IUD users. The promotion over the past few years of the injectable, a more convenient alternative, might have drawn former and potential IUD users to this method.