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Abstract
Objectives We aimed to explore and understand the extent and type of evidence on fertility reduction and its association with family planning (FP) in Southeast Asia.
Design Scoping review, following the methodological principles developed by Arksey and O’Malley and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines for reporting.
Data source We searched PubMed/MEDLINE, ProQuest, EBSCO, Scopus, Web of Science, Google Scholar and reference lists of relevant articles between 1 January 2012 and 31 December 2022. Only open-access articles in English were considered.
Study selection For inclusion, observational studies were selected for eligibility based on the original articles investigating the uptake of FP on women aged 15–49 years and its association with fertility decline in Southeast Asian (SEA) countries.
Data extraction and analysis Two reviewers screened the records independently for eligibility and extracted all data. The specific details of the studies, including data on the authors, year of publication, setting, study design, aims/objectives of the study, specific intervention, outcomes and main findings, were reported.
Results We retrieved 615 articles and retained 12 articles included in the analysis. Of these, 11 were quantitative studies and 1 was qualitative study. The frequently reported strategy of FP was the use of contraception. FP not only allows women to control their birth by spacing and limiting their pregnancies but also delay their first childbirth by using contraceptive methods.
Conclusion Our review suggests that the FP programmes aiming at reducing fertility should have a specific focus on improving the uptake and continuation of FP services.
- systematic review
- public health
- reproductive medicine
- sexual medicine
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The synthesis of the data employs a broad variety of study designs, settings and populations.
The potential for error in the selection of the eligible studies is minimised by double screening.
The analysis of this review mainly focuses on the definitions of the outcome, excluding any studies where fertility is included as a covariate or exposure variable. Thus, the generalisation of our findings is insufficient in other contexts.
This review was restricted in terms of language and publication date.
Introduction
Socioeconomic growth is often accompanied by declining fertility rates, and Southeast Asia is no exception. The fertility rate of Southeast Asia has declined from 5.5 in 1970 to 2.4 in 2015 and continues to fall.1 The fertility landscape of Southeast Asia is multifaceted, as the region is characterised by a high degree of cultural and ethnic diversity, as well as high levels of economic disparities within and between countries. Variations in fertility rates, such as the size of ethnic Malay family groups in Malaysia, reflect these disparities.1 Ethnic Malays prefer larger family and community sizes, whereas ethnic Chinese are more concerned with family lineage. As a result, the development of fertility policies across countries in the region is challenging, as it must consider the cultural and national diversity of the region. In addition, as the majority of countries in the region are developing nations, funding is a significant barrier and infertility is not typically viewed as a pressing issue.
According to projections, the global population is anticipated to reach around 9.45 billion by the year 2045. The population has experienced a notable growth of 2.1 billion in comparison to the figures recorded in 2015. It is worth noting that Asia continues to maintain its position as the most populous continent, accounting for around 55% of the global population.2 According to the Worldometer’s study, the population of Southeast Asia was at 668.61 million people as of 31 January 2023. This amount represents 8.34% of the current global population, which stands at 8.01 million people. The population is a key focal point in the pursuit of developing high-quality human resources. The implementation of population regulation measures is crucial for the preservation of high-quality human resources. Furthermore, fertility is also a critical issue, as its dynamics are closely tied to the socioeconomic development of a society.3 4
Fertility rates in SEA countries demonstrate a downward trend following the introduction of family planning (FP) programmes approximately 50 years ago.5 FP facilitates every couple to reduce the number of births, regulate the timing of birth and adjust birth spacing by using contraception.6 During the period from the 1970s to the 1980s, the main goal in Thailand, Vietnam, Indonesia and Singapore was to actively pursue the objective of diminishing the size of families by reducing the number of children. The FP programmes implemented in these countries have actively promoted the notion of restricting the number of children.1 Thus, Indonesia, for example, has received international recognition for its notable achievements in FP since it has effectively curbed the pace of population growth.7
The effectiveness of FP programmes in reducing fertility rates is dependent on various factors, including the unique characteristics of each country, such as its FP initiatives and contraceptive prevalence rate (CPR), as well as the sociocultural context in which these programmes are implemented.3 Sociocultural factors include the educational background of the women and their husbands, the geographical location of their dwelling, their current work status, their age, their breastfeeding status and their desire to have more children.8
In light of these circumstances, it is necessary to comprehend how FP strategies affect fertility reduction in SEA nations. Our goal is to map out FP practices in Southeast Asia and determine how they are affecting the region’s declining fertility rate. A scoping review is an appropriate methodology for our research topic, as it enables a comprehensive exploration of the existing literature to gain insights into the knowledge gaps, primary sources and various types of evidence available in the context of Southeast Asia.
Methods
This study undertakes a scoping review as the method to examine the association between FP and fertility over the last decade in the SEA region. Scoping review methodology is a synthesis tool for evidence-based healthcare practice and policy.9 10 Moreover, the scoping review methodology itself is defined as a method that rapidly aims at the key concepts of the topic of research, in this case, the issue related to FP and its association with the level of fertility.11
In contrast to systematic reviews, scoping reviews try to map the central ideas of a field of study, that are suited to address questions beyond those related to the effectiveness or experience of an intervention.12 The objective is to identify the range of evidence (quantitative and/or qualitative) that is available on a given topic and give a clear indication of the volume of literature and studies available, as well as to visually represent this evidence as a map or chart of the located data.9 10 Since it provides a broad and structured overview, a scoping review is noteworthy for policy-making, practice and research circumstances.13 Therefore, in this study, a scoping review is suited to provide an overview of the existing studies of FP and its association with fertility decline in a more precise review.
Search strategy
Research published between 2012 and 2022 was considered, as this time frame covers the inauguration of the 2012 London Summit, a ground-breaking effort to ensure freedom to access FP services for women in developing countries.14 Articles published in the journals as original research were included while other publication types, including conference proceedings, books and editorial reviews, were excluded. We only focused on four observational studies (cross-sectional, case–control, cohort and ecological study). We conducted electronic searches for eligible studies within each of the following databases: PubMed/MEDLINE, ProQuest, EBSCO, Scopus and Web of Science. Additionally, we conducted a hand search of Google Scholar and a reference list of included studies. The initial search terms used MeSH related to FP and fertility decline. The search terms are listed as follows: (“family planning” OR “contraception” OR “contraceptive use” OR “birth control”) AND (“fertility decline” OR “fertility reduction” OR “fertility decrease”) AND Asia (see online supplemental material 1). We specifically chose the relevant countries during the study selection within the databases. The results were exported to Mendeley and later exported to Rayyan for title and abstract screening. All studies included in this review had to meet the inclusion and exclusion criteria as described in table 1. Additionally, a description of the PCC (population, concept, context) elements is outlined below to guide the screening and identification of relevant studies.
Supplemental material
Inclusion and exclusion criteria
In detail, the eligibility criteria were explained using PCC elements, as follows: (1) Population: We included studies of women of childbearing age (15–49 years); (2) Concept: Our primary outcome was the reduction in fertility explained by the total fertility rate (TFR) and number of births. We considered all FP strategies or interventions identified by the search. Our review distinguishes FP from birth control by emphasising any strategy of limiting the number of children and birth spacing beyond the use of contraception and (3) Context: To be included, a study had to explore the uptake of FP and its association with fertility decline in SEA countries published in English within 10 years (2012–2022). As our main objective was to investigate the possible correlation between FP and the decrease in fertility in the SEA region, we considered any studies that met these criteria, regardless of the type of data employed.
Study selection
The search results from each database were imported to database-specific folders in Mendeley for data management (removing duplicates and referencing). After removing duplicates, data were exported into RAYYAN software for screening and data extraction. Title and abstract screening were done by two independent reviewers to select studies related to the PCC as described above. Disagreements that arose between the reviewers were resolved through consensus. If necessary, the third researcher was consulted to make the final decision. For multiple publications, the most recent one was retained.
Full text of all potentially eligible studies was retrieved during the stage of screening. All included studies, and those for which eligibility was uncertain, were assessed by the reviewers. Again, in case of disagreement, consensus was reached on inclusion or exclusion by discussion and if necessary, the third reviewer was consulted. Records that did not meet the inclusion criteria were excluded, and the reasons for exclusion were provided in the final report. Exclusion criteria were assigned using a predefined list of exclusion reasons in RAYYAN, such as background article, wrong population, wrong study setting, wrong publication type, wrong outcome, wrong study design or wrong study duration. Assessment of the quality of studies including risk of bias was not formally conducted within the scope of this review. The search results will be fully reported in the final report and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram to outline the number of studies remaining at each stage in the selection process (see figure 1).
PRISMA flow diagram. Adopted from Page et al.60 PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Data extraction
Study data were extracted using Joanna Briggs Institute (JBI)’s template for data extraction and entered into Microsoft Excel spreadsheets. We extracted information related to the characteristics of the included studies and results, including author(s), year of publication, study setting, aim(s) and purpose(s) of the research, methods, subject/study population, sample/informant, exposure measures/strategies, outcomes, key findings and highlights of the study (see table 2).
Data extraction tool
Data synthesis
The data collected from the included studies were descriptively tabulated, mapped and summarised. The PRISMA flow diagram was prepared using PRISMA 2020 new version and the map was created using QGIS V.3.28.3. We conducted qualitative synthesis using meta-aggregation to develop generalisable results. In this stage, we employed thematic analysis by reading through a group of results and looking for patterns in the meaning of the findings to find themes. One reviewer (AR) independently coded each line of text based on our specific review questions and subsequently organised these codes into related areas to construct themes using the free version of MAXQDA software. After defining the themes, the findings were evaluated for relevance to the review questions. The findings were grouped around three themes’ clusters: the use of contraception, birth spacing and control, and delay of first birth.
Patient and public involvement
None.
Results
Study characteristics
The database search strategy yielded 615 results, leaving 567 records following the deletion of duplicates (see figure 1). The remaining records were screened by title, abstract and full-text, and 10 studies were deemed suitable for inclusion from the database search. Two additional studies were identified through other methods, resulting in a total of 12 studies included in the synthesis. The overall information extracted from each study can be reviewed in online supplemental table 1. Of the 12 studies, 3 were quantitative studies with a single country focus, 8 were quantitative studies with a multicountry or regional focus and 1 was qualitative study. Six studies were published within the past 5 years (2017 onwards) and the remaining studies were published between 2012 and 2017.
Supplemental material
In terms of geographical distribution, this scoping review found 12 studies examined FP and its effect on fertility reduction in Southeast Asia (see figure 2). The most research was in Cambodia, Indonesia and the Philippines with the number of studies ranging from 8 to 10 studies. The fewest studies were conducted in Brunei Darussalam, Laos, Singapore and Timor-Leste with 1–3 studies. Meanwhile, studies in other countries, namely Malaysia, Myanmar, Thailand and Vietnam, are in the range of 4–7 studies.
Number of included articles by country.
Strategies of FP
According to figure 3, the number of strategies in FP included in studies can vary depending on the scope and focus of the research. FP encompasses a wide range of strategies aimed at helping individuals and couples make informed decisions about the number and spacing of their children. These strategies can include (1) Contraceptive methods (including postpartum contraception) refer to various forms of birth control such as condoms, oral contraceptives (birth control pills), intrauterine devices (IUDs), contraceptive implants, patches, injections and diaphragms. Each method has its own efficacy, mechanism of action and considerations for use; (2) FP policy, which is potential to have far-reaching effects on individuals, families, communities and societies, influencing demographic trends, health outcomes, economic development and social dynamics. By promoting reproductive health and rights, FP policies play a critical role in advancing sustainable development and improving the well-being of populations around the world and (3) Education on FP is defined as providing information and counselling services on FP options, reproductive health and responsible sexual behaviour that can empower individuals to make informed choices.
The number of strategies in family planning included in the studies.
As the most reviewed strategies of FP, the use of contraception was observed among poor women in Vietnam, Indonesia and the Philippines.15 Majumder and Ram found that the percentage of married women, contraceptive use rate and induced abortion were all factors that contributed to the fertility delay in rural areas. In urban areas, induced abortion, postpartum infertility and the percentage of married women have been identified as the main determinants of fertility change over a given period.
In line with this, contraception is found as the strongest factor influencing the control of TFR levels in Cambodia, Indonesia and the Philippines.16 Among the three countries, contraceptive effectiveness in Indonesia is still the highest since the late 1980s, at around 40%. In Cambodia, contraception has resulted in a considerable fertility decline in 2014, at 38.4%. In the Philippines, contraception was the largest factor in reducing fertility in 2013, at 42%. In another Indonesian study, rural Balinese women were highly motivated to use contraception to prevent pregnancy.17 Despite low formal education, contraceptive use enabled Balinese women to engage in strategic birth planning and successfully manage the number and timing of their pregnancies. Contraception, which is widely accepted in Bali, allows them to control the number and spacing of pregnancies, thus allowing them to maximise their limited financial resources and ensure the survival of their children.
Contraceptive use and fertility at the population level had a significant positive association with fertility in more than 95% of the countries studied. The effect of contraception in reducing fertility cannot be explained by one factor alone but by a combination of factors. For example, contraceptives may reduce the number of births and simultaneously reduce the risk of maternal mortality. Several reviews examined educational-based strategies3 17 18 as well as policy19 that aimed to enhance the successful implementation of FP programme.
Assaf and Moonzwe Davis mentioned that exposure to FP messages was not significantly associated with unrealised fertility. However, it has been found in the literature that FP messages have direct links to fertility preferences and behaviours. Meanwhile, in Cambodia, Indonesia and the Philippines, FP policies were targeted to focus on improving female education at the primary school level.19 Policies were also seen as one of the key elements that may influence the strength of FP programme in a country. Countries with stronger FP programmes have lower average birth rates than countries with weaker FP programmes.
Association between FP and fertility reduction
Access to FP enables women to space and control births
This part identified three publications about FP to space and control natality.15 17 20 A quantitative study in six Asian countries (Nepal, India, Bangladesh, Vietnam, Indonesia and the Philippines) from the 1990s to 2000s examined the effect of proximate determinants on fertility decline among poor and non-poor using Demographic and Health Survey (DHS) data.15 The study showed that an increase in postpartum infecundity among poor women can control births by reducing fertility which was a result of longer breastfeeding duration and menstrual regulations.
Another quantitative research using secondary data from 317 nationwide fertility surveys from 83 less-developed countries (7 of which were located in SEA countries) found that birth control results in postponing and limiting parity.20 The analysis indicated that the FP programme played a substantial role in postponement (spacing between birth) and predominant form of stopping childbearing (limiting). Timæus and Moultrie found that Indonesia, Cambodia, Philippines and Vietnam showed the tendency of controlling birth by limiting the number of children. Indonesia also showed the highest prevalence of birth postponement among Asian and six other SEA countries in the study.20
Furthermore, a qualitative study conducted in 2002 and 2007 of 39 reproductive age married women in rural Bali mentioned that the Balinese women were highly motivated to use contraceptives to space and limit their births.17 Despite their limited formal education, the use of contraception enabled them to engage in strategic birth planning and successfully manage both the number and timing of their pregnancies. In addition, access to contraceptives, which has become widely accepted in the community, enables them to maximise both their limited financial resources and their children’s likelihood of survival.17
Timæus and Moultrie mentioned that limiting refers to the use of birth control to limit childbearing.20 Natural birth control, such as postpartum amenorrhoea and infecundity, can also be used to limit and control women’s fertility.15 However, Majumder and Ram argued that contraception is the most effective factor influencing fertility decline.15 Access to contraceptives helped promote perceived and actual high levels of reproductive control.17
Access to FP allows women to delay first birth
Three articles15 21 22 explained that the factors of contraceptive use and delaying the age of marriage have a significant contribution to decreasing fertility. Postponing marriage will result in a delay in the first childbirth, thereby shortening the reproductive span for women. The results of a study by Majumder and Ram stated that women who marry at a younger age tend to have more average numbers of childbirths compared with those who marry later in life.15 These women have higher cumulative fertility for all ages, with the timing of marriage being critical as a determinant of overall fertility among non-poor women compared with poor women. In Indonesia, illegitimate children pose challenges for society’s acceptance, hence delaying marriage significantly contributes to reducing fertility rates.
Another research by Rogers and Stephenson outlined that delay in the age of marriage and sexual debut had a greater likelihood of fertility inhibition (41%–60%) in Cambodia and the Philippines.21 The fertility rates in Cambodia, Indonesia and the Philippines had a significant decline primarily due to the shift towards contraception as a result of the postponement of the marriage age.21 Additionally, a study by Timæus and Moultrie in 83 least developed countries from 317 national surveys found that Timor-Leste had characteristics of parity-independent birth restrictions in terms of childbearing and increased birth delays. However, fertility rates were still higher in most sub-Saharan African countries than in other remaining countries at the end of the study period.20 This raises the possibility that delay is not a geographically distinct pattern of family formation, but rather is a feature of the early phase of the fertility transition.
Access to FP increases the use of contraception
Of the 10 articles assessing the effectiveness of contraception in FP programmes, 43 18 23 24 specifically discussed how various factors such as social, cultural, economic, health and environmental aspects directly influence fertility rates through contraceptive use. The effect of the CPR on lowering the TFR was demonstrated in a study conducted in the Philippines, Singapore, Vietnam, Malaysia, Myanmar, Indonesia, Cambodia and Laos.3 The study found that stronger FP programmes, longer female education and greater gross domestic product (GDP) were associated with a rapid decline in TFR, resulting in a significant relationship between FP programmes and the increase in CPR.
Assaf and Moonzwe Davis noted that in SEA region (Cambodia, Indonesia, Myanmar, Philippines and East Timor) women who used either traditional or modern contraceptive methods were less likely to experience unrealised fertility (refers to the condition where the current number of children is less than the ideal number of children) compared with women who did not use any method while FP exposure has no significant association with unrealised fertility.18 Another study in three countries of Southeast Asia (Cambodia, Indonesia and Philippines) using Demographic and Health Survey data from 2003 to 2015 also showed that both contraceptive use and community-level birth rate were positively correlated with the fertility level and women who had many children were more likely to adopt contraceptive use.24
The role of contraception in declining the number of births was also explicitly indicated by a study using various data sources in 172 countries, including all SEA countries.23 The contribution of contraception in reducing the risk of maternal mortality is complex and commonly interrelated. The decline in maternal deaths is associated with fertility decline resulting from averted births by contraceptive use as the effect of prevention on complicated pregnancies and unsafe abortions.
Meanwhile, five articles reported an estimation of the relative effects of the proximate determinants on fertility using the Bongaarts model.15 16 21 25 26 This model measured how abortion, contraceptive use, marital and extramarital sexual exposure, and postpartum infecundability may reduce fertility. According to Bongaarts’ model, the reduction in the Index of Contraception in various SEA countries reflects increased contraceptive use and decreased fertility rates. Increased contraceptive use had fertility-inhibiting association in the Philippines,15 16 21 Cambodia,16 21 Indonesia,15 16 Vietnam15 25 and Malaysia.26
Results from the decomposition analysis showed that contraceptive use decreased fertility most in those countries (except in Vietnam 1997–2002 and the Philippines in 1998–2008), emphasising the need for accessible and affordable FP services. In the Philippines, for instance, Rogers and Stephenson described that the TFR fell by 14.3% from 2000 to 2011, with a 7.5% drop in fertility attributable to contraception.21 Lai et al also reported that contraception also had emerged as the leading fertility-reducing factor in the Philippines, accounting for about 42% reduction in 2013.16
Meanwhile, the promotion of safe and effective modern contraception, together with delaying marriage and sexual debut, was evidence for fertility reduction in Cambodia, in spite of shorter exclusive breastfeeding periods.21 Rogers and Stephenson reported that the TFR in Cambodia experienced a significant fall of 28.9% from 2000 to 2011, primarily attributable to a 21.8% decrease in fertility resulting from increased use of contraception.21 Additionally, it has been revealed that contraception was also identified as the primary factor for fertility reduction in Cambodia, accounting for an approximately 38.4% decline in 2013.16 Majumder and Ram also found that the decrease in fertility rates in Asia was caused solely by non-marriage factor, with a further decrease of approximately 2% among non-poor women and 11% among poor women attributable to increased contraceptive use.15
In Indonesia, fertility rate dropped by 41% in 2012 as a result of the successful FP programme over the past 20 years, which emphasised the availability of contraception.16 According to a study by Majumder and Ram, increasing contraceptive use among poor and non-poor women in Indonesia led to a 13% and 6% fertility drop from 1997 to 2007.15 Consistent with these results, a 2002 qualitative study by Withers and Browner found that, despite having less access to formal education, Balinese women enthusiastically used birth control to limit the frequency and spacing of their pregnancies. Access to contraceptives has become widely accepted in Bali and other parts of Indonesia, which has contributed to high levels of perceived and actual reproductive control and enabled people to optimise their limited financial resources while increasing the likelihood of survival for their children.17
Results from decomposition analysis indicated that contraceptive use reduced fertility by 6.3% in Vietnam between 1997 and 2002, although it had the least likelihood.25 Fertility rates were most affected by changes in the proportion of married women and induced abortion in both urban and rural areas. IUD was the most popular method in Vietnam from 1997 to 2002, followed by withdrawal.25 Furthermore, Majumder and Ram found that the main reason for the fertility decline in Vietnam between 1997 and 2002 was the significant increase in the use of contraception among both poor and non-poor women, accounting for 15% and 16%, respectively.15
Among three major ethnic groups in Peninsular Malaysia, marriage postponement and contraceptive use are the two most important proximate determinants of fertility, but the effects are not uniform across the ethnic groups. In 2004, the Bongaarts’ model also predicted a 0.53 index of contraception for Peninsular Malaysia.26
Discussion
Our review of 12 studies on FP and fertility covered all countries in Southeast Asia. With a few exceptions, the reviewed studies provided evidence for strategies on FP and their effect on the reduction in fertility. We were able to detect similarities in the association between FP and fertility decline by comparing evidence across study settings. The results of this scoping review found that the most dominant use of contraception in Indonesia, Cambodia and the Philippines is in the form of controlling birth to limit parity.20
A study in Saudi Arabia, however, shows that 60% of contraceptive use was used to space pregnancies (spacer) and 40% to limit births (limiter).27 Another study in Ghana described that among women who are currently using contraceptives, the main motivation was for spacing out their childbirths (19.7%) compared with only around 0.77% for limiting.28 The difference in the result might be explained by the differences in the sample’s characteristics. In this review, the majority of the samples in this scoping review were women aged 15–49 yearsd. A study in Malawi, in contrast, had participants in a relatively younger age group (18–35 years).29 It was found that differences in the purpose of contraceptive use are influenced by the woman’s age, as younger women use contraception to space pregnancy, whereas older women use contraception to terminate pregnancy. Moreover, women’s education level also showed a significant positive association with birth spacing.27
Our review highlights that the association between FP and fertility reduction as contraceptive use increases the likelihood of spacing births and limiting the number of children.15 17 20 Our review aligns with a study in Malawi, which discovered that women who were exposed to the FP intervention had longer intervals between births compared with control women. The intervention also allowed women to have more control over birth spacing and their postpartum fertility, which in turn, could have health benefits in the long run.29
Contraceptive use also plays an important role in inhibiting fertility, as outlined by the studies in Pakistan and Bangladesh.30 31 Similarly, contraceptive use was the main fertility inhibitor in various African countries, such as Eswatini, Democratic Republic of the Congo and Namibia.21 32 33 A possible explanation for this evidence may be the availability of a choice of methods with good-quality counselling and information. Other reasons include adequate access to safe, effective, affordable and acceptable FP services. Also, some modern methods, in particular long-acting and permanent methods, are more effective at averting unintended pregnancy.34 The effect of contraceptive use in reducing fertility rates reaffirms the importance of providing accessible, affordable and quality FP services to women in SEA countries.
According to this review, contraceptive use and delaying the age of first marriage significantly contributed to the decline in fertility as the fertility period of a woman was influenced by the age of her first marriage. As the age of first marriage increases, fertility may decline due to a reduction in the number of women who are at risk of giving birth and the use of contraception to delay the birth of the first child.35 Our findings confirmed that contraception is a significant feature in the cultural transmission model of fertility reduction. Although contraception initially had a minor effect on family size, women tend to use protection and implement fertility management at the end of their reproduction.36
Contraception is used to delay the first pregnancy for three main reasons: women’s social and biological status, the type of contraception and incompatible governmental policies for adolescents. On one hand, the use of modern contraceptives to delay the first birth can be widely accepted by students, teenagers, unmarried women and women whose marriages are insecure. On the other hand, the use of long-term contraceptive methods such as implants and IUDs is considered inappropriate for delaying the first birth due to their effect on delaying the return of fertility, imposing fertility cessation and permanently limiting future fertility.37 The use of contraceptives before the first birth was influenced by various sociodemographic factors, such as religion, caste, education, wealth index, media exposure, age at marriage and zone classification.38
Meanwhile, Spanish women delay having children for a variety of reasons, including but not limited to age, health, personal matters and other reasons.39 Motherhood typically occurs later in life for women with a higher level of education and a partner while non-working women start their motherhood at a younger age. The age at the first birth increases proportionately with monthly income. Another study suggests that husbands’ agricultural employment in rural area might delay the first child’s birth. Similarly, unemployed women tend to delay their first child due to burden of child expenses.
Our review reported that the strength of the FP programme determines the pace of fertility decline, simultaneously with various determinants, including socioeconomic (GDP, wealth index, women and partners’ education levels, etc), breastfeeding practice, induced abortions and numerous demographic factors, such as age at marriage, parity and so on. This finding supported previous studies in Africa that the performance of FP programme influences fertility level attributed to the political situation, economic growth and sustainable population policy as well as sociocultural factors.40 41 Considering the diversity of geographical and cultural backgrounds between countries in the SEA region, similarly, the fertility transition in China, to some extent, also indicates the crucial role of the FP programme concerning FP policy, political and cultural changes, socioeconomic development, regional differences, and several individual factors, including women’s and husbands’ age, marital and childbearing ages, fertility intention, and socioeconomic status.42 43 The relaxed FP policy in China, which was started in 2013 and 2016, contributes to the change in contraceptive method choice in which couples are more likely to use short-term contraception, compared with the era of strict FP policy (one-child policy) with the domination of long-acting irreversible contraceptive use.43–46 Nonetheless, anticipating the increase in pregnancies and reducing unsafe abortions, due to the relaxed FP policy, China’s government encourages women to use postpartum contraception.47 This strategy implies that a strong FP policy is still demanded even in the context of low fertility rate, which is expected to maintain a balanced population structure and preserve the TFR at a reasonable rate.
Controlling fertility is challenging, especially in resource-poor SEA countries. Hence, creating effective and comprehensive FP programmes is necessary. It is argued that despite the demand for allocating high-cost budgets for ensuring well-maintained population health, contraception and education, it is possible to shrink the costs by developing well-designed FP programmes that increase contraceptive use and fertility rates subsequently.40
Those ideas emphasise more focus on the factors related to the FP implementation. In Indonesia, for example, it was found that age, wealth index, number of living children, internet exposure, place of residence, region and educational attainment were all factors associated with contraceptive use among married women.48–50 In addition, a global-level study showed that women’s knowledge, partner participation, cost of health service and attitude of health practitioners influence the decision of contraceptive use among women.51
Given that Southeast Asia had strong and moderate FP programmes based on policy, service, record-keeping and method availability, Seltzer argued that FP programmes have evolved over the years, and one of the critical characteristics that has changed is the emphasis on different service delivery channels.52 Through pilot and experimental programmes, it gradually became accepted that more robust programmes required multiple service delivery channels to make services more available.53 The success of FP programmes in this region changed the country’s demographic characteristics, such as family size and functions, household savings and consumption, and welfare, by delaying pregnancy and decreasing the number of children.54
Correspondingly, demographic mitigation policies through FP programmes were very successful in developing countries, including Southeast Asia. Although the demographic change (one of the effects of population decline) differed across countries in this region, it transformed their social-normative and economic, leading to renegotiating and reinterpreting the intergenerational obligations.54 It also has profound economic, social, and political consequences and equality, where policies are now dynamic, evolving to reflect current trends and anticipate future population changes.55 For example, Indonesia is projected to reach demographic bonus in 2045 and the government developed long-term national plan and prepare the golden generation, emphasising national stability and preparing for future capital and its problems.56 57
As the evidence showed that unmarried adolescents have a higher unmet need for contraception due to several issues,58 the FP programme should also target younger generations. Adolescent’s contraception is complicated by cultural beliefs that perceive contraception as taboo.59 Legal issues and attitudes of healthcare workers further affect adolescent’s contraceptive use. Thus, removing barriers to contraception, especially for adolescents, is also crucial.
Limitations
Compared with systematic reviews, our scoping review did not examine the methodological quality of the studies or quantitatively condense evidence across studies (using meta-analysis). We focused on outcome definitions, excluding studies with fertility as a covariate or exposure variable. As we also had limited access to subscription-based journal articles, only open-access scholarly articles included in this review. In addition, as outlined earlier, we included only studies published in English; therefore, we might have missed quite some evidence published in other languages.
Conclusions
This review demonstrates that FP plays an important role in reducing fertility. The extent to which each FP strategy was associated with the level of fertility was profound across settings. This suggests a high potential for knowledge transfer, as countries can learn from one another as they implement strategies to increase awareness of available FP services. We, therefore, conclude that FP programme determines the pace of fertility decline by limiting birth, delaying first pregnancy and increasing the use of contraceptives. The FP programmes aiming at reducing fertility should have a specific focus on improving the uptake and continuation of FP services. Our findings may help decision-makers to alter FP initiatives to reach out to people with cultural and social differences, including the most socially and economically disadvantaged groups. Moreover, it is imperative to acknowledge that the unmet need for contraceptives has occurred not only among those who are married but also among unmarried young people who are sexually active. A further study with a focus on younger generations is thus also suggested. All authors have made substantial contributions to the development of the manuscript.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
Ethics statements
Patient consent for publication
Acknowledgments
The authors would like to acknowledge Dr Jerico F Pardosi for his valuable knowledge on scoping review and assistance in the development of review protocol.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors have made substantial contributions to the development of the manuscript. AR was the guarantor who was responsible for overall work of the study and coordination with the research team. AR conceptualised this work. SK, DNF and EFH designed the search strategy methods. AR, SK, DNF, EFH, AAB, HM, AST, DPS and MMPN were involved in screening of literature and data extraction. AR, SK, DNF, EFH, AAB, HM, AST, DPS, MMPN, MMelissa and MMuthmainnah drafted the manuscript, read and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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