Our study found striking evidence of socioeconomic inequalities in modern contraceptive use in countries of the Newly Independent States. We found both community-level and individual-level socioeconomic inequalities in modern contraceptive use at a regional level. However, country-level analyses revealed a more mixed picture. In 4 of 10 countries community-level socioeconomic status was significantly associated with modern contraceptive use. We also found associations in 7 of 10 countries for individual-level socioeconomic status and in all but two countries for education. In addition, some sub-regional similarities emerged in Central Asia and in Caucasus, but not in Eastern Europe.
Our study contributes to a scant literature on community-level socioeconomic status and modern contraceptive use. The few studies that studied community-level socioeconomic factors and modern contraceptive use had mixed results[10–16]. The study that most closely resembled ours examined community-level mean household assets using Demographic Health Survey data in association with modern contraceptive use in 6 countries in Africa and found an association of increased community-level assets with increased modern contraceptive use only in one of the six countries, Burkina Faso. The authors suggested this finding might be due to increased economic development in Burkina Faso. In the three studies on community-level socioeconomic characteristics and contraceptive use in high-income countries, an inverse association was found between levels of community disadvantage and contraceptive use[10–12]. Our results provided limited support to the hypothesis that community-level disadvantage is associated with lower contraceptive use primarily in the context of a high level of economic development. In Central Asia the strongest association between poor community-level socioeconomic status and modern contraceptive use was found in the most developed country, Kazakhstan, and in Eastern Europe the same could be said regarding Ukraine, although in Ukraine the association was not statistically significant. Further research might examine more closely associations between community-level inequalities and national economic development levels.
Several similarities emerged in Central Asian countries. First, the only countries in our study in which community-level socioeconomic status had a statistically significant association with modern contraceptive use after adjustment for individual-level factors were Central Asian countries. In three of these countries, Kazakhstan, Tajikistan, and Uzbekistan, women in the poorest communities were less likely to use modern contraceptives, while in Kyrgyzstan, women living in the poorest communities were more likely to use modern contraceptives. Central Asian countries also were similar in that individual-level socioeconomic status was positively associated with modern contraceptive use in all countries except Uzbekistan, in which there were no individual-level differences in use of modern contraceptives in unadjusted or adjusted analyses. In addition, Uzbekistan is the only country in our analysis in which the odds of modern contraceptive use were higher among women with lower education, and also had the highest overall percent use in Central Asia (58%). Previous literature on modern contraceptive in Central Asia, although scant, may elucidate our findings.
One study previously examined modern contraceptive use in Uzbekistan. After Uzbekistan gained independence, the government launched a new family planning program in an effort to reduce the use of abortion as contraception. This program centered on use of the IUD, and has been attributed to increasing the use of modern contraceptives in Uzbekistan. If the government family planning program targeted less educated women, it could explain our findings. This apparent equality in Uzbekistan might be considered a success of a targeted government-sponsored family planning program, and is consistent with research in other middle-income countries showing that higher provision of public capital may compensate for low levels of human capital, i.e. education, in regards to modern contraceptive use. On the other hand, the government reproductive health program in Uzbekistan has been criticized for being coercive and constraining reproductive choice. The potential of a trade-off between reproductive choice and equity in modern contraceptive use is important to consider in efforts to achieve reproductive health equity.
Our findings also support a previous study comparing Kazakhstan and Belarus that found greater inequality in modern contraceptive use in Kazakhstan than in Belarus. The authors hypothesized that a reason for the higher degree in equality in Belarus was due to the fact that the health system in Kazakhstan had undergone more market-based reforms than that in Belarus. Our findings regarding both community and individual wealth support this hypothesis – in adjusted analyses, individual wealth or community wealth were not associated with modern contraceptive use in Belarus, whereas in Kazakhstan women in the poorest communities and in the poorest quintiles of individual wealth were less likely to use modern contraceptives.
We found the most marked inequalities in modern contraceptive use by individual socioeconomic status in the Caucasus region, including Georgia, Armenia, and Azerbaijan, although community wealth was not independently associated with modern contraceptive use in these countries. These countries also had the lowest overall rates of modern contraceptive use. Our findings build on previous research regarding individual-level inequalities in access to health care and the need for family planning in this region.
Previous research identified the Caucasus region as a region with large inequalities in access to health care. A study of 8 countries of the former Soviet Union (Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine) in 2001 found inequalities in access to health care in all countries, but that the inequalities were most marked in Georgia and Armenia, and that these inequalities persisted in a 2010 follow up survey[35, 36]. Our study builds on this research by showing that inequalities by individual socioeconomic status extend to access to contraceptives in these countries.
Previous research has also identified an urgent need for increased family planning programs in the Caucasus. In Georgia, a comparison study between 2005 and 2010 suggested that despite having declined by 16% (from 3.7 to 3.1 abortions per woman), abortion rates were still the highest documented worldwide. In Azerbaijan and Armenia, where abortion rates are also high, there is also a clear need for family planning programs. A survey conducted in 2005 in Azerbaijan found that among married women who have never used modern contraceptives, the most frequent reasons stated were fear of side effects (35.8%) and lack of knowledge about family planning (31.8%). The same study found lack of availability of contraceptives at health centers, particularly outside the capital city. A survey in Armenia in 1995 of women attending an abortion clinic found that the most frequent reason for not using contraception was lack of knowledge (60%), followed by unavailability or cost (15%), and that most women (90%) wanted further information on contraception. Another study in Armenia in 2002 found that only 19.4% of post-partum care providers provided information to patients regarding birth spacing and contraceptives. These previous findings suggest that lack of knowledge may be an important factor contributing to the individual-level inequities in modern contraceptive use in the region, and that community-based programs to increase knowledge of family planning are needed. An example of such a program can be found in Armenia, where a national family planning media campaign in 2000 successfully increased contraceptive use. Considering the inequalities identified in Armenia in this analysis, it would be of interest for future interventions to evaluate whether they are effective across communities and individuals of varying socioeconomic status.
We found few commonalities between the Eastern European Newly Independent States that we studied: Belarus, Moldova, and Ukraine. These countries share cultural and religious characteristics, but differ in levels of democracy and development, with Belarus having the most totalitarian government in Eastern Europe, and Moldova being the poorest Eastern European country. The general fertility pattern in Eastern Europe relative to Western Europe tends to be earlier childbearing followed by abortion or contraception to space or limit subsequent children. Despite these similarities, there are few similarities in patterns of inequalities between countries. Likewise, the countries in the Caucasus region displayed more similar patterns of modern contraceptive use, despite large cultural and religious differences between countries. These findings suggest that from a regional perspective, cultural and religious differences do not drive inequalities in modern contraceptive use.
This analysis describes patterns in individual-level and community-level inequalities in modern contraceptive use that generate hypotheses regarding multilevel factors influencing contraceptive use. Three factors that merit future research in the context of the post-Soviet transition are gender equality, social capital, and health system characteristics. Despite official policies proclaiming gender equality during the Soviet era, power differentials between men and women differed historically throughout the region[2, 42]. Eastern European countries of the Soviet Union (Belorussia, Moldova, and Ukraine) shared relatively more egalitarian gender beliefs and women had greater access to education and employment. In contrast, countries of the Caucasus and Central Asia observed more traditional values and cultural norms in respect to women and their roles in the family[44–47]. Future research might explore the role of evolving male/female power dynamics in socioeconomic inequalities at the individual- and community-level.
The influence of social capital on modern contraceptive use is another important avenue for future research to unpack the community-level and individual-level inequalities described in this analysis. Social capital is a known determinant of access to health care in the former Soviet Union. Social capital in the form of both personal networks and communication networks are also known to be influential to contraceptive use in Eastern Europe and elsewhere via access to resources and knowledge. The Newly Independent States are an opportune region to explore associations between social capital and inequalities in modern contraceptive use due to their shared experience of economic transition.
Finally, health system characteristics themselves are an important macro-level determinant of equality in access to health care. Because the ten countries included in our analysis have undergone health system reform to varying degrees since the dissolution of the Soviet Union, they present an ideal opportunity to measure the impact of these reforms on family planning. Future researchers might collect data on specific characteristics of the health system of each country, such as degree of privatization and introduction of user fees, including the extent to which they apply to family planning programs, and conduct in-depth analysis of the association of these characteristics with trends in inequalities in modern contraceptive use.
Strengths and limitations
Our study had several strengths. First, ours is one of the few studies to consider how community-level socioeconomic status influences modern contraceptive use, and how these associations differ across countries. To do so, we were one of very few studies that have created a community-level socioeconomic measure using MICS or DHS data, an approach that should be considered more frequently. Second, we drew on the shared sociopolitical history of the Newly Independent States to examine both regional and within country associations between both community- and individual-level socioeconomic status and modern contraceptive use. This novel approach serves to stimulate hypotheses regarding within country and between country differences in reproductive health and family planning services. Finally, we took advantage of the comparability and comprehensiveness of MICS and DHS survey data on contraceptive use to create a unique dataset encompassing ten Newly Independent States.
Despite the strengths of our analyses, there are several limitations to be noted. First, we constructed our measure of community-level socioeconomic status by aggregating an individual-level measure, and thus may not have fully distinguished the poverty level of the community from the individuals who comprise it. In order to minimize this bias, we used the entire sample from the surveys to compose this measure, as opposed to the sample of married/partnered women for analysis. Second, we examined cross tabulations between community and individual measures to ensure that there were not empty strata, such that although the measures were correlated, there were poor individuals in all levels of community socioeconomic status and vice versa. Another limitation regarding the measure of community wealth is that it is not strictly comparable among countries. We adopted the approach of using within-country wealth indexes so that a community would be labeled ‘poor’ relative to its own country; however, this means that a poor community in Ukraine is not necessarily at the same absolute level of poverty as a community in Uzbekistan. This may limit inferences for total associations between community-level wealth and modern contraceptive use.
There also are limitations in the measures of household wealth. The distribution of wealth index scores varied by country; some countries had larger absolute difference in wealth when comparing poorest and richest quintiles than in other countries. Such differences in absolute wealth disparity between poorest and richest quintile may influence the comparative magnitude of the coefficients for quintiles of wealth across countries, as well as the degree to which we see a trend within each country of increasing contraceptive use with increasing wealth. Therefore, interpretation of comparisons and trends between countries should be cautious.
The measure of educational status also has some limitations. Women in the youngest age category, aged 15–19, would not have had an opportunity to complete higher education. Because these women have a lower prevalence of modern contraceptive use, they may have biased the estimate for the association between low education and modern contraceptive use away from the null. However, the number of women in this age category is limited (n = 1146), representing only 2% of the study sample. Additionally, we may have not fully captured all relevant aspects of educational status since we did not include partner’s level of education. Understanding better how the socioeconomic status of the woman-partner dyad influences modern contraceptive use is fertile ground future research.
Another limitation is that because we did not have information on sexual activity and therefore limited analyses only to women who were married or in a union, our results are not generalizable to the all women in NIS countries. In particular, because younger women may be less likely to be married or in a union, inference from our findings for younger women should be made with care. We also did not have information on pregnancy intention for the seven countries for which we used MICS-3 data. Because of this we did not take pregnancy intention into account in our analysis, and were therefore unable to measure “unmet need” for contraception.