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Characteristics of users of the birth control program. 2007 National Health Survey, Colombia /Caracteristicas de las usuarias del programa de Planificacion Familiar. Encuesta Nacional de Salud de 2007, Colombia/Caracteristicas das usuarias do programa de planejamento familiar. Enquete Nacional De Saude de 2007, Colombia.

Introduction

Less than 40 years after the appearance of the term "population boom", fertility rates have diminished in almost every country in the world; in fact, the Global Rate of Fertility (GRF) is below the level of population replacement. (1) In America, the GRF ranges between 1.5 for Canada and Cuba and 4.0 for Haiti and the French Guyana, going through 2.1 for the USA, 2.4 for Colombia, and 3.7 for Bolivia. (2)

During the 20th century, Colombia endured significant changes in its demographic variables. During the first three decades, the country had high birth rates (42 per thousand) and general mortality (23 per thousand) that produced relatively low and constant growth; close to 2% annually. By early 1940s, the mortality rate began to decrease, until reaching 13 per thousand during the first half of the 1960s, while fertility was kept in birth rates. This demographic behavior generated a population growth close to 3.4% during said period, giving way to the so-called "population boom". (3) As of the second half of the 1970s, a rapid drop in fertility and mortality is perceived, which led to again having population growth rates around 2% annually during the second half of the 1990s, equal to those seen during the beginning of the current century. (3) This strong drop in fertility (from seven children per woman during the first half of the 1960s, to 2.4 in 2009) showed that Colombia controlled its growth rate during a short period. (3) Among the causes contributing to this situation is the development during recent decades of a broad range of contraceptive options, (4) which increases the possibility of the method selected to be adapted to each user according to age, parity, health status, risk factors, beliefs, and other factors characteristic for each cultural group. In Peru, during 2002, a prevalence of 71.3% was reported of modern contraceptive methods in women cohabitating, (5) similar to that found in Mexico in 2006 (70.9%) (6) and in El Salvador in 2008 (72%), (7) while in Colombia, in 2005, a prevalence of use was found at 78%. (8)

Birth Control (BC) in Colombia has had progress since 1960 because, among others, of the commercialization of the first generation of contraceptive pills, (9) and the inclusion of BC activities in its maternal and infant protection programs in 1969. (10) As of that time, a decrease was noted in indicators of maternal mortality and GRF. Regarding state BC programs, Colombia is a pioneering country in Latin America in the offer of modern contraceptives. (11) Resolution No 769 of 03 March 2008 adopted the Technical Standard that modernized and increased the contraceptive offer for female and male populations, in response to that regulated by Agreement 380 of December 14, 2007 from the National Council on Healthcare Social Security, which approved including the Subcutaneous Hormone Implant and the new hormonal methods in micro oral and injectable dosage, and the male condom. The regulation includes counseling for delivery of the different methods, including emergency contraception. The National Health Survey (NHS) held in 2007 considered some aspects related to reproductive health, among them BC. This article focuses on describing the use of Birth Control methods from a subsample of female users of the Healthcare Service Provider Institutions de Colombia, which were included in the 2007 NHS.

Methodology

A secondary analysis was performed of the data from the subsample of 2033 users BC programs surveyed in the 1170 Healthcare Service Provider Institutions (IPS, for the term in Spanish) included in the 2007 NHS. For this study, we explored the following variables: schooling, marital status, type of insurance, motive for consulting, reception of information about BC methods, BC methods most used, and free selection of the method, among others. This information was gathered through the 2007 NHS Module 1 users' instrument. With said variables, a univariate analysis was conducted with the frequency distribution of each of the variables that account for BC in men and women; a bivariate analysis, with relation to age, gender, educational level, marital status, and social security, relating them to BC. The analysis presented is done exclusively on the data gathered during the 2007 NHS of the women surveyed and does not infer on the country's population.

Results

The 2007 NHS interviewed 2033 users of the BC program of the IPS selected, 48% of public origin. According to educational level, the highest percentage of women surveyed was in basic secondary and middle school (55.2%), followed by those in basic primary (24.1%). Regarding marital status, women cohabitating represented 54.5%, followed by single women 25.0%, married women 16.6%, widows represented 0.6%, and separated women 3.3%. As per type of insurance, 48.9% were affiliated to the subsidized regime, 35.3% to the contributive regime, 11.9% had no type of affiliation to social security, and 1.9% had credentials as a displaced citizen or demobilized from an illegally armed group. With relationship to users from the BC program surveyed, it was found that 35.7% consulted for the first time and 61.7% attended control consultation. A total of 2.6% consulted for other types of services like surgery, non-specific consultation, IUD insertion, retention of the device, to rule out pregnancy, or to obtain information on BC methods.

Of the people who consulted, 89.0% stated having received information about the different BC methods from the attending physician. Of the BC methods, hormonal methods were the most used with 60.3% (30% injection and 30.3% pill), followed by barrier (22.9%), with the IUD being preferred with 19.1%, and, finally, the permanent methods with 12.5%, corresponding to tubal ligation with the highest contribution at 10.9%.

In all levels of schooling, free selection of the BC method was above 87.1%; this percentage corresponded to individuals without educational level; with women with basic primary education at 93.5%, those in basic secondary and middle school at 93.9%, in technical or technological education at 93.0%, in university education at 96.8%, and those in graduate education at 100.0%. According to marital status, free selection of the method was at 100.0% for widows, 95.7% for married women, 94.6% for single women, 92.8% for those cohabitating, and 90.9% for women who were separated. Of the total number of BC users who did not freely decide on the method and another person decided for them, in 89.4% the decision was made by the healthcare personnel (77.2% the physician, 12.2% other personnel); in the remaining 10.6% the decision was made by the partner or another family member (3.3% each).

Of the women who selected IUD insertion as the BC method and who still had not undergone the procedure, 39% decided not to use an BC method prior to the insertion procedure, 30.5% opted for the condom, 7.3% for the pill, 14.6% had not decided, and lower percentages opted for other methods like the injection (4.9%) and lactational amenorrhea (1.2%). Of the participants who had selected tubal ligation as BC method, none had undergone the procedure at the time of the survey; 55.2% had been programmed for the forthcoming days, 11.7% for the following months, and 33.1% ignored when the procedure would be done.

Of the total number of individuals pending tubal ligation, 46% was not going to use any BC method until they were operated; 24.5% were going to use hormonal methods (15.3% injection and 9.2% the pill); 23.9% barrier methods (17.8% condom, 5.5% IUD, and 0.6% ovules), and 5.5% natural methods like abstinence or the rhythm method (3.7%), and lactational amenorrhea (1.8%). A total of 24.5% of the women, who were awaiting tubal ligation, selected hormonal methods as the first option prior to the surgical procedure; barrier methods were the second option (23.9%), and natural methods (5.5%); 46% stated not having selected a method.

A total of 98.2% of the women surveyed manifested having understood the information provided on the use of the BC method selected.

Regarding the information on where to obtain the BC method selected, according to their affiliation to Social Security, it was noted that 100% of the individuals affiliated to the Military Forces and to the National Police force received said information, 91.7% if those in the ISS, 82% of those affiliated to the contributive regime, 78.6% of those in the subsidized regime, 66.7% of those displaced, and 60% of those in the Public Teaching Service.

Discussion

The data indicate that the BC methods most used by the population surveyed in Colombia were the pill, injection, IUD, and female sterilization. These results are different to those found in Peru, where it was observed in the 2004 Demographic and Family Health Survey that the methods most used by women were: periodic abstinence (17.5%), injection (11.2%), female sterilization (10.4%), the pill (7.4%), and the IUD (7.1%).

In the subsample of the 2007 NHS it was found that among those using BC methods, the highest percentage corresponds to women with an educational level of basic secondary and middle school, followed by women with basic primary; while in Peru, (12) the 2004 Demographic and Family Health Survey reported that the use of contraceptive methods increases with educational levels; among those without education, less than half use BC methods, while in those in higher education BC use is higher than 75%. With regard to the free selection of the BC method, the autonomy of the women surveyed to select the method is notable; in fact, it was found that nine of every 10 make the selection on their own. This aspect could be understood within the process of social development, especially that related to access to education and information, through which these women had gained autonomy. Only in 12.2% of those surveyed is the selection of the method influenced by healthcare personnel, specifically by the physician; in Mexico, (13) the partner intervenes in the selection of the BC method in 52.4% of the cases, only the woman in 39.6%, only the man in 6.1%, the physician in 1.7%, the nurse in 0.1%, and others in 0.1%.

Given that those who selected surgical methods must wait days and even months for the procedure, many of them decided not to practice birth control methods during that time, exposing themselves to pregnancy. This could be due to lack of information about its risks. Hence, it is necessary to offer more health education to women who have made this BC election. This study concludes that hormonal methods are the most used by women attending the BC consultation. The participants showed high autonomy to select the BC method.

Acknowledgments: the authors thank Comite para el Desarrollo de la Investigacion -CODI- of Universidad de Antioquia.

Referencias

(1.) Butz W. El doble cisma: Los implosionistas y explosionistas ponen en peligro los avances logrados desde la conferencia de El Cairo. [Internet]. Washington: Population Reference Bureau; 2004. [cited 2011 Jun 21]. Available from: http://www.prb.org/ SpanishContent/Articles/2004/ElDobleCisma.aspx

(2.) Population Reference Bureau. Cuadro de la poblacion mundial 2009. [internet]. Washington: Population Reference Bureau; 2009. [cited 2011 Jun 25]. Available from: http://www.prb.org/pdf09 /wpds09_sp.pdf

(3.) Profamilia. Salud Sexual y Reproductiva en Colombia. Encuesta Nacional de Demografia y Salud, 2000 [Internet]. Bogota: Profamilia; 2003. [cited 2011 Nov 25]. Available from: http://www.encolombia.com/salud/saludsex-portada.htm

(4.) Ojeda G, Ordonez M, Ochoa LF. Salud sexual y reproductiva en Colombia: Encuesta Nacional de Demografia y Salud, Colombia 2005. Bogota: Asociacion Pro bienestar de la Familia Colombiana y PROFAMILIA; 2005.

(5.) UNFPA. Salud Reproductiva. Peru: Prevalencia de uso de metodos anticonceptivos, en mujeres unidas, de 15 a 49 anos, segun area de residencia (1991, 1996, 2000). [Internet]. San Isidro: Fondo de Poblacion de las Naciones Unidas. [cited 2011 Nov 24]. Available from: http://www.unfpa.org.pe/ infosd/salud_reproductiva/salud_rep_02.htm

(6.) Godinez Leal L. Mexico: Cifras evidencian atropello a derechos sexuales y reproductivos de las mexicanas [Internet]. [cited 2011 Nov 24]. Available from: http://www.argenpress.info/2009 /06/mexico-cifras-evidencian-atropello.html

(7.) FESAL. Planificacion familiar. Conocimiento de metodos anticonceptivos [Internet]. San Salvador: FESAL; 2008. [cited 2009 Nov 24]. Available from: http://www.fesal.org.sv/2008/informe/ resumido/06-PlanifiicacionFamiliar.htm

(8.) PROFAMILIA. Tendencias en la dinamica anticonceptiva en Colombia, 1990-2005 [Internet]. Bogota: PROFAMILIA; 2005. [cited 2009 Nov 24]. Available from: http://www.profamilia.org.co/ encuestas/01encuestas/profundidad/tendencias/ dinamica.pdf

(9.) Sanchez Torres F. Historia de la Ginecobstetricia en Colombia [Internet]. [cited 2009 Nov 14]. Available from: http://www.encolombia.com /contenido_ginecobstetricia.htm

(10.) Eraso MP La medicina en Colombia, una resena historica [Internet]. Aldo Campana; 2008. [cited 2009 Nov 1]. Available from: http://www.gfmer.ch/Colombia_Pilar/INDICE.htm

(11.) Pais pionero en america latina en la oferta de anticonceptivos modernos. Terra Networks Chi le. (2008 Mar 05; Sexualidad) [Internet]. [cited 2009 Nov 25]. Available from: http://noticiascl. terra.cl/salud/interna/0,,OI2662510-EI5424,00. html

(12.) Aramburu CE. Fecundidad y Planificacion Familiar: Comparando las ENDES 2000 y 2004. [Internet]. [cited 2009 Oct 2]. Available from: http://www.gestiopolis.com/canales5/eco /consorcio/eys56/archivos/56-fecundidad -y-planificacion-familiaren-el-peru.pdf

(13.) Secretaria de Salud, centro Regional de investigaciones Multidisciplinarias. Encuesta nacional de salud reproductiva 2003, Tabulados Basicos. Mexico: Universidad Autonoma de Mexico; 2003.

Maria Isabel Lalinde-Angel [1]

Gloria Molina-Marin [2]

Martha Lucia Olarte-Lezcano [3]

[1] RN, M.Sc., Professor. Universidad Antioquia, Colombia.

email: ilalinde@ udea.edu.co

[2] RN, Ph.D., Professor. Universidad Antioquia,

Colombia.

email: molinag@saludpublica.udea.edu.co

[3] RN, Specialist, Professor. Universidad

Antioquia, Colombia.

email: email: marluo@msn.com

Article associated with the research: Contrato Interadministrativo de Cooperacion Ministerio de la Proteccion Social Universidad de Antioquia, Numero 519-2008, entre el Ministerio de Salud y Proteccion Social y Facultad Nacional de Salud Publica.

Conflicts of interest: none.

Receipt date: April 16th 2012.

Approval date: September 19th 2012.
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Title Annotation:articulo en ingles
Author:Lalinde-Angel, Maria Isabel; Molina-Marin, Gloria; Olarte-Lezcano, Martha Lucia
Publication:Investigacion y Educacion en Enfermeria
Date:Mar 1, 2013
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