Implementation of Family Planning Program (Keluarga Berencana) in Aceh Province

Family Planning (KB) is a national program to reduce birthrate and control the population growth in a country. The aim of this study was to identify the knowledge, use and contraception source/contraception type, contraception type selection based on information obtained, also level and reasons of discontinuation using the type of contraception. A secondary data study, from Demography and Health Survey of Indonesia (SDKI) Aceh 2017 was conducted. The sample of WUS as many as 955 people and 166 married men took part to the study. The result shows that 100% samples knew a type of contraception, 51,6 % married women use a type of contraception, and the highest level of termination in using type of contrasception was injection contraception (22,3%). Suggestion: health workers need to provide a strategic health promotion about contrasception type using informative and creative leaflet, health workers offer health education to women aged 15 – 19 years old, manage or activate KB program in KB village, implementation and socialization about SDM (Standart Day Method), targeting married man as a potential KB acceptor.


Introduction
Government efforts to reduce the high rate of growth in Indonesia is to set up a board which is specifically responsible in controlling population growth in Indonesia, National Family Planning Coordinating Board (BKKBN). Controlling population growth is done through the Family Planning (KB). KB is not only meant as birth control efforts, but also to build awareness of every family to have attention and support in social-cultural issues, economy, education, and health in order to become a prosperous family. KB also can help couples avoid unwanted births, birth spacing, and specify the number of children in the family (WHO, 2010).
Indonesia is the fourth country with the largest population in the world total population of Indonesia. Based on the projections of the National Development Planning Agency (Bappenas) 2013, Indonesia reached 265 million population in 2018. This amount consists of 133.17 million men and 131.88 million women. By age group, the population that children (0-14 years) reached 70.49 million, or approximately 26.6% of the total population. The productive age (14-64 years) is 179.13 million (67.6%) and the elderly as many as 85.89 million people (5.8%).
The population in the category of childbearing age, women or spouses of fertile age (PUS) is a priority category to use contraception. National Economic Social Survey Data (SUSENAS) 2015 depicts that most spouses of fertile age (PUS) still rely on hormonal contraception with the highest percentage is injection contraception (59.57%) and the pill (20.71%), but implants contraception (6.21%). (Susenas, 2015). This is in line with the data IDHS Indonesia, Injectable birth control (29%) is a contraception most widely used by married women, followed by the pill (12%), implant and IUD (each 5%), and MOW (4%) (Indonesian Demographic and Health Survey, 2017).
Based on data from the Aceh Provincial Health Profile 2017, number of spouses of fertile age (PUS) in 2017 amounted to 44,187, while the active family planning participants as many as 31,201 people (70.61%). 52% of married women use a contraception, 47% wear modern family planning method, and 5% using the traditional family planning method. Injection (26%) is a contraception that most widely used by married women, followed by the pill (10%), implant and IUD (each 2%), and MOW (4%). MOP contraception, implant, IUD and MOW is a Long-Term Contraception Method (MKJP) that recommended its use in Family Planning (SDKI Aceh, 2017).

Formulation of the Problem
One of indicator in family planning program is using contraception and CPR (Contraceptive Prevalence Rate). CPR is the percentage use of contraception by couples of reproductive age (PUS) that WUS (aged 15-49) are married or living together. The level of achievement of family planning services can be seen from family planning participants who are or have ever acessed contraception, family planning service, and type of contraception used by acceptors (Depkes, 2010). Aceh province has a higher active KB scope of coverage of 44,187 new family planning that the existing amount of PUS in the year 2017 a new family planning participants only 9,585 (21.69%) and active family planning participants amounted to 31,201 (70.61%) (Aceh Province Health Profile, 2017).
Improving the quality of family planning services in Indonesia, especially in Aceh is directed to maintaining the use of tool/method of contraception. An important indicator for measuring the quality of the use of tool/method of contraception is dropout rate. In general, 29% of women in Aceh who started using the tool/method of contraception within 5 years prior to the survey stopped using the tool/method that within 12 months of starting with variety of reasons and there are only 8% who use long term contraception method. In family planning (KB) needs, it decreases in SDKI 2012 (14%) to 12 percent in SDKI 2017 (IDHS Aceh, 2017).

Aims
This scientific paper aims to determine the impementation of the family planning program in Aceh province through secondary analysis of Indonesian Demography Survey Data or known as SDKI (Survey Demografi Kependudukan Indonesia).

Materials and Methods a. Scope
This research was sourced from secondary data from SDKI 2017. The research sample includes 92 census blocks covering 30 urban areas and 32 rural blocks census, samples of Women of Childbearing Age or Wanita Usia Subur (WUS) as many as 955 people and 166 married men. The 2017 SDKI sample frame using Census Block Sample Master of the results of the 2010 Population Census (SP2010). The sampling design is done in two stages: selecting a number of blocks with probability proportional to size (PPS) systematic with the size of a number of household listings SP2010, then sort of census block by category Wealth Index from the SP2010, and selected 25 ordinary households in each block census systematically selected from the results of updating households in each census block (SDKI, 2017).

b. Preparation Phase
This study uses two types of questionnaire that is a household questionnaire, women of childbearing age (WUS) the married man (PK). Questionnaires households and women aged 15-49 refers to the questionnaire DHS (Demographic Health Surveys) Phase 7 in 2015 which already accommodates some of the latest issue of the appropriate international comparability (SDKI, 2017).

c. Data Collection
Information on knowledge tool/ method of contraception in the 2017 Demographic and Health Survey obtained by asking respondents mentioned the way that can be used by married couples to prevent pregnancy. If the respondent can not answer spontaneously, the interviewer read an explanation of each tool/method of contraception and ask if the respondent knows the tool/method of the KB. Information collected includes tool/method traditional and modern family planning method. Tool/method of contraception modern consists of a method of operation of women (MOW) or female sterilization, method operation of man (MOP) or male sterilization, the pill, IUD, injections, implants, condoms, diaphragms, amenorrhea method lactation (MAL), and contraception emergency. Tool/method of traditional family planning consists of periodic abstinence, withdrawal, and other traditional contraception.

Results and Discussion Knowledge of Tool/Method of KB
According to the table 1 the percentage of knowledge maried women and men in the range of 98.2% to 99.3%, the highest married women knowledge is a about injectable contraception (98.6%), while married men about pill (90.4%). Beside, about traditional contraception, the percentage of married women knowledge is greater than married men by margin 9.4%. According to the table 2 is known that at the age of 30-34 years in married women and married men have better knowledge about the tool/method of contraception (100%). Similarly, married men and women in urban areas, ever heard information about tool/method of contraception (100%). All married men and women with college educational background, heard about the tool/method of contraception (100%).

Use of Tool/Method of Contraception
Based on Table 3, it is known that the use of the tool/method of contraception in of married women is dominated by modern methods, while the majority chose the traditional method of coitus interruptus with the lowest percentage at age 40-44 (2.0%) year, and the highest in at age 25-29 (4.8%). Based on the data obtained table that 66.7% married women aged 45-49 years did not use any tool/method of contraception.
Based on Table 4, it is known that married men prefer to use the traditional method with the highest percentage of periodic abstinence 100% at age 20-24 years. While at age 25 to 54 years is not much difference in the percentage with a range 92.6% -97.9%. However, there are 3.9% of married men aged 40 -44 years old choose modern methods such as sterilization.

Discontinuation of Using Tool/Method of Contraception
Based on Table 5, note that there are various reasons of discontinuation of using the contraception. The highest reason stops using tool / method of birth control injection is trying to become pregnant (56.3%), followed by health reasons (22.3%) on the Pill.

Discussion
Some of the problems in the implementation of family planning in Aceh are:

Knowledge about Tool/Method of Contraception
Almost 100 percent of married women and married men know a tool/method of contraception (99% and 98%). Sixty percent of married women and 7 percent of married men know all of modern tool/method of family planning. Above 90 per cent injection contraception is / very popular among women, while among men pills and condoms. By background characteristic, knowledge about tool/method of contraception in Aceh Province is good, marked with the percentage of married women aged 15-49 and married men aged 15-54 who have heard at least one kind of tool/method of contraception also a kind of modern family planning method reached 100% at age 30-34 (SDKI Aceh, 2017). 100% of married women aged 15-49 and married men aged 15-54 who have heard a type of contraception tool/method has a higher educational background in University. Knowledge is a result due to an object sensing process. Most human knowledge is derived from the information read and heard (Notoatmodjo, 2014).
There are significant differences in the level of knowledge about the IUD after WUS given health education leaflets media (Istiqomah, I, 2016). While the study results from Hand, L., Suharmiati, Hariastuti, I., Latifah, C (2012) that family planning information can be improved by improving the competence of health workers (nurses) who provide family planning care through technical skills training in counseling, upgrading the client chooses the type of contraception, as well as increased public awareness. Lack of knowledge about contraception methods, sources of supply, cost or poor accessibility are obstacles that exist in developing countries (Jahan U, Verma K, Gupta S, Gupta R, Mahour S, Kirti N, et al, 2017).
Beside knowledge, motivation is a factor that affects the use of tools / contraception. Research results of Rozi, Utami, and Lasri (2017) there is a correlation between level of knowledge and the motivation of male contraception use of PUS.The motivation for using contraception vary across the population. This is particularly relevant to the research results, in which the woman or man who is given prior information to choose or decide to use the KB with the percentage more. Selection tool/method of contraception based on information received between women who use modern tool/method of contraception within a period of 5 years prior to the survey is sterilization, by 67, 9% were told about side effects or problems of the methods used, while injection contraception and pill ranges between 34 -39.3%. As source of contraception service, the government hospital is a source of service that deliver all information items (Family Planning Method Information Index) as many as 38% (IDHS Aceh, 2017).

Use of Tool/Method of Contraception
Family planning refers to conscious efforts by couples to limit the number of children they have through the use of contraception (H Survey, 2016). The use of contraception can prevent at least 25% of all maternal deaths by preventing unwanted pregnancy and unsafe abortion and also protect against sexually transmitted infections (Weldegerima B, Denekew A, 2008), such as Human Immunodeficiency Virus (HIV), Chlamydia, Syphilis, etc.
The use of birth control currently in Aceh province was highest in married women aged 35-39 years (59.4%), while not using birth control was highest in married women aged 45-49 years (66.7%) (ISDK Aceh, 2017). Some women use contraception to space births, while the other women adopt contraception to stop labor. The use of tool/method of contraception in married women is dominated by modern methods, while the majority chose the traditional method of coitus interruptus with the lowest percentage at the age of 40-44 (2.0%) year, and the highest at age 25-29 years (4.8%). This is in line with a research by Wani, RT, Rashid, I., Prophet, SS, and Dar, H (2019) that one of the factors that determine or relate to the use of birth control is age. Besides, there are other factors such as marital status, length of marriage, family type, number of children, and how often are exposed to information about family planning.
Today, the modern methods of family planning of short-term available at all levels of government and private health facilities, while the long-term methods is provided in health centers, hospitals and private clinics. Costs can affect the range of contraceptive use by acceptors. Cost of contraceptive use significantly influence the selection of contraception methods. Acceptors considers the cost to be incurred to obtain contraception services are not expensive, have the possibility of 0.078 times more likely to choose non MKJP contraception compared with acceptors which considers the cost to be borne to obtain contraception services are expensive (Septalia, R & Puspitasari, N, 2016).
The side effects of contraception are the determinant of the use or discontinuation of use of contraception itself. Almost all hormonal contraceptives have side effects, according Hartanto (2015) side-effects is one factor that can influence the selection of contraception methods. Acceptors have experienced side effects from the use of contraception, have the possibility of 5.443 times more likely to choose non MKJP contraception compared with acceptors have never experienced any side effects from the use of contraception (Septalia, R & Puspitasari, N, 2016). This is in line with research by Mato and Rasyid (2014)  Based on the research, it is known that most birth control users are women. Based on this research also it was found that men who have a good knowledge will participate in using of contraception (Moyo et al, 2012 andBani et al, 2014). A good knowledge will shape a positive perception, where the husband with a positive perception about contraception will highly participate to use contraception than men whose negative perception (Purwanti, 2014).

Discontinuation Using Tool/Method of Contraception
Theoretically, every tool/method of contraception almost 100% effective. But the behavior of users and service providers sometimes cause the device/drug becomes less effective. Many things can cause the dismissal of the use of tool/method of contraception, such as fertility, menopause, abstinence, was not fertile, and the couple wants to have another child. Within episodes of use a tool/method of contraception that began in the 5 years prior to the survey, the percentage of discontinuation within 12 months according to the side effects of injections are as much as 9.5%, while the percentage distribution of discontinuation tool/method of contraception within 5 years prior to the survey according to the main reason for stopping injections are because trying to become pregnant (56.3%) and side effects (22.3%) (ISDK Aceh, 2017).
Based on this research, it was found that the spousal support is highly correlated with the incidence of discontinuation using the tool/method of contraception (Prasad, 2015) and there is a higher tendency of family income, the lower the incidence of drop outs KB (Aini, AN, Mawarni, A., Dharminto, 2016 ). In addition, the factors that most determine the incidence of discontinuation of contraceptiob are wife age, number of children and child composition that has been owned by PUS (Indrawati, L, 2013).

Conclusion
Health workers are required to have a specific strategy in delivering health promotion about tool/method of contraception through informative and interesting leaflets. There are several possible strategies, health workers need to provide reproductive health education to women aged 15-49 years old, forming of effective family planning programs in KB villages, implementating and disseminating of SDM (Standard Day Method), and targeting married men as potential acceptors.