ANALYSIS OF FAMILY PLANNING DROPOUTS IN WOMEN OF REPRODUCTIVE AGE

The Family Planning Program (FPP) is one of the strategies carried out by the government to suppress the increase in population growth. Unfortunately, women of reproductive age (WRA) often stop participating in FPP or drop it out, unaware of increasing the risk of conception. This study uses secondary data from the 2017 IDHS for 945 WRAs who have used modern FPP methods. It uses cross-tabulation to determine the distribution of husbands' approval regarding the FPP method, wanting more children, side effects of family planning, the role of family planning service providers, and the incidence of dropping out of FPP in North Sumatra Province. The results indicated that 238 out of 707 WRAs (25.8%) dropped out of FPP. The FPP dropping out in North Sumatra Province mostly occurred to WRAs who experienced side effects of FPP methods (238 WRAs) and who changed their minds to want more children (67 WRAs). The BKKBN of North Sumatra Province must provide training to FPP service providers on the side effects of the methods to improve their counseling skills, which must be used properly to serve the WRAs before they decide to use contraceptives.


Introduction
The population problem is a global concern from year to year, indicated by the drastic increase in the world's population. In 2010, the total world population reached 7 billion, and it is estimated that this number will continue to grow to reach 9 billion in 2045 (BPS, 2020).
Indonesia is a country that has a fairly high population growth rate. Data from the Central Statistics Agency (BPS) shows it is currently ranked as the fourth largest population after China, India, and the United States. The population growth rate in Indonesia is 1.31% per year. In 2019 the total population of Indonesia was 268,047,600 million, consisting of 134,6657.6 males and 133,416.9 females (BPS, 2020).
The Indonesian explosion of population growth rate requires a strong, preventive strategy. One of the national development priorities in the National Long-Term Development Plan (RPJPN) 2010-2025 is realizing a balanced population growth, one of which sign is a decrease in the Total Fertility Rate (TFR). The 2012 IDHS showed a TFR of 2.6, meaning that an Indonesian woman gives birth to an average of 2.6 children during her lifetime. The target indicator set in the BKKBN Strategic Plan is 2.33 children per woman in 2017 (BKKBN, 2015).
The Indonesian population in 2020, according to BPS, is made up of 268,074.6 million people in total, with a population growth rate of 1.31% from 2010 to 2019. Meanwhile, the population of North Sumatra alone is 14,562.5 million people, with a population growth rate of 1.2 from 201 to 0 in 2019. North Sumatra has the fourth largest population in Indonesia after West Java, DI Yogyakarta, and Central Java, with 49.31 million, 39.69 million, and 34.71 million people, respectively (Badan Pusat Statistik Provinsi Sumatera Utara, 2020). The high population rate is directly proportional to the slow rise of new FPP acceptors, which is only 419,691 people (19.06%), in addition to its FPP acceptors dropping out of 418,713 people (18.57%).
The Areas outside Java-Bali II have a greater FPP dropout of 33.6% than the Areas outside Java-Bali I (32.9%) or of Java-Bali (30.5%). Looking at each region, the highest incidence of FPP dropout in the Java-Bali region happened in DKI Jakarta (35.7%), followed by Banten (33.6%) and the Special Region of Yogyakarta (32.9%). In the Areas Outside Java-Bali I, the highest incidence happened in North Sumatran Province (39.4%), followed by South Sulawesi (38.1%) and NAD (37.7%). Meanwhile, the Areas Outside Java Bali II, Papua, West Papua, and Southeast Sulawesi Provinces are in the highest order, with FPP dropout percentages of 49. 8%, 45.1%, and 43% respectively. (BKKBN, 2018).
In the efforts to control the number of births and create healthy and prosperous small families, the government has conceptualized and regulated birth spacing through Family Planning Program, with the aid of contraceptive methods (Nurjannah, 2017). But FPP now needs our greater attention as we are facing a population explosion.
Many women found they had not intended to become family planning acceptors but changed their minds after counseling (Cohen, R., 2017). Counseling and communication with successful acceptors provide great opportunities to develop willingness and motivation for mothers (Hawkins, 2016). An important factor in the family planning program is the selection of the right contraceptives (Septalia, 2017).
For sexually active women, the pregnancy rates in the first year can reach 90% without family planning or contraceptives. Some women delay pregnancy for various reasons, such as education, career, or finance. Choosing the right contraceptive method can help women to delay pregnancy. Most contraceptive methods are effective when used properly. Contraceptive failure can be caused by various factors, namely incorrect use, missed or irregular use, or because the method chosen is less effective. The choice of family planning method by EFA is adjusted to the needs of each couple. Family planning methods can be done using various contraceptives (BKKBN, 2014b).
Knowing the drawbacks of a method and the way to handle them is important before a potential acceptor decides what to use. Potential acceptors need to be aware that there are still no contraceptive methods completely perfect. Three things are important for prospective family planning acceptors to know: the effectiveness, safety, and side effects of a method. Side effects that often occur due to using contraceptives are amenorrhea, weight changes, dizziness, and headaches. If excessive side effects cannot be prevented to a minimum by avoiding risk factors, most of which are already known, the user tends to give up the contraceptive device and prefer to switch to another contraceptive (Setiawati, 2017).
The problem with family planning is that it is not yet fully accepted by couples of childbearing age, as there are still many who do not wish to become acceptors. We are also facing acceptors who drop out of FPP. In Indonesia, the number of FPP dropout events has increased, reaching 11.46% in 2008 and then 15.09% in 2012 (BKKBN, 2014a).
According to the 2012 Indonesian Demographic and Population Survey (IDHS), over 27% of FPP participants quit using contraceptives after 12 months for a variety of reasons, including a wish to become pregnant again (29%), a fear of side effects or health problems (18%), confused about what method is more effective (9.0%) and other reasons (4.8 %). By methods, the highest dropout rates occurred in pills (41%), condoms (31%), injections (25%), implants (8%), and IUDs (6%). According to Bilqis et al (2020), an increase in the dropout rate will have an impact on a decrease in CPR in Indonesia, where the CPR rate in Indonesia has already decreased by 0.69%. The results of the 2017 IDHS found that 37% of episodes of FPP methods were discontinued within 12 months. The most common reasons for the dropout were the side effects or health problems for 73%, and wanting to get pregnant for 27% (BKKBN, 2018).
To prevent FPP dropout, health workers can provide counseling about side effects. Counseling is more of a service than just a process. It runs and integrates with all aspects of FPP services, not just giving information in a one-time discussion at the time of delivery. Counseling is an important aspect of FPP and Reproductive Health services. Effective counseling is needed so that clients know how to use the correct family planning device, how large the side effects of each family planning method are, how to overcome misinformation, and ensure that they choose the best family planning method according to the client's health and condition (Cohen, R., 2017).
Our study aims to re-affirm the determinants previously found in similar research and to see if other determinants exist in the incidence of FPP dropout incidences in North Sumatra Province in WRAs.

Method
The data used in this study is secondary data from the 2017 RPJMN KKBPK Program Performance Indicator Survey. The 2017 RPJMN KKBPK Program Performance Indicator Survey is an annual survey conducted by the Research Center for Family Planning and Family Welfare of the BKKBN, which provides information about the achievements of the Population Program, Family Planning, and Family Development.
The data used in this study are the data on contraceptive use by Couples of Fertile Age (CFA) with their inherent characteristics to describe the FPP discontinuation incidence in North Sumatra in 2017. The dropout status was known through their answers based on their participation in contraceptive methods in the last 12 months. The population was all women aged 15-49 years in North Sumatra Province, with a total of 2521 WRAs. The inclusive criteria consist of the range of age between 15-49 y.o., being married or living together, and using modern contraception. Based on this, our study takes in 945 WRAs as samples.
Our data is secondary data from the 2017 Government's IDHS as data instruments, containing Husband's Approval Regarding Birth Control Methods, Wanting More Children, Side Effects of Family Planning Method, and The Role of Family Planning Service Providers. Data collection is carried out by taking the 2017 IDHS data from the official website and then coding and classifying them according to research variables. The dependent variables in this study are the FPP dropouts.
In this study, univariate analysis was used to categorize the dependent variables, i.e. the FPP dropouts, and the independent variables, i.e. socio-demographic factors, socio-psychological factors, and the role of family planning service providers. The bivariate analysis is carried out next to analyze the relationship between these two variables using cross-tabulation and the Kaplan Meier method with 95% CI.

Result and Discussion
The proportion of contraceptive dropout events in North Sumatra in women aged 15-49 years, according to the RPJMN Indicator Survey data, is as much as 7.4% of the 876 CFAs who have used birth control tools in the last 12 months. The result showed that the WRAs whose husband's did not agree with the FPP methods dropped out of the FPP more than those whose husbands agreed, with 235 (24.9%) compared to 3 WRAs (0.3%), respectively. The WRAs who skipped birth control discussions with their partners experienced more drop out, or as many as 132 (14.0%), than those who had the discussions, or as many as 106 (11.2%). The WRAs who wanted to have more children dropped out of the FPP more than the ones who did not, with 148 (15.7%) compared to 90 WRAs (9.5%), respectively. The WRAs who experienced side effects dropped out of FPP more than the ones who did not, with 238 (25%) compared to 90 WRAs (9.5%). In the case of FPP Service Providers, as many as 17 out of 40 WRAs dropped out of FPP despite having good access to FPP services. For the ones with bad access, 221 out of 667 WRAs dropped out of FPP. Several factors can affect a person's desire to have children. Some of these are 1) the number of children they already have, 2) each family's belief of the ideal number of children which is defined by their affordability of raising children, and 3) a more modern belief of having fewer children to keep up family quality, 4) busier lifestyles in urban areas which tend to make parents decide to have fewer children than in rural areas. 5) higher levels of education which fashion their desire of having no more children (Handayani, 2019).
Based on the study results, it was found that women who wanted to have more children and still used family planning were 156 WRAs (16.5%) compared to 67 WRAs who dropped out (6.7%). This is little as compared to 551 WRAs (58.3%) who desired no more children and used FPP in ratio to 148 WRAs (15.7%) who dropped out. Women choose to use contraception when they already have the ideal number of children (Aviisah, 2018;Sitorus, 2021). Therefore, women with many children are more likely to use contraception because they are more likely to have reached their ideal family size. The desire of whether to have more children affects the use of FPP methods. Sumartini (2017) revealed that the desire to have children is adjusted to the ideal number of children that a married couple has previously decided to have. Alayubi (2018) stated that many CFAs still hold the traditional values of children in a family, that children number defines and enforces status in society. Family size also defines the ideal number of children (Khairunnisa, 2015). Today the government is still trying to reduce the rate of birth rates, but it turns out that there are still many obstacles to the implementation of birth control, so the government has not succeeded in realizing two children per family (Sitorus, 2020).
Based on IDHS data (2012), it was stated that for family planning acceptors who stopped after five years duration, the main reason was due to side effects (14.4%), and the side effects cases for IUD itself were 19,232 cases (27.7%). As for the various reasons put forward by family planning acceptors, they stopped using contraceptives after 12 months of use due to contraceptive failures, wanting to get pregnant, wanting to change methods, and other reasons (BKKBN, 2014b).
The results also indicate that the majority of WRAs who felt side effects of FPP did not drop it, or as many as 535 (56.6%), compared to the other 238 (25.2%) who did. On the other hand, WRAs who did not feel the side effects of FPP and didn't drop it are as many as 172 (18.2%). None from this group dropout the FPP.
Stomachache is one of the side effects of using the IUD method, and it creates a negative perception in the community and is considered incompatible to use. On the contrary, it is a common thing and can be overcome if the acceptor is willing to consult with the service providers. Most of the side effects cannot seriously impact the acceptors' health, and it is hoped that the acceptors will be proactive in this regard. The results of Purwaningrum (2017) showed that of the 31 samples of IUD family planning acceptors who experienced abdominal pain, 18 of them (58.06%) had it only sometimes and the 13 others (41.94%) had it frequently. Each contraceptive method has a different effective period. An IUD has a long effective period of up to 10 years, and so does the side-effect. Common side effects include menstrual disorders, vaginal infections, IUD expulsion, perforation, heartburn/pain/cramps in the lower abdomen, and husband's genitals pain (Purwaningrum, 2017).
Contraceptive safety is one of the considerations in selecting methods by WRAs (Weni, 2019). Health workers as service providers play an important role in contraception; they provide information and advice related to its use (Siregar, 2021). Injectable contraceptives are highly effective and simple to use, but they have negative effects, particularly in altering the menstrual cycle. Although injectable contraception is one of the most effective, widely used, and widely accepted methods of contraception, there are still many acceptors of 3-month injectable contraception who are unaware of its side effects (Happy, 2021).
Although oral contraceptives are among the most commonly recommended by doctors, the dropout rate is still relatively high for various reasons, including discomfort or difficulty in taking them every day, as well as the chance of forgetting to take birth control tablets. FPP failures can be attributed mostly to the acceptor's reluctance of using the birth control pills. The side effects of birth control pills include feeling disturbed and uncomfortable when using birth control pills, and they are among the reasons why acceptors are less obedient (L. Nelson, 2018). In contraception, the CFAs' knowledge about FPP importance's and contraceptives' dos-and-don'ts also matters (Ismah, 2021). Caecilia (2020) pointed out that birth control pills can have a variety of negative effects. There are five side effects mostly encountered by pill takers. These include weight increase, headache, nausea, acnes, and migraines. Meanwhile, the most common side effect of taking implants is a change in the menstruation cycle, which occurs in around 60% of the acceptors during the first year of implantation. Although less common than prolonged bleeding or spotting, reduced menstrual cycle length and amenorrhea can also happen (Haslan, 2020).
The results of Haslan (2020) show a relationship between the use of FPP implants and weight gain. An implant is a type of contraception in the form of an elastic rubber containing hormones, which is attached to the upper arm. Implants can be used for up to 5 years. Implants can cause menstrual disorders, such as amenorrhea and spotting, weight gain, acne, breast tension, and vaginal opening feeling dry which leads to coitus discomfort.
In society, hormonal contraception is not uncommon. Almost 80% of FPP acceptors use hormonal contraceptive methods. However, the fact that it brings up many side effects has turned down many acceptors because they do not understand how the hormonal contraceptive method works. Hormonal contraceptive acceptors often feel nausea, headaches, weight gain, breast swelling, and changes in menstruation. These effects are harmless but often uncomfortable and the acceptors can't be made familiar with these side effects (Apolonia, 2018). Meanwhile, menstrual irregularities are greater in users of the 3-month than the 1-month injection type of contraception. The statistical analysis results showed that respondents who used the 3-month type of contraception were 15.4 (1/0.065) times more likely to experience menstrual pattern disorders than those who used the 1-month injectable contraceptive.
This research can contribute to FPP, especially to the problem of dropouts in North Sumatra which is still high because of the not enough effort. However, the study is still limited by the exclusion of equally important variables in birth control dropout, such as religious, cultural, and economic aspects.

Conclusion and Suggestions
Most of WRAs joining FPP are those who took junior high school for their last education level, still work, are included in poor economic level, live in rural areas, have three children alive, do not want to have another child, and have no side effects of birth control. There are no significant differences in education, employment status, area of residence, husband's approval, discussions with spouses, or family planning service providers' role concerning the incidence of FPP dropout of the WRAs in North Sumatra Province. Researchers hope to conduct further research by including aspects such as religion, patriarchal culture, and economics that are assumed to equally matter in the occurrence of FPP dropout.