The proportion of couples in Shanghai, China, practicing contraception and the method chosen vary substantially by the stage of the relationship.1 Twelve percent of couples had had premarital intercourse, and they were unprotected by a contraceptive method two-thirds of the time. Between marriage and first birth, 43% of couples practiced contraception, although more than half of those couples used traditional methods. After their first birth, 98% of couples adopted a contraceptive method--mostly the IUD--although discontinuation and failure rates remained high.
To investigate contraceptive method choice, switching and discontinuation before marriage, between marriage and first birth and after first birth, researchers used public records to identify newly married couples in two districts of Shanghai between August 1987 and August 1988. All couples who planned to delay having a child were invited to participate in the study (N=7,220); in addition, 691 couples who did not intend to delay having a child were randomly selected. The researchers interviewed participating couples three months after their wedding, and then again one and five years later. The interviews covered the couples' demographic characteristics, sexual behavior, and reproductive and contraceptive histories. Infertile couples were excluded from the analyses.
The researchers examined the data using simple tabular analysis and single-decrement life-table methods. They categorized couples as using the IUD, the pill, the condom, traditional methods (periodic abstinence or withdrawal) or "other methods" (e.g., ointments, suppositories and spermicides); the IUD, the pill and the condom were designated as "effective" methods, whereas traditional and "other" methods were considered "less effective."
Overall, 7,336 fertile couples participated in the study. The mean age at marriage was 26.6 for women and 28.7 for men; at first pregnancy, the mean age was 27.4 for women and 29.4 for men. Approximately 70% of both male and female participants had at least a high school education, and about 25% were white-collar workers.
Of the 912 couples (12%) who had had premarital intercourse, one-third had ever used contraceptives. Twenty-four percent of the 629 premarital pregnancies ended in induced abortion; 73% were carried to term--with all couples being married before the birth--and 3% ended in miscarriage or other outcomes. To delay the birth of their first child, 43% of the couples in the study practiced contraception after marriage; on average, the time from marriage to conception was 10 months longer for those who used a method than for those who did not (13.5 months vs. 3.7 months). Between marriage and first birth, there were 7,859 pregnancies, of which 88% ended in live births, 9% in miscarriages or stillbirths and 3% in induced abortions. After their first birth, 98% of couples practiced contraception. Approximately 3,700 pregnancies occurred after first birth, with 2% ending in live births, 2% in miscarriages or stillbirths and 96% in induced abortion.
For couples who practiced contraception prior to marriage or between marriage and first birth, traditional methods accounted for 52-55% of episodes of use, and the condom for 22-37%. However, after the first birth, the IUD was used in nearly half (47%) of all episodes of contraceptive use, whereas the condom and traditional methods were used in 23% and 21%, respectively.
As couples moved through stages of their relationship, both the proportion of months of exposure to the risk of conception that were protected by use of contraceptive methods and the proportion that were protected by effective methods increased. Before marriage, 32% of months of exposure were protected--22% by traditional methods, 8% by effective methods and 2% by other methods. Between marriage and first birth, the proportion of exposure that was protected increased to 42%--18% by traditional methods, 18% by effective methods and 6% by other methods. By the third year after first birth, 96% of exposure was protected--6% by traditional methods, 88% by effective methods and 2% by other methods.
Of the three effective methods, the pill protected the smallest proportion of months of exposure--about 2% before marriage and 1% in each subsequent interval. The proportion of exposure protected by the IUD, however, rose from about 2% before marriage to 76% by the third year after first birth. The condom protected almost 4% of months of exposure before marriage, a proportion that rose to a peak of 17% during the first year after first birth and then declined gradually to 11% by the third year after first birth.
Among newly married couples who wished to wait less than six months before becoming pregnant or had no reproductive plans, 72% reported not using a contraceptive method, 17% reported relying on effective methods, 8% traditional methods and 2% both; the mean time from marriage to conception among these couples was seven months. In comparison, 6-10% of couples who wished to wait six or more months before becoming pregnant used no method, 34-48% effective methods, 33-44% traditional methods and 10-17% both; their mean time from marriage to conception was 12-20 months.
The 12-month probability of and reasons for discontinuing contraceptive use varied by the type of method and the phase of the relationship. The overall probability of discontinuing any method was 70% before marriage. It was 44% for non-method-related reasons (i.e., access difficulties or the recommendation of another person), 22% for desire for a child, 21% for method failure and 10% for method-related reasons (i.e., side effects, inconvenience, health concerns and method ineffective). The probability of discontinuing was greater for effective methods than for less-effective methods (76% vs. 67%). Effective methods were more likely than less-effective methods to be discontinued because of contraceptive failure (43% vs. 13%) and method-related reasons (21% vs. 5%); less-effective methods were more likely than effective methods to be discontinued because of desire for a child (23% vs. 19%) and non-method-related reasons (48% vs. 30%).
Between marriage and first birth, the overall probability of contraceptive discontinuation decreased to 55%; desire for a child was the most commonly cited reason (29%). The probability of discontinuation for the IUD (31%) was lower than that for other effective or less-effective methods (54-57%). In addition, the IUD had a lower probability of discontinuation than other effective methods or less-effective methods because of desire for a child (11% vs. 29-30%), method failure (4% vs. 7% each) and non-method-related reasons (7% vs. 18-21%).
The overall probability of contraceptive discontinuation continued to decrease after first birth, to 41% within two years after first birth and to 20% at year three or later after first birth. The risk of discontinuation after first birth because of desire for a child was stable at less than 1%; however, the probability for method failure, method-related reasons and non-method-related reasons declined from 14-19% within the first two years after first birth to 4-9% at year three or later.
Although the probability of discontinuation for the IUD dropped to 11% in the first two years after first birth and then remained relatively stable, the probability for other effective methods did not decrease until three years after first birth, when it dropped to 32%. For less-effective methods, the risk of discontinuation increased to 71% during the two years following first birth before decreasing to 40% at year three.
The researchers comment that the low level of contraceptive use found within premarital relationships may, in part, be caused by a combination of social stigma and the fact that modern contraceptive methods require visits to a medical or family planning center. They describe the neglect of sexually active single people as the "most important defect of family planning provision in Shanghai," and suggest that "the provision of free condoms, together with appropriate information, education, and communication materials, to everyone, regardless of marital status, would be a step in the right direction."
According to the researchers, their "most surprising" finding was the delay in adoption of methods until two or more years following first birth, especially in light of China's one-child policy. They suggest as a possible explanation that sterilization is not considered an attractive option in Shanghai because of the possibility that a child might die and because of the hope that the one-child policy might be relaxed. --J. Rosenberg
1. Che Y and Cleland J, Contraceptive use before and after marriage in Shanghai, Studies in Family Planning, 2003, 34(1):44-52.