'I wanted to enjoy our marriage first but I got pregnant right away': a qualitative study of family planning understandings and decisions of women in urban Yogyakarta, Indonesia.

ABSTRACT

BACKGROUND: Despite several decades of investment into family planning and maternal health systems strengthening, Indonesia's maternal mortality ratio remains among the highest in Southeast Asia. Among postpartum women unmet need for family planning is greater than at any other time, thus there is great potential to improve the reproductive health outcomes of Indonesian women through enhanced postpartum family planning access. This article explores the socially embedded nature of family planning choices in the Indonesian context, drawing on the experiences of a sample of urban dwelling and predominantly middle class women. METHODS: This was an ethnographic study which explored the reproductive experiences of women residing in Yogyakarta City, and Sleman and Bantul regencies. Fieldwork was undertaken over 18 months from September 2014 to March 2016. This article draws on 31 in-depth interviews (IDIs) conducted with 20 women aged 21 to 38 years who had given birth less than two years prior. RESULTS: Though there was great variance across women's reproductive trajectories, the majority had limited understandings of family planning, especially in relation to contraception. Societal norms pertaining to women's fertility and reproduction underpinned women's desires to become pregnant soon after marriage. Normative ideals concerning family size and the composition of families underpinned women's desires for a maximum of two to three children, with at least one child of each sex. Negotiations concerning timing of pregnancies and family size occurred within spousal relationships. The majority of women were using some form of fertility control to prevent or space pregnancies, with method choice decisions often informed by family members, friends and family planning providers. Quality of care among family planning providers was often lacking, perpetuating misinformation, and women's choices were not always respected. CONCLUSIONS: Our analysis reveals the socially embedded nature of women's postpartum family planning understandings and choices, and the ways in which social and relational factors sometimes constrain and at other times support women's reproductive agency. We identify key areas for health sector reform to enhance women's understandings of postpartum family planning and improve family planning quality of care.