Characterizing Family Planning Utilization in Adult Women and Adolescents in Pohnpei, Federerated States of Micronesia

Family planning allows people to attain the number of children they desire and to determine when and how far apart their pregnancies occur. Ensuring access to family planning resources, such as contraceptives to prevent pregnancy, is essential to improving maternal and child health around the world, as outlined in the United Nation’s Sustainable Development Goals (United Nations [UN], 2020). Target 3.7 of the Sustainable Development Goals calls for universal access to family planning by 2030 and the monitoring of family planning indicators. Over the past 20 years, increasing family planning utilization has led to a 40% decrease in the number of maternal deaths in low-income countries and has improved health outcomes for children worldwide (Ahmed et al., 2012; Cleland et al., 2012). Family planning also has economic implications: it boosts savings in maternal and child healthcare and leads to better educational and economic outcomes for women (Darroch et al., 2016). However, one in ten women globally have an unmet need for family planning (Family Planning International [FPI], 2009).

The Federated States of Micronesia (FSM) is an independent Pacific Island nation in the Western Pacific Ocean located north of Papua New Guinea (Cash et al., 2021). It is made up of four states comprising of 607 small islands. According to a 2010 census, the total population of FSM was 102,843 (Federated States of Micronesia [FSM] Statistics Division, n.d.). The capital state of FSM, Pohnpei, was estimated to have a population of 36,832 in 2020 (FSM Statistics Division, n.d.). Although FSM is an independent nation, it has a compact of free association with the United States which entitles it to certain US federal programs and funding such as the Human Resources Service Administration (HRSA) Title V Maternal and Child Health Block Grant.

Similar to other Pacific Island nations, FSM has a high rate of maternal mortality, and it falls into the high-risk category for reproductive risk (FPI, 2009; United Nations International Children’s Emergency Fund [UNICEF], 2013). The rate of maternal mortality in FSM in 2017 was 88 deaths per 100,000 live births, while in the United States, the maternal mortality rate was 17.3 deaths per 100,000 live births (UNICEF, n.d.; Centers for Disease Control and Prevention [CDC], n.d.). FSM recently fell short of meeting Millennium Development Goal 5, which is to improve maternal and child health, and reproductive health is a key facet of this goal (Pacific Island Regional MDGs Tracking Report, 2011). In addition, the adolescent fertility rate was 37 per 1,000 women ages 15–19 (The World Bank, n.d.), compared to 16.7 per 1000 in the US (CDC, 2019).

Having access to family planning is important for both adults and adolescents. One previous study of youth not attending school in FSM found that 76.1% were sexually active and 88.3% rarely or never used condoms (Corner et al., 2005). Short-term health outcomes of unmet need for family planning for adolescents include unintended pregnancies and sexually transmitted infections (WHO, 2020). When compared to women 20–24 years old, adolescent girls who are pregnant have higher risk of adverse outcomes such as eclampsia, puerperal endometritis, systemic infections, low birthweight, preterm delivery, and severe neonatal conditions (Ganchimeg et al., 2014). Additionally, abortion is not available in FSM, so there is potential for pregnant girls to turn to unsafe practices if they cannot afford to travel off-island for an abortion.

The long-term impacts of unmet need for family planning include health, educational, and economic effects. In low-income countries, only 11% of adolescents who become pregnant continue with their education, and the children of adolescent parents tend to perform worse in school (Molina et al., 2010). In small island states, improved access to family planning could lead to saving in healthcare spending. One study found that in Vanuatu and the Solomon Islands, meeting family planning needs would save Vanuatu $5.19 million and the Solomon Islands $3.36 million over a fifteen-year period (Kennedy et al., 2013). Providing family planning also has other beneficial effects, such as increasing the female labor force (Bloom et al., 2009).

The data that have been published on reproductive health in FSM have been limited and mostly focused on sexual risk behavior, pregnancy, healthcare seeking, and HIV/AIDS (Smith, 2013). To understand the full picture of reproductive health, it is also important to consider the prevalence of family planning utilization, associated risk factors, and barriers to utilization. Family planning utilization in Pohnpei was examined for both adolescents and adult women of reproductive age using representative survey data collected in 2019. This study aimed to determine the prevalence of overall family planning use among adolescents and adults, prevalence of specific family planning methods, reasons for not utilizing family planning, and factors associated with family planning utilization.

This study is the first to characterize family planning utilization and related variables in FSM. In addition to describing family planning utilization, we give several recommendations on how to increase access to and utilization of family planning resources.

In the United States, 64.9% of women of reproductive age (15–49 years old) currently use family planning (CDC, 2018). In contrast, 31.6% of women 18–49 years old in Pohnpei reported using family planning. Women who are young and/or unmarried reported utilizing family planning significantly less than older and/or married women. This is consistent with previous findings that young, unmarried women in low- or middle-income countries tend to have less access to family planning (Chandra-Mouli et al., 2014). In addition, we found that family planning utilization is significantly associated with factors that are indicators of healthcare access, including health insurance and whether a woman has ever had a pap smear. Although the results were not significant, women with a higher family income and those who have had an annual exam in the past year reported the use of family planning at a higher prevalence. Similarly, family planning use stratified by ever having a clinical breast exam is insignificant, but the trend indicates that women who have had a breast exam were more likely to use family planning (42.9%) than those who had not (30.2%). Women who had more previous pregnancies had a significantly higher prevalence of family planning utilization, likely due to the desire to limit their family size.

Similarly, 71.5% of high school age, sexually active adolescents in Pohnpei reported not using any family planning during last sexual intercourse. In 2019 in the United States, only 11.9% of sexually active adolescents reported not using any family planning during last sexual intercourse (Centers for Disease Control & Prevention, 2019). We found that the prevalence of condom usage for boys was significantly higher than the prevalence of condom usage for girls, and condom usage decreased as age increased. Condoms are readily available at most high schools in Pohnpei, and there is less stigma for boys around using condoms than for girls. In agreement with previous research, family planning use in youth may be associated with risky behaviors (Pinhey & Wells, 2007). Adolescents who chewed betel nut were significantly less likely to use any family planning during last sexual intercourse, and although not significant, adolescents who smoked tobacco, used any tobacco, and drank alcohol reported using family planning at lower rates than those who did not. However, there is no clear relationship between family planning use and the age of first sexual intercourse or the total number of sexual partners.

Based on the finding that young, unmarried women are using family planning at low rates, interventions to increase utilization of family planning to promote healthy families should target this group. The most common reason that women reported for not using family planning was that they simply didn’t think about it, so it may be important to ensure access to family planning methods that do not require consistent thought, such as shots, contraceptive implants, or intrauterine devices (IUDs). These methods were found to be underutilized in the high school adolescent population. Currently, there is no required sex education curriculum at schools in Pohnpei State. Previous research has found that adolescents who receive sex education are significantly more likely to use family planning, and sex education is also associated with delaying the age of sexual initiation and first pregnancy (Lindberg & Maddow-Zimet, 2012). By providing students with education on family planning, adolescents would be able to make informed decisions on when to have sex and whether or not to use family planning.

Another factor that should be considered when planning an appropriate intervention is stigma and the general attitude toward family planning utilization in Pohnpei. Currently, the misconceptions in the Pacific Islands region around family planning, especially for adolescents, serve as a barrier to increasing the uptake of family planning (White et al., 2018; Winn-Dix et al., 2016). In addition to improving access to family planning resources, it is important address these cultural barriers and familial factors to improve utilization (Bongaarts & Bruce, 1995). Previous research has found that men’s attitudes toward family planning are a better indicator of family planning utilization than women’s attitudes in Micronesia (Brewis, 2001). Future interventions should target both men and women at a young age. While many Pohnpeian women do not speak with their healthcare providers about family planning until after they have had their first child, it may be important to initiate these conversations earlier—during routine well woman visits or cancer screenings, for example. Therefore, there may be an opportunity to join efforts on increasing prevalence of annual well woman visits with increasing education on family planning. While increased education of and access to family planning does not mean someone must use family planning, having the option provides many potential benefits—decrease in maternal deaths, improved health outcomes for children, and improved educational and economic outcomes for women, although this relationship has not been specifically studied in FSM (Ahmed et al., 2012; Cleland et al., 2012; Darroch et al., 2016). It can also minimize unintended pregnancy and the spread of sexually transmitted infections (WHO, 2022).

This novel study characterized family planning utilization in adult reproductive-aged women and adolescents in Pohnpei. A strength of this study was the survey design—both the Rapid Youth High School Survey and the Hybrid Survey were administrated by trained individuals and had high response rates. The Rapid High School Survey included all high schools in Pohnpei, so is highly representative of Pohnpei high school students. The Hybrid Survey collected data from a large representative sample of overall adults residing in Pohnpei. One weakness is the small sample sizes, which is simply due to the small population of Pohnpei. Another is that the Rapid Youth High School Survey includes adolescents over the age of 18 who would also be eligible for the Hybrid Survey. This could have led to some individuals surveyed twice and being present in both samples. However, this number is small enough that it should not greatly affect our results. Additionally, the Rapid High School Survey does not capture out of school youth, who may be at higher risk for some behaviors being examined in this study. Finally, some responses were self-reported, which may have introduced response bias, especially for questions on sensitive topics such as sexual behavior. One major limitation is the descriptive nature of this study that does not allow us to control for confounding factors. Additional analytical studies are needed to further understand how multiple factors together are associated with family planning in Pohnpei.

In Pohnpei, the prevalence of family planning utilization is low for both adolescents and adult reproductive-aged women, and it is especially low for girls and women who are young and/or unmarried. These findings indicate the need for a better understanding of obstacles to family planning utilization and possible interventions that target both access and cultural barriers.