The prominent factors of the selection of injecting contraception equipment in women of childbearing age in Yogyakarta

The prominent factors of the selection of injecting contraception equipment in women of childbearing age in Yogyakarta Nur Azizah Indriastuti1*, Riski Oktafia1, Agista Wulan Aviani


INTRODUCTION
According to the United Nations, the world population in 2015 was recorded as many as 7.3 billion people. However, in 2019, it had reached 7.7 billion people. 1 In this data, Indonesia has also experienced an increase, as seen from its population census data conducted by the Central Bureau of Statistics (BPS), which showed that in 2010 there were 238 million people. By 2020, it had reached 271 million people. 2 Bantul Regency became one of the largest districts, especially in the Special Region of Yogyakarta Province, which experienced an increase in population.
Since it was recorded that there were 760 thousand people in 2010, this region had increased its population in 2018 to 1 million people. 3 Subsequently, the family planning (KB) program could control this everincreasing population growth. According to the World Health Organization (WHO), contraceptives worldwide show more than 4 million users. 4 Contraceptive use has increased in many parts of the world, particularly in Asia and Latin America, and use is lowest in Sub-Saharan Africa. Based on basic health research conducted by the Indonesian Ministry of Health (2018a), the number of Indonesian women of childbearing age (WCA) is the largest in Southeast Asia with a percentage of 70%, followed by Vietnam 25.5%, the Philippines 23%, Thailand 20% and Myanmar 15%. In the Special Region of Yogyakarta Province, 74.8% of WCA use contraception, Bantul Regency itself has 27.9% WCA. 3 Many WCA using contraceptives has several reasons: fear of unplanned pregnancy, the need to prevent HIV and other sexually transmitted infections, encouragement from health care providers and health workers, or encouragement to control the desired number of children. 5 According to the Indonesian Ministry of Health, offers various types of contraceptives are available and can be used by the community in the family planning program. Each of the multiple ORIGINAL ARTICLE rule contraceptive use as prohibited. 9 Another factor is parity, WCA with multiparas will choose injectable because it is more comfortable and has low side effects. 11 Based on a preliminary study conducted in the Brajan hamlet, Special Region of Yogyakarta, it was found that there were 296 active family planning participants, including 107 people who used injections. The interview results with the cadre mothers stated that women of childbearing age who are using injectable contraception have numerous reasons: device affordability, device practicality, the cost-effectiveness of the device, and minimum effects of the device. Based on this incident, the researchers were interested in analyzing the related factors that could influence the choice of injectable contraceptives in Brajan Hamlet, Tamantirto, Kasihan, Bantul, Special Region of Yogyakarta.

METHODS
This study was designed as qualitative research with a descriptive-analytical approach. This research used the purposive sampling technique. Several samples in this study were nine samples. The inclusion criteria in this study of women of childbearing age who used injectable contraception were willing to sign the informed consent and communicate well. This research was conducted on January 22 -February 06, 2021, in Brajan hamlet, Bantul. The instruments used in this study were interview guides, field notes and voice recorders. Analysis of the data in this study was conducted by analyzing and classifying the meaning of the interviewees' statements-furthermore, the conclusion was drawn in several major themes.

RESULTS
Nine participants were interviewed from January 22 to 6 February 2021. All participants were women of childbearing age in Brajan hamlet, Bantul. By the participants' criteria, all of them were using injectable contraceptives. The age range of participants started from 22 years to 44 years. The religious background of the participants was Muslim. Nine participants had varied work backgrounds. Five people had been working as housewives, one person had been working as an entrepreneur, one person had been working as a private employee, and one person had been working as a laborer. The results of this study contained six major themes through in-depth interviews with these participants. These themes are: 1.1. Mother's injectable contraception use experience. The experiences of some participants who used injectable contraception were positive reactions. This is based on the following participants' arguments: contraceptives has its advantages and disadvantages. 6 There are two sorts of contraception, in this case, namely simple contraception (calendar and intercourse interrupted) and modern contraception. Modern contraceptives are divided into three subtypes: short-term contraceptives (injections, pills, and condoms), longterm contraceptives (intrauterine device (IUD) and implants), and permanent contraceptives (medical operative women (MOW) and medical operative men (MOP). 7 Based on data from the Indonesian Ministry of Health about the prevalence of contraceptives, the use of non-long-term contraceptives (non-MKJP) was 69.33%. This percentage illustrated how WCA preferred these contraceptives compared to long-term contraceptive methods (MKJP) that are only used by 30.67% of the total population of Indonesia. 6 Furthermore, injectable contraceptives were recorded as much as 48.56%, followed by oral contraceptive pills, which was 7.39%, and the lowest one was MOP, which registered as many as 0.70%. In the Special Region of Yogyakarta Province, as many as 157,734 WCA are known as active family planning participants. Meanwhile, the method chosen by women in Yogyakarta is the injection method, reaching 31.5%. In this case, Bantul Regency had 28.6% of the use of injectable contraception, according to data from the Representation of the National Family Planning Coordination Board of D.I. Yogyakarta. 3 The data from the Ministry of Health of the Republic of Indonesia showed that WCA mostly chooses injectable contraceptives. 6 By the research of Syabana et al., WCA chooses injectable contraception over others because it has relatively small side effects, is economical, and is widely available in clinics and other health services. 8 In addition, the choice of injectable contraceptives can also be influenced by factors that are considered according to the individual. 9 According to Hasnani, WCA considers socio-economic factors in choosing injectable contraception. This contraceptive is deemed to be cheap, practical and easy to obtain. 10 In addition, there are norms and cultural barriers that

ORIGINAL ARTICLE
an option over a 1-month injection (combination). Acceptors felt that the contraception was comfortable, safe, effective, and did not interfere with their spouse's sexual relationship and could be used after childbirth. However, our study found that there were also participants who experienced negative feelings such as worrying about having menstruation disorders when using injectable contraceptives. According to Nurullah's research, DMPA contraception has a higher interest rate than combined injection contraception due to convenience, frequency, cost-effectiveness. 14 This study is also in line with Rilyani et al., 15 , who said a significant relationship between injectable contraceptives and the incidence of menstrual disorders in family planning acceptors. This is because users of injectable contraceptives more than one year had a five times chance of experiencing menstrual disorders than acceptors who used under one year. 1.1.2. The duration of injectable contraceptives use The results showed that almost all participants had a long experience in injectable contraceptives. The duration of contraceptive use was the goal of the participants to delay and regulate pregnancy. Following Kusuma's research, the time of contraceptive use depends on the respondent's purpose, whether to space births or end fertility. In addition, a good pregnancy distance for mothers to get pregnant again is the most ideal, which can be calculated from after the mother gives birth until she will enter the next pregnancy period, which is 2-5 years. 16 This is also in line with Fitriana & Diza's research that found 27 acceptors (77.1% of total acceptors) used injectable contraceptives for more than one year rather than other acceptors who used injectable contraception under one year. This means that the interest in injectable contraceptives is still high because of the advantages other than some disadvantages. The proof is that DMPA injection contraception is still the choice of acceptors. 17 1.2. Mother's Perception of the Use of Injectable Contraceptives Mother's perception of the use of injectable contraceptives includes the reason for choosing contraception, the belief to be loyal with contraception use choice and the injecting contraception understanding. 1.2.1. The mother's reason for choosing injectable contraception The results showed that the five participants had reasons for choosing by looking at the advantages of injecting contraception and choosing because of their own choice. The benefits include; ease of installation and convenience of the contraception. This study is by evidence from Anggriani et al. that the reasons for using injectable contraception are the benefits of injectable contraception, the ease of using injectable contraception, the convenience of using injectable contraception, and the cost of injectable contraception. 18 In addition to this, we also found another four participants had reasons for choosing injectable contraceptives because their midwives supported them after delivery. Following the research of Prihati et al., most respondents chose injectable contraception because of their own choice. As many as 80.6% and 12.2% were motivated by midwives. In this case, hence, midwives were also influential to play a role in providing service information, information, counseling, and explain about contraceptives. 19 Based on this, it can be seen that the participants' reasons for using injectable contraceptives are related to the advantages of injectable contraceptives and the support of health workers in choosing contraception. So that it helps participants in choosing injectable contraception.

The mother's belief on choosing the same injectable contraception
The results showed self-efficacy or confidence in almost all participants choosing injectable contraception. This belief was proven by the participants who wanted to continue using injectable contraception. Following research from Pratiwi, injectable contraception remains a trend in choosing contraceptive methods by women. While injecting contraceptive methods is practical, safe, and provides a sense of comfort to WCA, this greatly affects mothers' use of injectable contraception. Therefore, mothers will feel satisfied and, eventually, more confident in choosing injectable contraception. 20 This study is also in line with Sulaiman et al., which concluded that there was an influence between self-efficacy on the use of contraceptives in couples of childbearing age. 21

The Injectable contraceptives understanding
The results showed that the nine participants had sufficient knowledge of injectable contraception. The nine participants said that 3-month injectable contraception is a contraceptive injected every three months in the buttocks, aimed to delay pregnancy, and could affect hormones in the body. They also knew how it works to thicken the uterine wall and have side effects such as; menstrual disorders and weight gain.
This research follows Wildan's study, which found that knowledge about birth control and family planning (KB) is important for understanding the various available contraceptive tools/methods. Furthermore, this knowledge will affect the selection of appropriate and effective contraceptive methods. 13 Other findings from Ginting also support this evidence by showing mothers who have a high level of knowledge, especially about health, will tend to improve their health. 22 In other times, Sartika et al. also found a relationship between knowledge and the use of injectable family planning. Some respondents have a high level of knowledge because they understand correctly about the types, benefits and methods of using contraception. 23

Social support of mothers choosing injectable contraception
Mother's social support for choosing injectable contraception includes the husband's help, friends' experiences of using injectable contraception, and health workers' role in determining injectable contraception. 1.3.1. Husband's support for injectable contraceptives use According to Song & Habibi, the husband has an important role in determining or choosing injectable contraception. This kind of support could be in the form of emotional support such as interpersonal communication related to planning the desired number of children, award support such as taking his wife to re-install contraception, instrumental support such as the husband providing funds or costs incurred for installing contraceptives and informative support such as advising to use contraceptive. 25 The results of this study are also supported by the study of Batubara & Debataraja, which showed a significant relationship to the husband's support with the choice of injectable contraceptives. 24 Another research from Yulia & Bratasena also revealed a connection between the husband's support and selection of injectable contraception. As the head of the family, the husband plays a big and dominant role in making decisions regarding needs or problems in the family, including family planning. 25

Friends' experience in using injectable contraception
The results showed that most of the participants chose injectable contraception because of the experience of friends, relatives or close people who had used injectable contraception or experience using other contraception. This study follows research by Astuti & Ilyas, which showed that family members, relatives, neighbors, and friends often had a significant influence on contraceptive methods by a partner. 26 This study is also in line with research by Liwang et al., According to them, frequently, family members, relatives, friends and neighbors influence the use of contraceptive methods because they have shared experiences or use other people's experiences as a reference to determine the choice of contraceptive method to be used. 27

The role of health workers in giving contraception choice
The results showed that the four participants chose injectable contraception because their midwife advised them to use it. This study follows the research of Sartika et al. there is a relationship between the role of health workers in using injectable family planning. Health workers should play a role in providing counseling, motivation, and guidance regarding family planning programs that can be followed by acceptors, one of which is the selection of contraceptives. 23 However, this study is not by the results of research by Bakri et al., which stated that there was no relationship between the support of family planning officers and the choice of contraception in women of childbearing age. This was evidenced by respondents' never attended counseling on family planning when they first used contraception. 28 1.4. Advantages of injectable contraceptives The advantages of injectable contraceptives that participants felt included the mild side effects, the ease of installation, the costefficiency of injectable contraceptives, and the breastfeeding safety in contraception use.  29 This study is also in line with Meysetri et al., which revealed that there were side effects such as menstrual disorders, weight gain and headaches on the use of injectable contraceptives. 30 Based on this, we can understand that the eight participants experienced side effects while using injectable contraception, but participants still chose and used injectable contraception. This is due to the participants' belief that injectable contraception is safer than other contraceptives, and participants know how to handle it. Another research from Puji et al. showed that most respondents have a good role in managing the side effects of 3-month injections in the Ngambon Health Center work area in 2014. A good role in dealing with side effects has a positive impact on overcoming mothers' complaints. 31

Ease of installation
The results showed that most participants said that injectable contraception is more practical than contraception inserted in the uterus or requires surgery. This study follows research by Liwang et al., hormonal contraception tends to be chosen because of the ease of use, and non-hormonal contraception tends to be selected because of advice from health workers. 27 Based on this, most participants mentioned that it was easy because injectable contraceptives were only injected. According to the research of Anggriani et al., the ease of using injectable contraceptives in this case, respondents had no difficulty in injecting because of good health facilities. In this case, the respondent's reason for choosing injectable contraception. 18 1.4.3. The cost of injectable contraceptives The results showed that all participants chose injectable contraception because they felt it was more economical and cheap in the pocket. This study is in line with Septianingrum's research which showed a person's income and income affect the choice of contraception. This is due to the high cost of contraception, so they choose contraceptives that are more expensive cheap. 11 Several participants in our study stated that the 3-month injection KB was quite reasonable and affordable; the use was also quite long, i.e., once every three months, so it did not interfere with their family's economy. In addition, injectable contraceptives were easy to obtain with minimal side effects. Furthermore, these results were supported by Astuti & Ilyas, which revealed a relationship between the reasons for choosing respondents who used the injectable contraceptive method for economic reasons as many as 32 people (84.2%), and the use of the injectable contraceptive method. 26 1.4.4. Injectable contraceptives which are safe for breastfeeding. This study indicated that some participants revealed that it was recommended to continuously use this injectable contraceptive after giving birth to provide breast milk to the baby. This result is following Adnara et al. which said that the coverage of breastfeeding for infants affects the choice of injectable contraceptive methods, especially DMPA injectable contraceptives. 32 This study is also in line with Alifariki et al., which said mothers who use hormonal contraception containing dominant estrogen inhibit breast milk production. Conversely, hormones containing progesterone increase milk production. Based on this, injectable contraceptives are the choice of participants who are

ORIGINAL ARTICLE
breastfeeding. 33 1. 5.1. Sources of information related to injectable contraception. This study shows that participants choose to use injectable contraception because of the sources of information related to injectable contraception. Information about injectable contraception can come from information provided by health workers and non-health workers. 1.5.1. The importance of information from health workers related to contraception The results showed that some participants stated contraception was important to provide information before choosing and using injectable contraception. The data could be in the form of advantages, disadvantages and what side effects would be caused after using injectable contraceptives. Patients need support and information to make the best decisions related to health care and medical action.
Based on this study, several participants did not receive information related to contraception. This proves that the right to information was not fulfilled as stated in Law no. 36/2009. Reproductive rights related to information are contained in article 72 D, namely "Obtaining correct and accountable information, education, and counseling regarding reproductive health". 34 1.5.2.
The search of injectable contraception information This study indicates that some participants first searched for injectable contraceptives through friends, posters, and social media such as Facebook and WhatsApp before using contraception. This research is supported by Rohkmah & Nurlaela (2020), which stated that the most sources of information are obtained from health workers, as many as 521 respondents (41.6%), and the lowest is from social media as many as 46 respondents (3.7%). Health workers and the health office are more familiar with injectable family planning and other contraception using information technology media.
Based on this study, several participants revealed that if they searched for information through social media pages following the research of Sartika et al. (2020), there was a relationship between information media and the use of family planning acceptors in using injectable contraceptives. 23 The relationship between the role of information media in influencing attitudes towards family planning participation. However, the mass media has the least influence on the choice of injectable contraceptives. 1.6. Mother's injectable contraception choice motivation Mothers' motivation for choosing injectable contraception includes injectable contraception to delay pregnancy, maternal health conditions, providing comfort for participants. 1.6.1. Injectable contraception to delay pregnancy The results showed that some participants chose injectable contraception to delay pregnancy, whereas most participants had 1-3 children. This study follows research conducted by Astuti & Ilyas, which stated a relationship between parity and injectable contraceptive methods. 26 This is because many respondents are classified as primiparous (giving birth once) as many as 22 people (84.6%), respondents classified as multiparous (giving birth 2-4 times) and as many as 38 people (82.6%). In comparison, respondents classified as grand multipara (delivered five times) as many as two people (66.7%). 26 This study is also in line with Septianingrum et al., which said that commonly, mothers who had already had more than one child are likely to choose effective contraceptives with a long enough period without side effects. 11 Therefore, they decided on a KB injection for three months. 1.6.2. Injectable contraceptives affect health conditions The results of this study indicate that the three participants chose injectable contraception because of the health of the participants while using injectable contraception. The participants' health conditions included gaining weight, having reflexes, and not menstruating. This study is following the research of Rusminah et al. that the description of the side effects of injectable contraceptives depo medroxy progesterone acetate (DMPA) is a change in menstrual patterns, weight gain and depression, while the side effects for injectable contraceptives are nausea and anxiety, headache and mild breast tenderness. 29 This study is also in line with Ipaljri's research, which stated a significant relationship between the use of DMPA injectable contraceptives and weight gain in injecting family planning acceptors. According to it, it was known that from 49 respondents, 30 respondents (61.2%) experienced weight gain while 19 respondents (38.8%) did not experience weight gain. 35 However, this is different from the statement by the two participants. During the use of this injectable contraception, they did not gain weight. 1.6.3. The convenience of contraception use The results showed that all participants felt comfortable while using injectable contraception. This study follows the research of Anggriani et al., which said that injectable contraceptives could be used after childbirth, having no effect on the quality and volume of breast milk, and having a long-term method compared to birth control pills, which all of them are beneficial for mothers. Another reason is the convenience of using injectable contraceptives. 18 According to Dunia et al., the comfort of injecting family planning injections has made many acceptors choose injectable contraceptives as short-term contraception. 36 Injectable contraception has become the prima donna of KB acceptors because it is seen as being able to provide comfort from the process of KB installation until the effectiveness of the injectable KB function is completed. The injectable family planning acceptors stated this in their research who matched the content and hormonal reactions of this type of family planning. The effectiveness of injectable family planning that could prevent pregnancy up to 92% made the acceptors feel comfortable carrying out their daily activities inside and outside the home. There is no need to worry about the arrival of pregnancy. 36 Based on this, it is known that the participants' convenience in injecting contraception includes the convenience of the device, scheduled for control, another contraceptive income, does not affect daily activities and ability it is safe for mothers.

CONCLUSION
Several factors that influence the choice of injectable contraceptives in women of childbearing age in Yogyakarta include the mother's experience while using injectable contraception, mother's perception of using injectable contraception, social support of mothers choosing injectable contraception, advantages of injectable contraception, sources of information related to injectable contraception and mother's motivation to choose injectable contraception. Furthermore, mothers' experience using injectable contraceptives generally makes them feel comfortable and safe. But some mothers feel worried because of menstrual disorders. In addition, mothers used injectable contraception in the long term. Apart from that, the mother's perception of injectable contraception is that injectable contraception has advantages, mild side effects, and is an easy installation method. In addition, mothers view injecting contraception as more comfortable and safe. Therefore, mothers could be feeling sure to choose injectable contraception. Subsequently, the mother's social supports for choosing injectable contraception were obtained from the husband's support, the experience of friends who use injectable contraception, and the midwife's participation. Meanwhile, the advantages of injectable contraceptives include mild side effects, cost-effectiveness, easy installation, and breastfeeding safety. Therefore, mothers tend to choose injectable contraception. Source of information related to injectable contraception were obtained from health workers, social media, relatives and friends. Afterward, the mother's motivation to choose injectable contraception was to delay or regulate pregnancy intervals, provide comfort during use, and maintain a healthy body condition.