19 Sep 2012 ... Indonesia, the world's largest archipelagic state is the world's third most populous
..... Nonetheless research shows that dating and premarital sex among Indonesia
youths is ..... Reproduksi Remaja (PIPR) or Youth Centers.
UNFPA-‐ICOMP Workshop on Operationalizing the Call for Elimination of Unmet Need for Family Planning in Asia and the Pacific Region 18-‐19 September 2012 The Imperial Queen’s Park Hotel, Bangkok
Addressing the Unmet Need for Family Planning Among the Young People in Indonesia Prepared by: Assoc. Prof. Dr. Mary Huang Soo Lee Ms Lim Shiang Cheng
Asia and the Pacific Regional Office
1
International Council on Management of Population Programmes
1. National Overview Indonesia, the world’s largest archipelagic state is the world’s third most populous democracy and home to the largest Muslim population in the world. Total population was estimated to be 234.2 million in 2010. The people are unevenly dispersed over 17,508 islands although there are five main islands, namely, Sumatra, Java, Kalimantan, Sulawesi and Irian Jaya or Papua, bordering with Papua New Guinea. By religion, 86.1% are Muslims. Ethnic groups include Javanese who make up 40.6%, Sundanese (15%), Madurese (3.3%), Minangkabau (2.7%), Betawi (2.4%), Bugis (2.4%), Banten (2%), Banjar (1.7%), other or unspecified groups (29.9%)1. Bahasa Indonesia is the official language. While the majority of people live in rural areas (56%) Indonesia like most countries in South-‐East Asia has been experiencing fast growing rural urban migration especially among the younger population. GDP per capita was $3,469 in 2011 and is fast increasing2. Table 1: Country Context Size of population Population Growth (%) Ethnic groups
Religions Languages
234.2 million 1.183 Javanese (40.6%), Sundanese (15%), Madurese (3.3%), Minangkabau (2.7%), Betawi (2.4%), Bugis (2.4%), Banten (2%), Banjar (1.7%), other or unspecified (29.9%)4 Muslim (86.1%), Protestant (5.7%), Roman Catholic (3%), Hindu (1.8%), other or unspecified (3.4%)5 Bahasa Indonesia (official, modified form of Malay), English, Dutch, local dialects (the most widely spoken of which is Javanese)6 Table 1: Country Context (Continued)
1
CIA, The World Factbook, Indonesia, website, date accessed 2 March 2012. The World Bank. Indonesia, website, date accessed 18 march 2012. http://data.worldbank.org/country/indonesia 2
3
Ibid 1. Ibid 1. 5 Ibid 1. 6 Ibid 1. 4
2
Population living below the national poverty line (%) Crude birth rate (per 1000 population) Crude death rate (per 1000 population) Life expectancy at birth (years) Total Fertility rate Contraceptive prevalence rate for women (ages 15-‐49) Maternal mortality ratio Infant mortality rate HIV prevalence rate (15 – 49) HIV prevalence in vulnerable groups
137 198 79 71.6210 2.2311 5612 22813 (per 100,000 live births) 26.9914 (per 1,000 life births) 0.215 Direct Sex Workers (10.4%), Indirect Sex Workers (4.6%), Transgender (24.4 %), MSM (5.2%), Injecting Drug Users (52.4%)16
2. Socio-‐demographic Profile of Young People 7
Ministry of National Development Planning/National Development Planning Agency. (2010). Report on the Achievement of the Millennium Development Goals in Indonesia 2010. 8 The World Bank. Birth rate, crude (per 1,000 people). website, date accessed 18 march 2012. http://data.worldbank.org/indicator/SP.DYN.CBRT.IN 9 The World Bank. Death rate, crude (per 1,000 people). website, date accessed 18 march 2012. http://data.worldbank.org/indicator/SP.DYN.CDRT.IN 10 Ibid 1. 11 Ibid 1. 12 Ibid 2. 13 Ibid 8. 14 Ibid 1. 15 Ibid 1. 16 Jakarta (Indonesia): Ministry of Health (MoH), National AIDS Commision (NAC), and Family Health International (FHI)—Aksi Stop AIDS (ASA). (2007). Program Integrated Biological-‐Behavioral Surveillance of Most-‐at-‐Risk-‐Groups (MARG).
3
Indonesia has a relatively young population with median age of 27.7 years for males and 28.7 years for females. However distribution of the population by age groups translates into more than 21 million aged between 10 and 14, 21.6 million from 15 to 19 and 21.5 million aged 19 to 24. As a percentage of the total population, young people aged 10 to 24 made up 26.6% of the total population of Indonesia. A detail analysis of the total population of young people reflects slight declines in fertility levels since the beginning of this millennium. As is evident from figure 1, total population of young people aged ten to twenty-‐four was around 24 million in 1950 and it increased steadily until it reached a peak at around 65.8 million in 2000 but since then it has begun to decline slowly. Figure 1: Total Population of Young People 10 to 2417 Estimated Population aged 10-24 (thousand), 1950 - 2010
70000 60000 50000 40000 30000 20000 10000 0 1950
2.1
1960
1970
1980
1990
2000
2010
Literacy Rate
17
United Nations, Department of Economic and Social Affairs, Population Division (2011). World Population Prospects: The 2010 Revision, CD-‐ROM Edition
4
Literacy rates have improved over the past decade as reflected in the literacy rate of the young people aged 15 to 19 and those 20 to 24 (Figure 2). Among youths age 15 to 19, literacy rate increased from 99.55% to 99.63% between 2009 and 2010. These rates are also a little higher than that of those aged 20 to 24. Although data from the Statistical Year Book of Indonesia (2011) showed that less than 1% were illiterate, when translated into numbers the figure can be quite large because of the size of the total population. Nonetheless the EFA Global Monitoring Report (2010) by UNESCO reported that in 2010 the number of illiterate youths 15 to 24 was projected to decline from 1.4 million to 1.1 million by 2015 (Figure 3). Figure 2: Youth Literacy Rate18 Youth (aged 15 - 24) Literacy Rate, 2009 to 2010 99.7 99.6
(%)
99.5 99.4 99.3 99.2 99.1
2009
2010
15-19
99.55
99.63
20-24
99.28
99.42
Figure 3: Total Numbers of Youth Illiterates, 1985 – 2015 (Projected)19 18
Ibid 3. UNESCO. EFA Global Monitoring Report 2010 -‐ Reaching the marginalized.
19
5
Total Numbers of Youth Illiterates (15-24) 1600 1400
(Thousand)
1200 1000 800 600 400 200 0
1985 - 1994
2000 - 2007
Projected 2015
Total
1421
1431
1099
Male
497.3
644
604.4
Female
923.7
787
494.6
2.2 Youth Unemployment Youth unemployment remains a major challenge for the country despite the economic progress the country has been chalking up in recent years. World Bank in 2011 warned that youth unemployment in Indonesia was higher than average national unemployment rates. While in most countries youth unemployment is two to three times as high as that of the average population (estimated to be 7 to 8 percent), unemployment among those aged 19 to 24 was 30%20. This has huge implications on social problems including delayed marriage (due to lack of employment), and increase risk of premarital sex. 3. Reproductive Health Status 3.1 Age at First Marriage 20
Jakarta Globe (27 March 2011). High Rate of Youth Unemployment Presents Big Challenge: World Bank. http://www.thejakartaglobe.com/bisindonesia/high-‐rate-‐of-‐youth-‐unemployment-‐presents-‐big-‐challenge-‐world-‐ bank/431663
6
Over the past few decades the mean age at first marriage of females aged 25 to 49 has increased from 17.1 years in 1991 to 19.6 years in 2007, an increase of 2.5 years (UNESCO, 2010) and although data reflect an increasing trend, the fact is that that 9% of Indonesian girls are married in their teens 21 . Being such a huge country it is not surprising that provincial differences in percentage of teenage marriages are evident. Jones and Gubhaju also revealed that while teenage marriages are not common in the more urbanized areas of Jakarta, North and West Sumatra and the Riau Islands it cannot be said of other parts of the country especially South Kalimantan, Central Sulawesi, Papua, Bangka Belintung, West Nusatenggara Gorontalo and East Java. Early marriage in the rural areas is common, partly due to poor access to education and poverty. This difference has resulted in 19% of urban girls giving birth before 20 compared to 40% among their rural counterparts. The Indonesian demographic and health survey 2002 -‐ 2003 reported that the median age at first marriage for girls was 20.2 years. Trends in proportions of females 15-‐19 years old currently married in Indonesia between 1990 and 2005 shows a very slow downward trend with the proportion from around 17% to 14% in 200522. Figure 4: Mean Age at First Marriage23
21
Jones G. W and Bina Gubhaju (2008) “Trends in Age at Marriage In the Provinces of Indonesia.” Asia Research Institute , University of Singapore 22 Blanc A.K., Tsui A. O., Croft T.N., & Trevitt J. L., Trends in Contraceptive Use and Discontinuation among Adolescents: A Multi-‐Country Comparison. 23 Statistics Indonesia, National Family Planning Coordinating Board, Ministry of Health, Jakarta, Indonesia and Macro International Calverton, Maryland USA. Indonesia Demographic and Health Survey 1991, 1997, 2002-‐2003 and 2007.
7
Mean Age at First Marriage (Female aged 25 - 49), Indonesia, 1991 - 2007 20.5 20 19.5 19 Age
18.5 18 17.5 17 16.5 16 15.5
Female
1991
1997
2002-2003
2007
17.1
18.6
19.2
19.8
3.2 Youth Fertility Rate In Indonesia the median age at first birth was only 21.5 years in 2007 (Indonesian Demographic and Health Survey 2007). According to the same report, 9 % of women aged 15 to 19 had started childbearing, with 7 % of them had had a live birth, and 2 percent were pregnant with their first child when the survey was conducted. Such figures are not surprising in a country where most of the population is Muslims and there is a cultural expectation for brides to get pregnant soon after marriage. Nonetheless a comparison of the adolescent fertility rates measured over four surveys, 1991, 1994, 2002/2003 and 2007 reveals a downward trend declining the fastest between 1997 and 2007 when the adolescent fertility rates reduced by almost half from 62 to 36 per 1,000 women aged 15 to 19. The 2007 DHS report also found that youths from rural areas and those with lesser education were more likely to start childbearing earlier than urban and better-‐educated women and this is an issue that certainly needs attention. Figure 5: Adolescent fertility rate (the number of births per 1,000 women ages 15-‐19)24 24
Ibid 23.
8
80 70 60 50 40 30 20 10 0 Adolescent Fertility Rate
1991
1994
1997
2002/03
2007
67
61
62
51
35
3.3 Abortion in Indonesia Although reliable evidence of abortion does not exist, researchers estimated that about two million induced abortions occur each year in Indonesia and deaths from unsafe abortion represent 14–16% of all maternal deaths in Southeast Asia25. It is estimated that in Indonesia because abortion is illegal and is often performed under unsafe conditions 15-‐30% of the maternal mortality is the result of unsafe abortion26. The same Guttmacher Institute’s Brief also reported that most of those who went for abortion were married adults and educated with unmet need for contraception. Among married women who sought abortion their reasons included unmet need for contraception, contraceptive failure as well as having completed their desired family size. Unmarried women who went for abortion often cited the desire to complete their education as the reason. By age, 8% were below 19 years compared to 46% between the ages 20 to 29 and 37% aged 30 to 39. In urban areas, 85% of abortions were performed by trained personnel the other 15% were attributed to traditional birth attendants. On the other hand, 80% of all abortions in the rural areas were performed by traditional birth attendants. The problem is also accentuated by the fact that nearly half of all women seeking abortion go to traditional birth attendants, traditional healers 25
Sedgh G and Ball H, Abortion in Indonesia, In Brief, New York: Guttmacher Institute, 2008, No. 2. The Department of Family and Community Health, World Health Organization, Regional Office for South-‐East Asia. WHO, Family Planning and Indonesia An Overview. http://www.searo.who.int/LinkFiles/Family_Planning_Fact_Sheets_indonesia.pdf 26
9
or masseurs first and methods used ranged from herbal remedies (Jamu), abortive massage, injectable abortifacient, foreign objects or preparation inserted into the womb and acupuncture. 4. Knowledge of Sexual and Reproductive Health In general young Indonesians, those aged 20 to 24 know more about reproductive health changes than their younger 15 to 19 counterparts27and between the two surveys there was consistent pattern of change in the percentage of those who knew the answers to various statements on reproductive health. Taken as a whole the percentage of males who did not know any sign of change in the male body at puberty, remained at 17.3% between 2002/03 and 2007. However fewer females were quoted to say that they did not know any sign of change in the male body (2.01% to 18.1%). The pattern was also similar with knowledge about the female body. At any rate it was also apparent that more young men knew about wet dreams than their female counterparts while more females knew more about menstruation than the males (refer to Table 2). Knowledge about pregnancy, contraception and STIs among Indonesian youths age 15 to 19 and 20 to 24 between 02/03 and 07 followed the same pattern as their knowledge on reproductive health changes (Table 3). There was no significant difference in knowledge of fertile period, risk of pregnancy, contraceptive methods syphilis, gonorrhea as well as genital warts, by gender as well as over the two time periods. However many more females (70%) than males (63%) had no knowledge of symptoms of STIs. Table 2: Knowledge of Physical Changes at Puberty -‐ Percentage of Unmarried Women and Men Age 15-‐24 Who Know of Specific Physical Changes in a Boy and a Girl at Puberty, By Age28 Indicator of Physical Females Males 27
BPS-‐Statistics Indonesia, National Family Planning Coordinating Board, Ministry of Health, Jakarta Indonesia and ORC Macro Calverton, Maryland USA. Indonesia young Adult Reproductive Health survey, 2002-‐2003 and 2007 28 Ibid 27.
10
15 -‐ 19
Changes
02/ 03
In a Male Developed muscles
07
20-‐24 02/ 03
Total
07
02/ 03
07
15 -‐ 19 02/ 03
07
20-‐24 02/ 03
07
Total 02/ 03
07
26.3 21.9 27.2 24.0 26.8 22.6 33.1 22.4 30.4 24.9 32.0 23.4
Change in voice Growth of facial hair, pubic hair, or hair on chest, legs, and arms Increase in sexual arousal Wet dreams
52.2 52.6 65.6 59.7 56.7 54.8 35.5 32.9 44.6 37.6 39.2 34.7 24.8 30.5 32.8 35.2 27.4 31.9 29.3 35.3 35.1 40.5 31.7 37.3
Growth of Adam’s apple Hardening of nipples Others
20.9 29.7 28.3 32.0 23.4 30.4 10.7 10.2 10.4 12.0 10.5 10.9 0.3 0.4 0.6 0.4 0.4 0.4 0.3 0.4 0.6 0.7 0.4 0.5 13.2 21.2 13.4 18.9 13.3 20.5 16.5 25.3 17.0 24.2 16.7 24.9
Don’t know any signs In a Female Growth of pubic hair and underarm hair Growth in breasts Growth in hips Increase in sexual arousal Menstruation Other Don’t know any signs
24.0 18.9 14.7 16.1 21.0 18.1 19.7 18.5 13.5 15.6 17.1 17.3
6.3 5.3 5.9 4.3 6.2 5.0 9.5 5.4 16.6 7.9 12.4 6.4 12.4 16.1 16.8 18.5 13.8 16.8 25.5 23.8 28.6 25.4 26.8 24.4
17.0 17.1 19.9 18.1 18.0 17.4 11.2 12.6 16.9 14.7 13.5 13.4 52.1 18.3 6.3 68.5 16.4 12.0
53.5 16.6 5.2 75.4 6.2 13.5
58.7 19.1 9.3 72.7 14.9 8.2
60.3 15.4 4.3 77.9 5.7 12.7
54.3 18.6 7.3 69.9 15.9 10.7
55.6 16.2 4.9 76.2 6.0 13.3
47.4 13.4 5.5 32.3 7.3 30.6
46.8 10.0 2.7 31.8 2.2 9.8
51.9 16.3 10.3 42.2 7.5 24.3
52.9 13.5 4.6 36.8 1.7 10.8
49.3 14.6 7.5 36.5 7.4 28.0
49.2 11.4 3.4 33.7 2.0 10.2
Table 3: Percentage of Indonesian Youth (Unmarried) With Correct Responses on Fertile Period, Risk of Pregnancy and STI by Gender29
Knowledge
Unmarried Females 15-‐19 20-‐24 Total 02/03 07
02/03
07
02/03
29
Ibid 27
11
Unmarried Males 15-‐19 20-‐24 Total 07
02/03 07
02/03 07
02/03
07
Fertile period – halfway between periods Risk of Pregnancy-‐ a woman can become pregnant after one instance of sexual intercourse Contraceptive method – any method Contraceptive method –modern method Heard of STIs -‐ Syphilis Heard of STIs -‐ Gonorrhea Heard of STIs – Genital herpes No knowledge of symptoms of STIs
27.9 23.6
30.7 30.1
29.0
25.8
26.4 20.3
38.0 20.7
32.2
20.5
45.5 54.6
57.6 56.5
41.0 49.8
51.8 55.2
93.2 95.6
97.5 97.8
94.6
96.3
89.0 91.4
94.0 95.0
91.1
92.8
93.2 95.6
97.5 97.7
94.6
96.2
89.0 91.2
93.9 94.7
91.1
92.6
61.7 61.7
68.0 74.8
81.9 84.9
89.6 92.0
23.2 31.7
32.3 35.8
25.9 18.0
28.9 18.9
5.8
9.3
1.9
1.4
70
71
60
63
3.8
72.0 74.1
7.4
52.5 62.5
1.1
70.4 70.0
2.4
45.1 52.0
In most Asian families, sex is a subject that is rarely discussed and the Indonesia Young Adult Reproductive Health Survey, (2007) confirms this fact. In response to questions on where and from whom they received information of physical changes, menstruation, wet dreams, reproductive health, HIV/AIDS and STI (Table 4), the young females most frequently quote their friends ahead of mothers, teachers and siblings. The data also showed that the males did not discus sexual issues with their mothers nor fathers but instead chose to do so with friends, teachers and occasionally religious teachers. Table 4: Percentage distribution of sources of information on sexual and reproductive health among adolescents30 Information Source of Information (ever discussed with) priority Women Men First
Second
Third
Never
First
Second
Third
30
BPS-‐Statistics Indonesia, National Family Planning Coordinating Board, Ministry of Health, Jakarta Indonesia and ORC Macro Calverton, Maryland USA. Indonesia young Adult Reproductive Health survey, 2007
12
Never
Physical changes at puberty
Friends Teacher (44.4%) (40.7%)
Mother (20.1%)
(18.3 %)
Friends (48.4%)
Teacher (31.5%)
Menstruation (before first menses) Wet dreams (Before having first wet dream) Reproductive Health
Friends Mother (49.2%) (37.4%)
Siblings (15.2%)
(30.0 %)
Friends (41.2%)
Teacher (11.8%)
Religious leader (5.4%)
(50.1%)
Friends (71%)
Mother (48%)
Teacher (40%)
(15.0 %)
Friends (58%)
Teacher (37%)
(29.0%)
HIV/AIDS
Televisio Teacher n (78%) (50%)
Television (76%)
Teacher (43%)
STIs
Teache r (60%)
Friends/ Relatives (56%)
Teacher (39%)
Health Service Provider (16%) Friends/ Family (37%) Television (24.3%)
magazine/ Newspaper (40%) magazine/ Friends/ Newspaper Relatives (34%) (32%)
Book/ (15.2%) magazine/ Newspaper (7.8%)
5. Dating and Sexual Experience Indonesian girls are expected to remain virgins until their marriage unlike boys who are not burdened by physical evidence of their sexual encounters prior to marriage. Nonetheless research shows that dating and premarital sex among Indonesia youths is on the rise. Data from the Indonesia Young Adult Reproductive Health Survey, 2002-‐ 2003 and 2007 showed that females tended to start dating later than boys and comparison of data from the two survey years reveal that young people are beginning to date at a younger age. For example, among the females in 2002/2003 only 18% reported that they had their first date between 12 and 14 years and this corresponding percentage increased to 19.9% in the 2007 survey. The same was also true with the males but in the case of the males, fewer of them began dating between 12 and 14 and more (12.8%) compared to only 9.5% who started dating after 17 years. Table 5: Age at First Date31 Age at first date Females Males 2002/ 2007 2002 -‐ 2007 31
Ibid 27.
13
17
2003 18.3 31.6 24.4
4.5 19.9 42.5 9.5
2003 13.2 28 28.4
4.0 14.9 40.3 12.8
Of those who were dating, the survey of 2007 revealed that among the females aged 12 to 15, six out of ten were holding hands, almost a quarter were kissing and 6.5% were petting. The percentages of those aged 20 to 24 engaging in similar activities were considerably higher. Many more males of the respective age groups were also doing likewise and as in the case of the females as age increased, significantly more were engaged in physical contact with their partners. Table 6: Percentage of Adolescents Currently Dating, By Behavior Practised With Dating Partner32 Dating Female Male Experience 15-‐19 20-‐24 Total 15-‐19 20-‐24 Total Holding 62.0 82.6 68.3 60.1 82.7 69.0 Hand Kissing 23.2 43.4 29.3 30.9 57.1 41.2 Petting 6.5 15.0 9.1 19.2 37.7 26.5 Before the conduct of the IYARHS in 2002/2003 and 2007 data on premarital sex were conducted sporadically at various locations by different researchers but suffice to say that most studies reported the fact that premarital sex was common and that young people were becoming more accepting of premarital sex. The IYARHS of 2002/2003 reported that among unmarried men and women ages 15 to 24, 5% and less than 1% respectively reported having had sex. The number who has had premarital sex could be higher because of the low age at marriage and many who had premarital sex could have been married at the time of the survey. By 2007 the percentage of those unmarried 15 to 19 year old males and females who ever had sex increased to 3.7% and 1.3% respectively and the corresponding percentages for those unmarried age 20 to 24 were 10.5% in males and 1.4% in females (Table 7). Data from the same survey found that 32
Ibid 30.
14
males, those living in urban areas as well as those who had completed their secondary education were more apt to have had premarital sex. Therefore unless contraceptive needs are met many may just be pregnant at the time of their marriage. Analysis of DHS data for Indonesia in 1991 revealed that one in five girls aged 20 to 24 was indeed pregnant at the time of their marriage. This is not discounting the numbers who had gone for abortion instead of choosing to get married. Table 7: Premarital Sexual Activity among Youths33 Year Percentage of unmarried women and men age 15-‐24 who have ever had sex Females Males 15-‐19 20-‐24 Total 15-‐19 20-‐24 Total 2002-‐2003