Explaining withdrawal’s persistence: correlates of withdrawal use in Albania, Armenia, Jordan, and Turkey observed in a cross-sectional study [version 1; peer review: 1 approved, 2 approved with reservations]

Background: Withdrawal dominates the contraceptive method mix in a geographical cluster of countries in South-Eastern Europe and Western Asia that have, in part, reached low fertility. This study examines the socio-demographic determinants associated with withdrawal use in Armenia, Albania, Jordan and Turkey that could explain withdrawal’s persistence and inform contraceptive programs in these unique settings. Methods: Cross-sectional data on 31,569 married women 15 to 49 years were drawn from the Demographic and Health Surveys in Albania (2017-2018), Armenia (2015-2016), Jordan (2017-2018), and Turkey (2013). For each country, multinomial regression models estimating withdrawal use among all women and logistic regression models estimating withdrawal use among contraceptive users were used to evaluate the association with age, marital duration, parity, education, residence, and household wealth. Results: The socio-demographic determinants associated with withdrawal use varied by country among all women and among all contraceptive users. While these associations were not all significant for all four countries general trends included that women were more likely to use withdrawal than not use contraception, but less likely to use withdrawal than other methods with increasing parity, higher education, and greater household wealth. Measures of association are reported by country for each correlate. Conclusions: Despite the similar contraceptive mix in these four countries, no single set of factors was found to explain withdrawal’s persistence. Withdrawal’s prevalence in this geographical cluster may instead result from different balances of intertwined circumstances that include couples’ fertility decisions, access to modern contraception and availability of abortion services.