Certain
Determinants Affecting the Current Choice of Family
Planning Methods Used by Women Attending Some
Family Planning Clinics in Baghdad City
Sanaa
Jafar Hamodi Alkaisi (1)
Amjad Daoud Niazi (2)
(1)
M.B.Ch.B, F.I.B.M.S.\F.M Associated Professor
of Family Medicine, Senior Specialist Family
Physician, Supervisor in the Residency Program
of Arab Board of Family Medicine, Member in
the Executive Committee of Iraqi Family Physicians
Society (IFPS), Co-manager of Bab Almudhum Specialized
Family Medicine Health Center , Baghdad, Iraq.
(2) M.B.Ch.B ., D.T.P.H., PhD. Professor of
Epidemiology and Community Medicine, Consultant
in Epidemiology and Community Medicine. Specialist
Physician . Baghdad, Iraq.
Correspondence:
Associated Prof. Dr. Sanaa Jafar Hamodi Alkaisi
Co-manager of Bab Almudhum Specialized Family
Medicine Health Center,
Baghdad, Iraq.
Email:
drsanaaalkaisi@yahoo.com
|
Abstract
Family
Planning methods have indeed found wide
acceptance in many parts of the world
and their use has had a major impact on
women's and children's health around the
world.
There are certain determinants (factors)
which affect women's current family planning
method choice.
The study was conducted on a convenient
sample including (400) women who attended
3 family planning clinics in Baghdad.
An interview was conducted by the investigator
on determinants of the current choice
of family planning method, the reasons
for this choice and persons who participated
in choosing the method. This study showed
that the oral contraceptive pills were
the most preferable (65.3 %) followed
by intrauterine device (19.8 %), then
hormone injection (10.8 %), then condom
(4.3 %).
The study found that the main determinants
of oral contraceptive pills choice were
duration of marriage < 15 years, age
of the last child >
2
years old and number of living children
>
4.
While the choice of injectable was determined
by husbands marriage aged >
25 years, the choice of intrauterine devices
was determined by husbands aged >
35
years old, unemployment of the wife, absence
of stillbirths and the age of last child
>
2
years old, and lastly the main determinant
of choice of condom is the absence of
female offspring.
The main reason which determines women's
choice is the harmlessness of the method.
The study found that the doctor was the
main person who participates in determining
the current family planning method choice.
The study recommends to increase knowledge
of both partners to choose appropriate
and suitable methods for them through
increasing the role of mass media and
preparing family doctors to offer family
planning services, and to involve husbands
in family planning counselling sessions
after communication with their wives to
decide the suitable method for them.
Key words:
Certain determinants ,Current Choice,
Family Planning methods
|
The Alma Ata declaration identified family planning
(F.P.) as an essential component of health for
all by the year 2000. [1]
A call to reduce infant and maternal mortality
rates by half was part of the platform of action
of the international conference on population
and development held in Cairo in 1994. [2]
This was reaffirmed at the fourth world conference
on women held in Beijing in 1995. [3]
No other technologic advance has so profoundly
affected women as the ability to control fertility
by using effective contraception. [4]
There are many factors determining the choice
of F.P. methods by women including factors related
to acceptability such as cost, mechanism of action
and characteristics of the methods and factors
related to safety and social aspects. [4]
Other factors influence individual contraceptive
expectation and choices such as their own knowledge,
the information they are given, their current
life style, religion, ethnicity, their own perception
and the perception of others. Also there are clients'
characteristics such as age, number and sex of
children and frequency of intercourse. [5]
Aims of the study :
1. To investigate the use of contraceptives
in a convenient sample of Iraqi women.
2. To know some demographic, socioeconomic
and fertility related factors which determine
women's current choice of F.P. methods.
3. To know reasons and persons behind women's
current choices of F.P. methods.
Sample size :
A convenient sample of 400 eligible ever married
women aged 15 - 50 years ware selected in three
FP clinics in Baghdad City (FP clinic Baghdad
Medical City Teaching Hospital, FP clinic of Al
- Kadhimiya Teaching Hospital and FP clinic of
Al - Habibiya Teaching Hospital).
It is a cross sectional survey of the studied
sample. The selection of the subjects was as 1
- 2 days a week excluding Friday (which is the
weekend in Iraq), from November 2003 to July 2004.
3.2 Inclusion criteria :
We limited our sample to women who are exposed
to conception, those who are married, aged between
15 - 50 years and fertile women.
Exclusion criteria :
Single, infertile and pregnant women (as
possible).
3.4 Method of data collection :
Method of data collection was by an exit interview
for women attending FP clinics, using a questionnaire
form (appendix) designed by the researcher.
The study was of two parts, the first part included
224 women and the second part included 176 women;,
the questionnaire was modified to reflect the
gender of the offspring of the respondents.
Statistical analysis :
Data were entered, compiled, coded, tabulated,
statistically analyzed and presented as percentage
distribution with examination of the determinants
of FP methods choice by using the (EP16) computer
program and Statistical Package for Social Science
(SPSS) computer program for doing these tasks.
A level of 0.05 was used to determine statistical
significance. [6]
In the analysis of data, the dependent variable
was contraceptive method which was used at the
time of survey.
Contraceptive methods include OCPs, IUDs, injectable
and condoms. Other methods such as diaphragms,
sponges, implants and chemical sterilizers were
not included because they were not available
at time of survey.
The independent variables include :
1. Demographic variables.
a. Age of women and that of their husbands.
The variable of women's age and her husband
was grouped by six age groups :
< 20, 21-25, 26-30, 31-35, 36-40,
and 40 years or older.
b. Age of marriage of both women and
their husbands. These variables are constructed
with seven groups : < 15, 15-19, 20-24, 25-29,
30-34, 35-39, and > 40 years.
c. Duration of marriage : this is replaced
by 5 groups : < 5, 6-10, 11-15, 16-20,
and > 21.
d. Wife and husband's education : we
measured it by five categories : illiterate,
primary, intermediate, secondary, college.
e. Wife and husband's occupation : is
constructed as two groups : employed and unemployed.
2. Fertility related variables :
a. Number of pregnancies : was categorized
into four groups : 1-2, 3-4, 5-6, and 7 or more.
b. Age of last child was categorized
into five groups : < 1, 1-2, 3-4, 5-6, 7
or more.
c. Number of living children was categorized
into five groups : 0, 1-2, 3-4, 5-6, 7 or more.
d. Number of dead children : was categorized
into six groups : 0, 1, 2, 3, 4, 5 or more.
e. Number of male and female offspring.
Each one was categorized into five groups :
0, 1-2, 3-4, 5-6, 7 or more.
f. Types of previous contraceptive method
use was categorized into two groups as users
and non-users.
The characteristics of the sample :
The studied sample size was 400 and analysis was
done on 400 questionnaires, (Table 1).
Women were distributed according to certain demographic
factors such as women's age, marriage age, educational
level, employment status and age of her husband,
his marriage age, educational level, occupation
and according to duration of their marriage, (Table
1).
1.1 Women's age:
Women at age below or equal to 20 years were the
least group (2.3%) and the largest group were
between 31-35 years (26.3%), (Table 1).
1.2 Educational level of women:
A large number of women had finished primary school
(56%) while a small percentage of women were illiterate
(4.8%), and (6.8%) had finished institute or were
college graduates, (Table 1).
1.3 Women's marriage age:
A large percentage were married at age 15-19 year
old (40.5%) followed by (33.3%) of women who were
married at age between 20-24 years old. The lowest
percentage of women were married at age equal
or more than 40 (0.3%) followed by (1.3%) of them
were married at age 35-39 years, (Table 1).
1.4 Occupation of the women :
94.2% of the women were housewives and only 5.8%
of them were working. (Table 1).
1.5 Age of husbands :
The largest percentage of husbands was aged equal
to or more than 41 years old (37.8%) and husbands
at age < 20 years were the least (0.3%). On
the other hand, husbands at age between 21-25
years old were also low (3.8%), (Table 1).
1.6 Husbands' education :
The largest number of husbands finished primary
school 38.5% and only 14.8% of them finished higher
education and 2.3% of them were illiterate, (Table
1).
1.7 Husbands' marriage age :
The largest percentage of husbands were married
between 25-29 years old (34.5%) with nearly equal
percentage of them married between 20-24 years
old (34.3%) and the least percentage of them were
married below 15 years and those who married at
> 40 years were also low (2.3%), (Table
1).
1.8 Husbands' occupation :
The largest percentage of husbands was working
husbands (88%) and those who were unemployed were
(12%), (Table 1).
1.9 Duration of marriage :
The largest percentage of women's marriage duration
was between 6-15 years (56%); this was followed
by 16% of the women had duration of marriage less
than or equal to 5 years, (Table 1).
Table 1 : Distribution of the study group by
certain demographic variables
| <
20 years |
9
|
2.2
|
| 21-25
years |
48
|
12
|
| 26-30
years |
93
|
23.2
|
| 31-35
years |
105
|
26.3
|
| 36-40
years |
97
|
24.3
|
| >
41 |
48
|
12
|
| Illiterate |
19
|
4.7
|
| Primary |
224
|
56
|
| Intermediate |
89
|
22.2
|
| Secondary |
41
|
10.3
|
| College |
27
|
6.8
|
| <
15 years |
30
|
7.5
|
| 15-19
years |
162
|
40.5
|
| 20-24
years |
133
|
33.3
|
| 25-29
years |
56
|
14
|
| 30-34
years |
13
|
3.2
|
| 35-39
years |
5
|
1.2
|
| >
40 |
1
|
0.3
|
| Housewife |
377
|
94.2
|
| Working |
23
|
5.8
|
| <
20 years |
1
|
0.3
|
| 21-25
years |
15
|
3.7
|
| 26-30
years |
46
|
11.5
|
| 31-35
years |
90
|
22.5
|
| 36-40
years |
97
|
24.3
|
| >
41 |
151
|
37.7
|
| Illiterate |
9
|
2.2
|
| Primary |
154
|
38.5
|
| Intermediate |
112
|
28
|
| Secondary |
66
|
16.5
|
| College |
59
|
14.8
|
| <
15 years |
3
|
0.8
|
| 15-19
years |
38
|
9.5
|
| 20-24
years |
137
|
34.2
|
| 25-29
years |
138
|
34.5
|
| 30-34
years |
62
|
15.5
|
| 35-39
years |
13
|
3.2
|
| >
40 |
9
|
2.3
|
| Unemployed |
48
|
12
|
| Employed |
352
|
88
|
| <
5 years |
64
|
16
|
| 6-10
years |
104
|
26
|
| 11-15
years |
120
|
30
|
| 16-20
years |
58
|
14.5
|
| >
20 years |
54
|
13.5
|
The distribution of women according to their
fertility status :
The number of pregnancies, age of last child,
number of living children, number of dead children,
number of still births, number of abortions and
sex of live offspring, (Table 2).
Most of the women in the sample had 3-4 pregnancies
(31.3%) and the minority of them had 1-2 pregnancies
(15.3%), 10.8% of the attendants had the age of
their last child less than 1 year, 40.3% of them
had 3-4 living children. The majority of attendants
had no dead children (82.5%) and no still birth
(92.5%) and no abortions (61.8%), (Table 2).
Table 2 : Distribution of the study group by
number of pregnancies. Age of last delivery, number
of alive children , number of dead children ,
number of stillbirth and number of abortions (N=400)
| 1-2 |
61
|
15.3
|
| 3-4 |
125
|
31.2
|
| 5-6 |
110
|
27.5
|
| >
7 |
104
|
26
|
| <
1 year |
43
|
10.8
|
| 1-2 |
177
|
44.2
|
| 3-4 |
84
|
21
|
| 5-6 |
41
|
10.2
|
| >
7 |
55
|
13.8
|
| 0 |
1
|
0.3
|
| 1-2 |
95
|
23.7
|
| 3-4 |
162
|
40.5
|
| 5-6 |
91
|
22.8
|
| >
7 |
51
|
12.7
|
| 0 |
330
|
82.5
|
| 1 |
53
|
13.2
|
| 2 |
13
|
3.2
|
| 3 |
2
|
0.5
|
| 4 |
1
|
0.3
|
| >
5 |
1
|
0.3
|
| 0 |
370
|
92.5
|
| 1 |
26
|
6.5
|
| 2 |
2
|
0.5
|
| 3 |
0
|
0
|
| >
4 |
2
|
0.5
|
| 0 |
247
|
61.8
|
| 1 |
82
|
20.5
|
| 2 |
38
|
9.5
|
| 3 |
17
|
4.2
|
| 4 |
10
|
2.5
|
| 5 |
4
|
1
|
| >
6 |
2
|
0.5
|
The distribution of women according to the
gender of offspring (males & females) :
Among 176 women 89.8% of them had 1-4 male children
and 82.4% of them had 1-4 female offspring, (Table
3).
Table 3 : Distribution of the mothers according
to the sex of the offspring (n=176)
| 0 |
13
|
7.4
|
| 1-2 |
102
|
58
|
| 3-4 |
56
|
31.8
|
| 5-6 |
5
|
2.8
|
| >
7 |
0
|
0
|
| Number
of female offspring |
| 0 |
22
|
12.5
|
| 1-2 |
98
|
55.7
|
| 3-4 |
47
|
26.7
|
| 5-6 |
7
|
4
|
| >
7 |
2
|
1.1
|
(n=176) after modification of the questionnaire
The distribution of women according to the
previous contraceptive methods choice either modern
(OCPs, IUD, injectable and condom) or traditional
methods (coitus interruptus, safe period and lactational
amenorrhoea) :
Most of the women in the study had previous old
methods choice of IUDs (39%); also 26.5% of them
had previous choice with injectables as modern
methods, 15.8% of them previously chose coitus
interruptus as traditional methods, (Table 4).
Table 4 : Distribution of the women by the
previous methods choice (N=400)
| Previous
modern contraceptive method choice |
| Method |
Number
of users
|
%
|
Number
of non users
|
%
|
| OCPs |
97
|
24.2
|
303
|
75.8
|
| IUDs |
156
|
39
|
244
|
61
|
| Injectables |
106
|
26.5
|
294
|
73.5
|
| Condoms |
49
|
12.3
|
351
|
87.8
|
| Previous
traditional method choice |
| Method |
Number
of users
|
%
|
Number
of non users
|
%
|
| Coitus
interruptus |
63
|
15.8
|
377
|
84.2
|
| Safe
period |
16
|
4
|
384
|
96
|
| Lactational
amenorrhoea |
21
|
5.2
|
379
|
94.8
|
The distribution of women according to the person
who mostly participates in her current method
choice :
The largest percentage of women in the sample
(31.8%) chose the current FP methods with the
aid of the doctors but still their own personal
experience affects their choice as 29.3% chose
their methods without other help, (Table 5).
Table 5 : Distribution of women according to
the person or source mostly affected in their
current family planning method choice
| Participates
in women's current family planning method
choice |
| Husband |
63
|
15.7
|
| Doctor |
127
|
31.8
|
| Relatives |
57
|
14.3
|
| Friends,
neighbours |
36
|
9
|
| Personal
experience |
117
|
29.2
|
| Mass
media |
0
|
0
|
| Nurses |
0
|
0
|
The distribution of women according to their
current family planning method use and the duration
of its use :
The largest percentage of women use OCPs (65.3%)
and the least current method use is condom (4.3%)
and the largest number of the women used the
current method for less than one year (56.8%)
and 35% of the women used the current method
for 1-5 years, (Table 6).
Table 6 : Distribution of women according
to the current family planning method use and
its duration of use
| Current
family planning method choice |
| OCPs |
261
|
65.2
|
| IUDs |
79
|
19.7
|
| Injectable |
43
|
10.8
|
| Condoma=s |
17
|
4.3
|
| Duration
of current family planning method use |
| <
1 year |
227
|
56.7
|
| 1-5
years |
140
|
35
|
| >
5 years |
33
|
8.3
|
The association of the current family planning
method choice with certain demographic and fertility
related variables :
The choice of OCPs is associated significantly
with marriage duration < 15 years (P<0.05)
age of last child (P<0.05) and number of
living children > 4 children (P<0.05),while
the choice of injectable is associated significantly
with husbands' marriage age < 25 years old
(P<0.05). The choice of IUDs is significantly
associated with many determinants : wife unemployed
(P<0.05), age of last children >
2 years old (P<0.05) and absence of stillbirths
(P<0.05). While condom choice in this study
is significantly associated only with absence
of female offspring (P<0.05), (Table 7).
Click here for
Table 7: Association of
current Family Planning method choice with certain
demographic and fertility related variables
(N-400)
The distribution of women according to the
reasons for current family planning methods
choice :
The main reason for the current family planning
choice of the women is that it is a harmless
method (61.3%). This is followed by the fear
of complications (15.8%) by the women then by
previous use of the current family planning
method and was suitable (14.8%) and the least
reason was about its price and its availability
(0.3%), (Table 8).
Table 8 : Distribution of mothers by the
reason of choice of current family planning
methods (n=400)
| Reason
for current family planning method choice |
| It
is a harmless method |
245
|
61.2
|
| It
was previously used and was suitable |
59
|
14.7
|
| It
is the most effective in preventing pregnancy |
31
|
7.7
|
| Because
of fear of complications |
63
|
15.8
|
| It
is the most available |
1
|
0.3
|
| It
is a cheap method |
1
|
0.3
|
Distribution of women according to discomfort
of the family planning methods used previously
:
The method with a high percentage of discomfort
was injectable (69.1%) then in equal percentages
are IUDs and condoms (65.1%) and the traditional
method which is associated with a high level of
discomfort is coitus interruptus (74.6%), (Table
9).
Table 9 : Distribution of women`s according
to discomfort of family planning methods used
previously
| Methods |
Users
|
Users
with discomfort
|
%
|
| OCPs |
358
|
95
|
26.5
|
| Injectables |
149
|
103
|
69.1
|
| IUDs |
235
|
153
|
65.1
|
| Condoms |
66
|
43
|
65.1
|
| Coitus
interruptus |
63
|
47
|
74.6
|
| Safe
period |
16
|
2
|
12.5
|
| Lactation
amenorhoea |
21
|
0
|
0
|
This study found the majority of the attendants
to the family planning clinics were between
31 to 40 years old (50.6%). This finding agrees
with the finding of a study in Nairobi which
showed the highest percentage of attendants
of the sample were aged 30-39 years old [7],
and the finding of this study disagrees with
the finding in Jordan which found that 50% of
women were aged between 20-40 years old with
only 5-6% below 20 years old of age and 25%
aged above 40 years old. [8]
Also the finding of a study in Sweden showed
a large percentage of attendants aged over 40
years old.[9]
The study found that women still receive less
education than men at secondary and post-secondary
level (10.3% vs. 16.5%) for secondary and (6.8%
vs. 14.8%) for post-secondary and these findings
agree with the findings in Baghdad. [10]
The study showed also unemployment in women
was very high, 94.3% of the women of the sample
were unemployed and only 5.8% were employed
and these findings disagree with a study in
Baghdad which showed that 27.7% of urban women
were employed. [11]
It was found that 12% of husbands of the attendants
were without any kind of work. This is may be
due to loss of their jobs which was done by
the occupation forces of Iraq. This finding
disagrees with a study in Baghdad in which all
husbands of urban women were employed or self
employed. [11]
The study showed that 56% of the attendants
in the sample had duration of marriage between
6-15 years. This disagrees with a study in Baghdad
which showed 61.7% of the urban women in Baghdad
had less than 9 years of marriage. [11]
More than half of the women attending FP clinics
had 3-6 children (63.3%). While in a study done
in Baghdad found 75.2% of the women had up to
4 children. [10]
The study showed that 20.5% of the women had
one abortion and 13.3% of them had one dead
baby. This finding mildly differs from the study
in Baghdad which showed 21.3% of the urban women
had one abortion and 3% of them had one dead
baby. [11]
The study showed that 7.4% of the attendants
were without male offspring and 12.5% of them
were without female offspring. This disagrees
with a study in Baghdad which found that 12%
of the attendants were without male offspring
and 16% of them without female offspring. [10]
The study showed that OCPs are the most common
modern type of contraception which is used currently
(65.3%) and the least type of contraception
which is used currently is condom (4.3%). This
finding disagrees with a study in Iraq which
found that condom was the commonest contraceptive
method used by the attendants (55%) and IUDs
the least used method(0.01%),[12] and the finding
of this study agrees with a study in Baghdad
which found that 70% of the attendants chose
OCPs and the smallest percentage of them chose
condoms (3%). [10]
The determinants of current FP methods choice
in this study were : duration of marriage, age
of husbands, age of last child, number of living
children, husband's marriage age, wife's occupation,
number of stillbirths and the number of female
offspring. This finding agrees with findings
of the study in Zigon (Myanmar) which showed
the number of living children and the age of
children were effective factors on women's choice[13],
while this result disagrees with the findings
of a study in Turkey which showed that education
of both spouses and mainly the education of
wives were associated with women's current FP
method choice. [14]
The study showed that the choice of OCPs was
determined by marriage duration < 15 years,
age of last child > 2 years old and
number of living children > 4 children.
This finding disagrees with a study in Great
Britain and Germany which found a significant
association between OCP choice and educational
level of mothers (as low educational level is
associated with low OCPs use and choice). [15]
The study found that choice of injectable method
is determined by husband's marriage age <
25 years as decrease use of injectable with
increase in husband marriage age. This finding
disagrees with a study in Nigeria which found
that parity is the main determinants of injectable
choice.[16]
The study found that the main determinants of
IUDs choice is husband age > 35 years
old, wife unemployment, absence of stillbirths
and age of last child > 2 years old.
This finding disagrees with the finding of the
study in Norway which found the main determinant
of IUD choice was the age of the mother and
number of children. [17]
The study found the main determinant of choice
of condom is absence of female offspring and
this finding disagrees with the finding of study
in Nigeria which found that the main determinant
of choice of condom was the age of wives). [16]
The study showed that doctor in 31.8% was the
main person who participates in the women's
current choice of FP method. This agrees with
a study in Panama. [18]
There was no role of mass media in women's choice.
This disagrees with a study in Nigeria which
showed that mass media was an important source
of information for most women.[16]
The main reason of using the current FP methods
as shown in this study is the harmlessness of
the method and 77.1% of women complaining from
the adverse effect of contraceptive methods
which indicates that till now no method is satisfactory
with no or very minimal adverse harmful effects.
The price and the availability of contraceptive
methods were not important reasons as only 1%
of women's choice was because the method was
cheap and 1% of their choice because of the
availability of the method.
The modern method with high percentage of discomfort
is injectable (69.1%) then the condom (65.1%)
and IUDs (65.1%) and the least one is OCPs (26.5%)
while coitus interruptus was the traditional
method with the highest percentage of discomfort
(74.6%).
| CONCLUSIONS
AND
RECOMMENDATIONS
|
Conclusions :
1. The preference
of oral contraceptive
pills as FP method was
higher (65.3%) than the
preferences of other modern
FP methods.
2. The factors
that determine the choice
of current FP methods
in the sample were : duration
of marriage < 15 years,
age of husband >
35 years old, age of last
child > 2 years
old, husband's marriage
age < 25 years, number
of living children >4,
unemployment of wives,
absence of stillbirths
and the absence of female
offspring.
3. There was no
role of mass media in
women's current choice
of FP method.
4. The main person
who affects women's current
choice of FP method was
doctor.
Recommendations :
1. There is a need
to increase awareness
of the people regarding
all aspects of family
planning. This is achievable
opportunistically by discussion
and the choice of contraceptive
methods must be the result
of dialogue in which the
totality of the individual
is assessed and emphasis
should be placed on developing
and distribution of contraceptives
that are devoid of side
effects, cheap, easily
available, effective and
easily reversible.
2. It is recommended
to change the knowledge
in a short time through
a wider use of mass media
education and it is necessary
to prepare family doctors
to offer FP services to
their patients and FP
counsellors should help
spouses make their choice
and decisions freely and
based on relevant information
to ensure continuation.
3. The need for
male sexual responsibility
and the need for communication
between spouses and husbands
should be involved during
FP counselling sessions.
4. A comprehensive
and rigorous FP information
program is crucial to
address existing constraints
on the choosing of appropriate
contraceptive methods
and continuous refresher
training programs should
be offered to counsellors.
5. There is a need
for continuing collaboration
between researcher and
FP associations, Ministry
of Health and policy makers
to encourage the import
of contraceptive methods
that are safer, more effective
and more widely acceptable
than those available.
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