Med. J. Cairo Univ., Vol. 81, No. 2, June: 137-142, 2013 www.medicaljournalofcairouniversity.net The Contraceptive Knowledge and Use among Women Attending Primary Health Care Centers of Al Dawahe District in Port Said Governorate BADR M. EL SHAMY, M.B.B.ch.; HEBATALLAH N. ABDELSATAR, M.D. and MOHAMED M. AWAD, M.D. The Department of Family Medicine, Faculty of Medicine, Suez Canal University, Egypt Abstract Background: Family planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births, it is achieved through use of contraceptive methods. Despite the high prevalence of medical contraceptive use, unplanned pregnancies remain frequent. Knowledge and use of contraceptives are the indicators most frequently used by the national and international organization to assess family planning. Aim of the Study: To assess knowledge and use of contraception among women attending Al Dwahe health care centers in Port Said Governorate. Subjects and Methods: A descriptive cross sectional study was conducted in all (three) primary health care centers of Al Dawahe district in Port Said Governorate. The study included 117 women according to sample size calculation and the inclusion criteria. A structured interview questionnaire was used to collect data. This questionnaire was constructed by Egyptian Demography and health survey (EDHS) 2008. EPI information program was used for data entry and management. Results: The mean age of the studied women was 31.41±16.97, all the studied women knew about pills and IUCD. The majority of sample knew about injections (93.2%), slightly more than three quarter of them knew about condom (75.2%) followed by (70.1%) least known method was male sterilization (19.7%). Lactational amenorrhea was the most recognized traditional method representing (47%). Regarding the ever use of contraceptive methods, the most common methods used by the studied women were the IUCD representing (64.1%) followed by pills representing (58.1%) then injection (34.2%). The least used method was emergency contraception (2.6%). No one used male sterilization as a contraceptive method. Conclusion: Despite the women's knowledge about many modern and traditional methods of contraception, the use was limited to certain methods: Pills, IUCD and injectables. Attention should be given to other methods to provide multiple choices for the women who found that pills, IUCD or injectables are unsuitable for her instead of not using any method. Key Words: Contraception Family planning Knowledge Use. Correspondence to: Dr. Hebatallah N.E. Abdelsatar, E-mail: hebanour20@hotmail com Introduction FAMILY planning allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births, it is achieved through use of contraceptive methods Hi. United Nations projections indicate that the Egyptian population will grow from 62.3 million in 1995 to 95.6 million by 2026 and will reach 114.8 million before it stabilizes in the year 2065 an increase of approximately 84.4 percent over the current total [2]. The 2008 EDHS results indicate that 60 percent of currently married women in Egypt are using contraception. The IUCD, pills, and injectables are the most widely used methods: 36 percent of currently married women interviewed in the EDHS were currently using the IUCD, 12 percent were relying on the pills and 7 percent were employing injectables. Relatively small proportions of women were using other modern methods; 1 percent was using the condom. Three percent of women reported use of traditional methods [3]. At the world level 63 percent of women of reproductive age who are married are currently using a contraceptive method for a total of 716 million worldwide [4]. Despite the high prevalence of medical contraceptive use, unplanned pregnancies remain frequent, beyond the lack of information which may explain part of the so called misuse of the contraception. Knowledge and use of contraceptives are most frequently used indicators by the national and international organization to assess family planning [5]. Subjects and Methods This study was a cross sectional-descriptive study. It was carried between February and May 2010. The target population was the married women 137
138 The Contraceptive Knowledge & Use among Women Attending or previously married women (divorced, widow or separated) who are at child bearing period (18-49y) and attending all the three primary health care centers serving Al Dawahe district in Port Said Governorate (either a client or accompanying a client). The following equation was used to calculate the Sample size Z 2 xpxq d 2 Z = Confidence interval = 1.96 for a confidence limit of 95%. P = The least prevalence of knowledge and use in Egypt = 40% [3] q = 100- p = 60% d = Maximum accepted error = Level of significance 10%. Sample size = 1.962x40x60/102 = 93 women. on 80% response rate, sample was 93/0.8 = 117 women. The sample was a random sample, within each center all women matching inclusion criteria was recruited until the total target sample size was reached. Relative equal distribution of numbers of women within each center was maintained. The Total number of the sample was 117 women. A structured interview questionnaire was used to collect data from women who accepted to participate in the study. This questionnaire is constructed by EDHS 2008 to identify contraceptive knowledge and use [3]. The questionnaire included data about: (1) Socio-demographic data (Age, Marital state, Educational level and Occupation), (2) Obstetric history (Gravidity, Parity, Number of living children), (3) Knowledge of the following methods regarding how the method is used: Nine modern methods: Pills, IUCD, Injectable, Implant, Vaginal methods (diaphragm and contraceptive foam or jelly), Male condom, Female sterilization, Male sterilization, and Emergency contraception and three traditional methods: Periodic abstinence, Withdrawal method and Lactational amenorrhea, (4) Sources of contraceptives knowledge, (5) The ever use of the previously mentioned contraceptive methods, (6) Current use of any contraceptive method, (7) Causes of not using a contraceptive method now. Ethical considerations: The study was approved by the ethics committee of Faculty of Medicine, Suez Canal University and has been performed in accordance with the ethical standards laid down in the Declaration of Helsinki (1964). Questionnaire was anonymous, did not contain any critical questions, and confidentiality of the data were maintained. Statistical analysis: EPI information program was used for data entry into computer, stepwise logistic regression analysis was used to determine the factors affecting contraceptive use. The level of significance considered statistically significant if (p-value is <0.05). The results were represented in Tables & Figures to show the frequency. Results Personal and obstetric characteristics of the participating women: A total of 117 women were enrolled in the study the mean age of the studied women was 31.41± 16.97, nearly half of the studied women (49.6%) were at age 25-34 years, more than two thirds of them were not working (68.4%), the majority of them were married (94.9%), two fifths of them (40%) were intermediate educated. The majority of the studied women got pregnant before, had previous deliveries and have children, slightly less than one third of them (29.3%) got pregnant two times, one quarter of them got pregnant three times, more than one third of them had two previous deliveries (35.3%) and more than one third of them (34.8%) have two children. knowledge of the different contraceptive methods: Table (1) showed that all the studied women knew about pills, IUCD and the majority of them know about injections (93.2%) and more than three quarter knew about condom (75.2%) followed by (70.1%) knew about implant. More than two thirds (67.5%) knew about emergency contraception, lactational amenorrhea was the most recognized traditional method representing (47%). Prevalence of methods of contraception: Table (2) showed that the current use of contraceptives; more than eight in ten women use a contraceptive method now; the IUD was the most common methods used by the studied women representing slightly less than two thirds (64.1%) followed by pills representing (58.1%) then injection (34.2%). Only (3.4%) used female sterilization and only (2.6%) used emergency contraception. no one used male sterilization as a contraceptive method. The current use of contraceptives; more than eight in ten women use a contraceptive method now. Reasons of not using contraception: Fig. (1) showed that the most common cause of not using a contraceptive method now was the desire to have more children (40%).
Badr M El Shamy, et al. 139 Factors affecting the use of contraceptive methods: Tables (3-5) showed the stepwise logistic regression model for the most commonly used contraceptive methods as dependant factor and the various personal characteristics as independent factors. Tables (3,4) showed the stepwise logistic regression model for pills and IUCD as a dependant variables in the sample revealed that the number of previous pregnancies among the studied women was statistically significant independent positive predictors of their use of pills and IUCD (the increase in the number of previous pregnancies of the studied women was associated with increase in her use of pills and IUCD). Table (5) showed the stepwise logistic regression model for the use of condom as a dependant variable in the sample, revealed that the working of the studied women was statistically significant independent positive predictors of their use of condom (the husbands of the working women used condom more than the husbands of the not working women). The stepwise logistic regression model for the use of vaginal methods and lactational amenorrhea as a dependant variable in the sample revealed that the age of the studied women was statistically significant independent positive predictors of their use of vaginal methods and lactational amenorrhea (Increase in age of the studied women was associated with increase in her use of vaginal methods and lactational amenorrhea). The stepwise logistic regression model for the use of withdrawal method as a dependant variable in the sample revealed that the educational level of the studied women was statistically significant independent positive predictors of their use of the withdrawal method. (The increase in the educational level of the women was associated with increase in her use of withdrawal method). The stepwise logistic regression model for the use of emergency contraception as a dependant variable in the sample revealed that the women's knowledge about emergency contraception was statistically significant independent positive predictors of their use of the emergency contraception (increase in women's knowledge about emergency contraception was associated with increase in her use of emergency contraception). Table (1): Knowledge of the studied women regarding the use of the F.P methods (n=117). Methods Knows how the methods is used Frequency (fr.) % Modern methods: Pills 117 100 IUCD 117 100 Injection 109 93.2 Implant 82 70.1 Vaginal methods 31 26.5 Condom 88 75.2 Female sterilization 49 41.9 Male sterilization 23 19.7 Emergency contraception 79 67.5 Traditional methods: Withdrawal 44 37.6 Lactational amenorrhea 55 47.0 Periodic abstinence 13 11.1 Table (2): The ever use of F.P methods by the studied women (n=117). Methods Current users of contraceptive methods The ever use of methods Frequency (fr.) % 97 82.9 Modern methods: Pills 68 58.1 IUCD 75 64.1 Injection 40 34.2 Implant 15 12.8 Vaginal methods 9 7.7 Condom 28 23.9 Female sterilization 4 3.4 Male sterilization 0 0 Emergency contraception 3 2.6 Traditional methods: Periodic abstinence 16 13.7 Withdrawal 15 12.8 Lactational amenorrhea 11 9.4 Table (3): Stepwise logistic regression analysis to show independent variables that could affect using of pills. Using of Pills Coef. SE Z-test p-value Educational level Number of previous pregnancy -0.18 0.35 0.16 0.18-1.12 1.97 0.264 0.049* Table (4): Stepwise logistic regression analysis to show independent variables that could affect using of IUCD. Using of Pills Coef. SE Z-test p-value Age group 0.25 0.24 1.051 0.293 Number of previous pregnancy 0.53 0.21 2.476 0.013*
140 The Contraceptive Knowledge & Use among Women Attending Table (5): Stepwise logistic regression analysis to show independent variables that could affect using of condom. Using of Pills Coef. SE Z-test p-value Working 1.18 0.46 2.566 0.010* Number of previous pregnancy 0.39 0.22 1.792 0.073 Menopause Pregnancy Fig. (1): Causes of not using F.P methods now (n=20). Discussion The present study had been conducted to assess women's contraceptive knowledge (regarding the use of the contraceptive methods) & use and the different factors affecting their knowledge & use, this will help health care professionals to address misconceptions, thereby improving consistent use of contraception, reducing risk of unintended pregnancies and improving maternal and child health. One hundred and seventeen women were recruited in the study according to the inclusion criteria, they were attending primary health care centers related to Al Dawahe district at Port-Said Governorate. The present study showed that the majority of the women had knowledge regarding the use of different modern and traditional methods of contraception, this fact is well supported by the observation that all the studied women knew about pills and IUCD and more than nine in ten women knew about injectable. Somewhat more than three quarter of them knew about male condom, (70.1%) of them knew about implant while more than two thirds (67.5%) know about emergency contraception, (41.9%) knew about female sterilization and more than one quarter (26.5%) knew about vaginal methods and only (19.7%) knew about male sterilization, this was regarding the modern methods while regarding the traditional methods, lactational amenorrhea was the most known method representing (47%) followed by withdrawal method representing (37.6%) and lastly periodic abstinence which represent (11.1%). These results were in agreement the results of EDHS 2008 by El-Zanaty & Way 2009 regarding pills, IUCD and injectables also lactational amenorrhea was the most known traditional method in both. While in EDHS 2008, knowledge of implant and female sterilization were higher than that of the present study (93.7%) and (57.6%) respectively. On the other hand the knowledge of male condom was higher in the present study (48.7%), (5.6%), (12.6%) and (8.5%) respectively but in the present study (75.2%) than in EDHS 2008 (67.5%) [3] Also the present study was in nearly congruent to that study by Arbab et al., 2008 which was conducted to determine the knowledge of, attitude to and practice of contraception among Qatari married women aged 18-49 years, women mostly knew about pills (90.0%) and IUDs (89.1%) with only 25% knew about injectable contraceptives, (15.9%) about condoms and these findings are relatively lower than that of the present study [6]. In contrast to the finding of the present study, Kenya DHS 2008-2009 showed that the male condom was the most known method to the women representing (89.2%) followed by injctables (88.5%) then pills (87.9%) then implant (67.2%) then female sterilization (66.8%), the condom has the benefit of reducing the transmission of sexually transmitted disease which is prevalent in this country [7]. The difference in knowledge about contraceptives also found by Tilahun et al., 2013 in Ethiopia that found that method-specific knowledge levels varied from 12% for vaginal contraceptives (diaphragm, foam, jelly) to 94% for injectable contraceptives [8]. Knowledge difference could be explained in light of past experience with contraceptive use or medical service that could provide health education related to reproductive health cultural difference between study settings. This study revealed that more than eight in ten women are currently using a contraceptive method (82.9%) while El-Zanaty & Way 2009 found that 60 percent of married women in Egypt are using a contraceptive method at the time of the study. This prevalence of using contraceptive methods in a study was better than in a study by Jain and Muralidhar 2011 in India that was reported to be many factors related to personal factors, service factors or disadvantages of methods. The increase in percent of use of contraceptive methods in the present study could be explained by the economic hardships and awareness of benefits of small families [9]. The desire to have more children was the most common cause of not using a contraceptive method
Badr M El Shamy, et al. 141 currently representing (40%) in the present study, this agree with the finding of Arbab et al., 2008 at which women who were not currently using any family planning method wanted to have more children (34.5%) [6] also another study by Okluna et al., 2006 found that discontinuation of IUCD mostly related to was the desire for pregnancy (57.0%) [10] while the results by El-Reffay 2004, showed that pregnancy was the most common cause of not using a contraceptive method representing (52.6%) at time of this study 1111. Another study by Olugbenga-Bello et al., 2011 about the prevalence and determinants of choice of contraceptive methods among rural women in Osun state, Nigeria found that the main reasons for non- use contraceptive were the fear of side effects, husbands' disapproval and the desire for more children, with religion and family setting [12]. The similarities between these results could be explained by less cultural differences in these study settings. The current study revealed that the IUCD was the most widely used methods by the studied women representing about two thirds (64.1%), the Egyptian ministry of health and population always encourage the use of IUCD. This is followed by pills which represent more than the half (58.1%) then injectables which represent more than one third (34.2%), male condom (23.9%), periodic abstinence (13.7%), withdrawal method and implant (12.8%), lactational amenorrhea (9.4%), vaginal methods (7.7%), female sterilization (3.4%) and finally emergency contraception (2.6%), no one of husbands of studied women used male sterilization as a contraceptive method as it does not match with our traditions and culture. These results were in agreement with the result El-Zanaty & Way 2009 in which the IUCD was the most widely adopted method; (60.4%) of studied women have used the IUCD at some point in their lives. Thirtyseven percent of women have ever used the pills, while (21.6%) have ever used injectables and also no one of the husbands of the studied women used male sterilization. In EDHS 2008 prolonged breastfeeding was the most frequently used method among traditional methods representing (12.1%) while in the present study periodic abstinence was the most frequently used method 131. In contrast to the results of El-Zanaty & Way 2009 in which only three percent report ever use of condoms, in this study the ever use of condom have increased to reach (23.9%) and there is also increase in use of vaginal methods which was (0.3%) in EDHS 2008 and reach (7.7%) in the present study, use of emergency contraception was (0.1%) in EDHS 2008 but in the present study it reached (2.6%), these noticeable changes in use of these methods are coinciding with the increase in level of knowledge of these methods 131. In sharp contrast to the pattern of contraceptive use in the present study is the pattern of contraceptive use in United States, national survey for population growth 2006-2008 which showed that the most widely ever used method is the female sterilization representing (99.1%) followed by male condom (93%) then pills (82.3%) then withdrawal method representing (58.8%), this could be explained by religious differences, as Islam prohibited sterilization. The high percent of the use of condom could be explained by its benefit in reducing the transmission of sexually transmitted diseases specially Acquired Immunodeficiency Syndrome (AIDS) which is prevalent in United States due to sexual behavior which is related also to religious factors [13]. The stepwise logistic regression model for the use of different contraceptive methods by women in the sample as dependant variables and socio-demographic characteristics of women in the study sample as independent variables with 95% confidence limits for the coefficient revealed that: The best positive predictor for the use of pills and IUCD among women in the study sample was the number of previous pregnancies. This means that the use of pills was more with increase number of previous pregnancies. This could be explained by the women desire to effective method. In a study by Thalji 2003 in Jordan about knowledge, attitude and practice of women towards family planning methods in Tafila, the IUCD was found to be preferable among younger less educated and those having children two children, while the reverse was true for oral contraceptive pills [14]. The best positive predictor of using vaginal methods and lactational amenorrhea among the study sample was the age group this means that women with increasing age use the vaginal methods and lactational amenorrhea more, which could be explained by preferring the use of non hormonal contraceptive methods by women with increasing age. The best positive predictor of using condom among husband's of the studied sample was working status of women this means that husband's of working women can use condom rather than husband's of non working women. This could be explained that working women could convince their husband's about condom use or that husband's of working women could be more co-operative and understanding the importance of family planning. The best positive predictors of using withdrawal methods was the educational level of the study sample which means that the increase in the educational level of the women is associated with increase in her use of withdrawal method, this may
142 The Contraceptive Knowledge & Use among Women Attending explained that the highly educated women has the ability to make her husband share with her in the process of family planning. The best positive predictors of using emergency contraception was the women's knowledge about emergency contraception this means that increase in women's knowledge about emergency contraception is associated with increase in her use of emergency contraception. Conclusion and recommendations: All the studied women knew about pills, IUCD and high percentage of them knew about injections (93.2%). More than three quarter knew about condom (75.2%) followed by (70.1%) knew about implant. More than eight in ten women are currently using a contraceptive method (82.9%). The IUCD was the most common methods used by the studied women representing (64.1%) followed by pills representing (58.1%) then injection (34.2%). The best positive predictor for the use of pills and IUCD was the number of previous pregnancies (pvalue<0.05). The present results for further educational interventions regarding other contraceptive methods to provide multiple choices for the women who found that pills, IUCD or injectables are unsuitable for her instead of not using any method. Limitations of the study: The knowledge in the present study was brief and limited to their use. In other words, knowledge about methods was not covered in terms of advantages, disadvantages and their mode of action. The study was carried out at primary health care centers. The sample was relatively small to test knowledge and use of less frequently used methods as vaginal methods, male and female sterilization. Also the role of husband was missed in this study, which could be of great importance in affecting the contraceptive use. References 1- World Health Organization WHO, Media Center, Family planning. Fact sheet N 351 Available from http://www. who. int/mediacentre/factsheets/fs351/en/index.html. Up dated May, 2013. 2- KHALIFA M., DAVANZ J. and ADAMSON D.M.: Population Growth in Egypt A Continuing Policy Challenge 2000. Rand Corporation Issue Paper IP-183. Available from http : //www. rand. org/pub s/is sue_pap er s/ip 183/ index2.html#fnl last updated October, 2010. 3- EL ZANATY F. and WAY A.: Egypt demographic and health survey 2008. Cairo Egypt. Ministry of Health and Population, National Population Council, El-Zanaty and Associates, Family planning. pp, 2009. 4- World Contraceptive Use United Nations, Department of economic and social affairs, population division. Available from http://www.un.org/esa/population/publications/ contraceptive/contraceptive.htm, 2007. 5- OGBEIDE D.A.: Profile of acceptors of contraception in the family practice clinic, Saudi Medical Journal, 2 (10): 817-818, 1999. 6- ARBAB A.A., BENER A. and ABDULMALIK M.: Prevalence, awareness and determinants of contraceptive use in Qatari women. Eastern Mediterranean Health Journal, 17 (1): 11-8, 2011. 7- Kenya National Bureau of Statistics (KNBS) and ICF Macro. Kenya Demographic and Health Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro 2010. available from http://www.unfpa.org/sowmy/resources/ docs/library/r313_knb S_2010_Kenya_DHS_2009_fi nal_report.pdf. 8- TILAHUN T., COENE G., STANLEY LUCHTERS S., KASSAHUN W., LEYE E., TEMMERMAN M. and DE- GOMME 0 Family Planning Knowledge, Attitude and Practice among Married Couples in Emma Zone, Ethiopia. PLoS One, 8 (4): e61335, 2013. 9- JAIN R. and MURALIDHAR S.: Contraceptive Methods: Needs, Options and Utilization. J. Obstet. Gynaecol. India, 61 (6): 626-634, 2011. 10- OKUNLOLA M.A., OWONIKOKO K.M., ROBERTS O.A. and MORHASON-BELLO 1.0.: Discontinuation pattern among IUCD users at the family planning clinic, University College Hospital, Madan. J. Obstet. Gynaecol., 26 (2): 152-6, 2006. 11-EL REFAAY S.: Study of knowledge, attitude and use of family planning methods at Kariet Amer in Suez governorate, Faculty of Medicine, Suez Canal University, Egypt, 2004. 12- OLUGBENGA-BELLO A.1., ABODUNRIN O.L. and ADEOMI A.A.: Contraceptive Practices Among Women in Rural Communities in South-Western Nigeria. Global Journal of Medical Research, 11 (2): 9, 2011. 13- Center for Disease Control and Prevention CDC Monitor the nation's Use of contraception in the United States: 1982-2008, Vital and Health Statistics, Series 23, No. 29. Available from http ://www. cdc. gov/nchs/dat a/series/ sr_23/sr23_029.pdf, 2010. 14-THALJI N.N.: Knowledge, attitude and practice of women towards Family Planning Methods in Tafila-Jordan. JRMS, 10 (1): 40-4, 2003.