An epidemiological study to assess unmet needs for family planning among married women in an urban slum area of Mumbai

INTRODUCTION

According to 2017 estimates, 214 million women of reproductive age in developing regions who want to avoid pregnancy are not using a modern contraceptive method. Use of modern contraceptives in 2017 prevented an estimated 308 million unintended pregnancies. Meeting all women’s need for modern methods of contraception would avert an additional 67 million unintended pregnancies annually.¹ In India, according to NFHS-4, total unmet need for family planning among currently married women (15-49 yrs) was 12.9%. Unmet need for spacing was 5.7% and for limiting was 7.2%while in Maharashtra total unmet need for family planning was 9.7% and unmet need for spacing was 4.3%.² According to DLHS-4, total unmet need 19% for spacing 10.8% and for limiting 8.2%.³ The National Population Policy (2000) has set the task of addressing the unmet need for contraception as its immediate objective.⁴ Women with unmet need are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the next child. The concept of unmet need points to the gap between women's reproductive intentions and their contraceptive behaviour_.⁵ Unmet need for limiting birth includes women who want no more children but are not using a family planning method and pregnant women whose pregnancy was unwanted while unmet need for spacing means pregnant women whose pregnancy was mistimed, amenorrhoeic women whose last birth was mistimed, and women who are neither pregnant nor amenorrhoeic who say they want to wait two or more years for the next birth, are unsure whether they want another child, or want another child but are unsure when to have it and are not using a family planning method.

Unmet need is a useful tool for monitoring family planning program and maternal health. Effective use of contraceptives helps to reduce maternal mortality by reducing unintended pregnancies and abortions.⁶ Unmet need is especially high among groups such as Adolescents, Migrant Urban slum dwellers, Refugees, Women in the postpartum period.¹ The unintended pregnancies end up in abortion which are most often unsafe accounting for large no of maternal deaths and among these two-thirds of unintended pregnancies in developing countries occur among women who are not using any method of contraception.⁷ Thus the present study explores the magnitude of unmet need for family planning among married women their associated sociodemographic factors and reasons for the same.

METHODS

Study design

Hospital based cross-sectional study.

Study area

Urban health Training Centre which is field practice area of Department of Community Medicine.

Study population

Married women of reproductive age (15–49 years) attending the General OPD for about a month having 24 working days. The daily average attendance at general Opd is around 25, thus total no of attendees in a month will be 600. The mothers fulfilling the inclusion criteria were enrolled in the study after the informed consent by using Simple Random sampling method prospectively till the desirable sample size was achieved in each area. Two-digit random number tables were used and 15 mothers were chosen randomly from total mothers every day and were interviewed. Thus total 375 women were included in the study.

Inclusion criteria

All married women in the age group of 15-44 years willing to participate in the study after the informed consent.

Exclusion criteria

If the women is accompanied by her in-laws or husband.

Study period

From September 2018 to October 2018.

Pre-designed, pre-tested questionnaire was used to collect data regarding sociodemographic characteristics. Every woman falling under the inclusion criteria was interviewed. Informal discussion was done with the study subjects in order to build rapport. The purpose of the study was explained using informed consent document and such consent was obtained from each of the study subjects. Ethical committee approval was taken. Socioeconomic status was calculated using B G Prasad scale (2019). Data was compiled using Microsoft Excel 2016 and was coded accordingly. Statistical Analysis was done using SPSS software version 23. Test of significance (Pearson’s Chi- square test or Fischer’s Exact Test) was applied to find out the association between the sociodemographic factors and other study variables. p values <0.05 was considered to be significant. Numbers and Percentages were used to represent data wherever required.

RESULTS

As shown in Table 1. Out of 375 women 85 (22.66%) were using contraceptives while 290(77.34%) of women were not using any type of contraception. Total unmet need for spacing birth was 69 (18.4%) which was 4 (1.06%) among pregnant women and 65 (17.33%) among non-pregnant women. Total unmet need for limiting birth was 98 (26.13%) which was 6 (1.6%) among pregnant women and 92 (24.53%) in non-pregnant women. Intender means if a woman wants to have child within 2years. Wants child later –If a women wants to have child and spacing she desires is 2years or more.

Unmet need for spacing birth (65+4)=69 (18.4%), Unmet need for limiting birth (6+92)=98 (26.13%), Met need for spacing =67 (17.86%), Met need for limiting =18 (4.8%), No need 102+19=121 (32.26%).

As shown in Table 2. unmet need for spacing birth was highest 27 (26.21%) in the age group of 20-25 years and lowest in 30-35 years 10 (12.04%) while unmet need for limiting birth was highest 10 (12.04%) in the age group of 30-35 years and lowest 2 (5.55%) in 15-20 years.

When the association between various sociodemographic variables and contraceptive need was studied, it was found that the association between education status of women and socio-economic status of the women and the unmet need were found to be statistically significant.

It is shown in Figure 1, 10 (50%) of women with no child and 24 (55.81%) women having one child had more need for spacing birth while women who had 2 children 26 (24.29%) had need for spacing and 41 (38.31%) had need for limiting birth.

51 (62.19%) of women who had more than two children had unmet need for limiting birth.

DISCUSSION

In our study out of 375 women, contraceptive needs of 85 (22.66%) were met while 290 (77.33%) women were found not using any type of contraception. Total unmet need was found to be 44.53% in which unmet need for limiting birth was 98 (26.13%) and unmet need for spacing birth was 69 (18.4%). This was quite higher as compared to the national and state figures i.e. 12.9% and 9.7% respectively as per NFHS 4 but our findings were similar to Lekshmi et al and Puri et al which showed that unmet need was 41% and 49.8% respectively.^8,9 Mukesh Shukla et al who did a study in urban slums of Lucknow also found that unmet need for spacing and limiting birth was 29% and 40%.¹⁰

It was seen in our study that overall unmet need for family planning and unmet need for limiting was high in the women aged 25-30 years. However, unmet need for spacing was highest among women in the younger age group (20-25 years). Demand for limiting the birth is expected to be higher among women in the middle age group (25-35year) as they might have already attained their desired number of children and hence would like to use contraceptives for limiting. On the other hand, demand for spacing would be higher among younger women who want to postpone their next pregnancy. Similar results were shown by Devis et al.¹¹

As shown in Table 3 although religion has no significant association was seen with the met or unmet needs but still the unmet need was slightly high among the Hindus as compared to Muslim community similar to the study by Mohanan et al. where more Hindus were using family planning methods as compared to Muslims.¹² It was seen in our study that unmet need was significantly associated with the socioeconomic and literacy status of the women .Illiterate women had highest unmet need while unmet need was decreasing with increasing educational status. Higher literacy level and a high socioeconomic status women are more aware about the importance of family planning and are making proper use of contraceptive methods similar results were seen in other studies.^13-15 We also found that literacy status of husband doesn’t show any significant association with unmet need. It was seen that unmet need for more in joint families and similar results were obtained by Rini Raveendran et al.¹⁶ It was also seen that unmet need was higher for spacing birth in women having one or two children while unmet need for limiting was higher for women having more than two children which shows women are interested in controlling their fertility when they have atleast one child and similar results were shown by Shahina Begum.¹⁷

In our study we found that the most common reason for not using a contraceptive was inconvenience or inavailability (34%) followed by lack of awareness (17%) and fear of side effects (14%) similar results were found by Akansha et al however Patel et al observed that most common reason for not using the contraceptives was inconveniency (48.78%) followed by refusal by spouse (21.95%), Lack of knowledge (17.07%), side effects (7.31%).^18,19

Husband’s disapproval (34.2%), lack of awareness (27.8%) and fear of side effects (24.1%) were common reasons behind the unmet need. ²⁰ Reasons for unmet need were similar to However in the study conducted by Nayak A et al it had been observed that the most common reason of unmet need was side effects of contraception 28.6%, followed by religious reason 21.4%, family opposition 21.4%.

CONCLUSION

The unmet need for contraception in our study was found to be was 44.53% which is much higher than the NFHS-4 data for urban Maharashtra i.e. 11%. Also we can see in our study that unmet need is increasing as the age advances thus family planning methods should be directed to this group. Here education of women was found to be significantly associated with unmet need thus improving the literacy rate among women may consequently lead to rise the job opportunities and thus improving the condition of the family which can increase the participation of women in the adoption of family planning methods. Among the main reasons for unmet need were inconvenience and lack of awareness therefore emphasis should be made on access to convenient methods and good communication along with counselling about the different contraceptive methods. Thus appropriate measures should be taken for motivating couples to adopt the family planning methods specially among younger age women and economically backward groups.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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