A knowledge, attitude and practices based study to know the awareness and acceptance of contraceptive methods in married couples coming to well-baby clinic of a tertiary care centre in Panvel, Maharashtra, India

INTRODUCTION

National program for family planning was the first National Health Program launched in 1952, still the coverage for family plannng is not of desired level. It’s an area to focus as numerous public health challenges can be attributed ever growing population of India. Family Planning and Family Welfare counseling is one of the major component of Well-Baby clinic run by Department of Public Health, Sri Sathya Sai Sanjeevani Centre, Kharghar by providing a gender sensitive Café-teria approach for suggesting family planning to the couples. In conversation with couples, especially those that belong to low socio-economic strata and don’t have access to education it was found that the level of awareness about options available in contraceptive methods is very less. Some who were aware are not willing to use it, for reasons like contraceptive methods are not safe, religious belief, wanting a boy or a girl etc. Some are willing to use but have no accessibility. Myths regarding contraception are very strongly imbibed in minds of people.¹ Family planning can play a major role in improving the financial, educational, social well-being of a family as a unit. So, need was felt to study the knowledge, attitude and practice of family planning methods in married couples.

The components of under 5 clinics are care for illness, growth monitoring, immunization and family welfare. All this is possible only with health promotion and Family planning which form the base of the care needed by the child as well as the family. The study focused on recording views and opinions of both partners and not just target the female partner who always bears the burden of family planning in traditional set up. This formed the novelty of the study, offering the women an array of choices so that she takes a well-informed free of bias decision. The major focus of the study was not just knowing the acceptance and awareness of contraception, but also couples were counseled for family planning in a gender sensitive cafe teria approach that all their myths and hesitancies were addressed and they were motivated for acceptance.

METHODS

Community based prospective qualitative study to know the knowledge, attitude and practices of methods of contraception was conducted from June 21 to December 22 in Well-baby clinics of Sri Sathya Sai Sanjeevani Centre for Child Heart Care & Training in Pediatric Cardiac Skills Kharghar. The study was approved by the institutional ethics committee. The sample size was arrived by the formula 4PQ/L², wherein P is the prevalence of use of any type of contraceptive method. P was taken as 68% according to NHFS-5 of Maharashtra. Eligible couples in the reproductive age groups who have not undergone terminal method of contraception and give voluntary consent for participation were included in the study randomly. Eligible couples are those in which the female partner is in the reproductive age group of 15 to 45 years.³ Couples were explained and counseled in local language regarding the objective of the study.

Data was recorded on a standardized pretested and validated questionnaire. Interviews were conducted by the Principal Investigator and Medical Social Worker. Interview of the couples were carried out in the local languages like Marathi and Hindi. Questionnaire included some direct and some indirect questions. The questionnaire was divided in four parts, part 1 included general information of the couple. Part 2 had questions pertaining to knowledge. Part 3 focused on attitudes towards family planning which had questions pertaining to gender dynamics in a couple and part 4 focused on practices of contraceptive devices. The educational, occupational and income parameters were recorded according to the Kuppuswamy scale. Anonymity of couples was maintained throughout the study. Confidentiality of the participants and the data generated from interview was maintained. The focus of the interview though was data collection each and every couple interviewed was counseled for family planning using gender sensitive café-teria approach. The interviews were conducted in an interactive way so that any hesitancy or myth regarding contraception can be addressed to mandatory statistical analysis was performed using soft wares like Excel, SPSS.

RESULTS

Our study focused on knowing the level of awareness and acceptance for various contraceptive methods in married couples. The couples belonged to semi urban areas and slums of Panvel block. Figure 1 show percentage of awareness levels of various contraceptive methods. 41% female partners were gravida 1, 27% gravida 2, 22% gravida 3, 7% gravida 4, 3% gravida 5 and one female partner was gravida 8 with only 1 child alive. Thus a total of 58% were gravida 2 or more and in dire need of contraception. Kuppuswamy scale was used for socio economic classification. 40% families belonged to lower middle class, 31% upper middle class, 24% upper lower and 5% upper class. Only 8 families had both partners working, mainly in unskilled category.

We found a relation between educational level and acceptance of contraception, more the literacy level more the acceptance, with a p value of 0.001. Figure 2 shows number of couples using any type of contraception. Only 55% of couples have acceptance towards use of any type contraception. Most common factor affecting the acceptance of any type of contraception was found to be the desire to have one more child as 41% of couple had only one child and 82 couples were practicing natural methods like abstinence, coitus interruptus, and safe period method along with use of barrier method. Other reasons that affected the acceptance are listed in Table 1.

The most commonly used method of contraception is barrier i.e. condoms which is 78.49%. Figure 3 represents percentage of use of various contraceptive methods. The reason for preferable use of condoms was its easy and readily available doesn’t require supervision or doctor’s consultation. Out of 180 participants, only 16% agreed to think about IUCD as an option and 51% denied to use it due bad experiences by their peers, like heavy menstrual bleeding, back pain, weakness.

Figure 4 represents percentage of mediums of awareness that contribute in increasing the awareness level regarding contraceptive methods. Surprisingly healthcare delivery system contributes only 30% in information education and communication regarding contraception which includes education through healthcare delivery professionals like ASHA worker, anganwadi Sevika, ANM, nurses and doctors. Digital medium of awareness included education through advertisements, IEC material like posters displays, newspapers, television, smart phones.

60.56% couples resorted to digital media for their queries regarding contraception. Table 2 shows no. of couples who would think of surgical contraception after their family is complete. The perception of the couple was considered for the family size. Gender discrimination is visible in willingness to go for surgical contraception. Almost all male partners had awareness regarding the option of vasectomy but only 5.56% males were willing for vasectomy. Though female partners were aware of vasectomy, a high percentage of women i.e. 81% agreed to opt for surgical contraception. As the biological effects of pregnancy are on the female partner the onus of FP also lands on her, showing the gender discrimination in the society regarding family planning. In a traditional Indian set up the decision making in the family lies with the male partner, even if the woman is earning there is power dynamics at play and the male partner is in the decision making role. Reasons for couples not decide or willing for contraception were like not yet thought about it, don’t feel the need, fear of side effects, religious beliefs and lack of awareness. Maximum number of participant couples had only one child and were planning for next so were not using any family planning method, in many couples there was hesitancy due to lack of awareness and hesitancy to seek help and guidance. These couples were counseled and given various options using gender sensitive café teria approach for spacing of the family. As contraception is prohibited in some religions, couples belonging to those religions were not ready to accept any type of family planning, though now some eligible couples from that religion are opting for physical contraceptive methods. Four couples had conceived after 4-5 years of marriage, so were hesitant to use any FP method in future.

DISCUSSION

The study focused on recording views and opinions of both the partners and not just target the female partner who always bears the burden of family planning in a traditional set up. The novelty of the study was maintained by the same and by offering the women an array of choices so that she takes a well-informed free of bias decision. Introduction and emphasis to family welfare component was given in well baby clinics at Sri Sathya Sai Sanjeevani centre with a dedicated staff providing counseling and availability of contraceptives was ensured through government support system using café-teria approach. Major focus of the study though being to know the acceptance and awareness of contraception, couples were counseled for family planning in a way that all their myths, hesitancy if any is addressed and they are motivated for acceptance.

Even though government ensures regular awareness campaigns, free availability of contraceptives, the use of those is not of a desired level. The use of any type of contraceptive methods is 68% as per the National Family Health Survey 2019-20 of Maharashtra. Our study found that use of any type of contraceptive methods among married couples is only 51.67%, much lower than the state average. The awareness and increase in the education levels of girls along with the accessibility to digital media may be the reason behind the use of contraception by women. A KAP study carried out by Singh et al in postpartum women also states a relation between the educational level and acceptance of contraception, more the literacy level more the acceptance.⁴ We also found the same results with a p value of 0.001. Around 60.56% couples came to know or explore digital media for their queries regarding family planning methods. Only 30% couples said they came to know about family planning methods from healthcare delivery system. The most commonly used method being the barrier method which is used by 78.49%. Being a patriarchal society it is observed that the onus of performing terminal method of family planning always falls on the women, who especially in rural India are not educated or empowered enough to make an informed choice. The female sterilization rate is 49.1% compared to male sterilization which is just 0.4% in a state like Maharashtra according to NFHS-5 data. Our study shows that even though the awareness levels for Male sterilization is 98% the percentage of male partners who showed willingness to opt for it is just 5.56% while female partners opting for surgical method of contraception is 80%. In a study by Korranne et al, none of the male partner got ready for sterilization.⁵ The high percentage of female partners showing willingness to surgical methods of contraception shows that gender discrimination plays a major role. Decision making capacity, place of the women in the family, financial independence and her educational status affects the choice a woman can make in the planning of the family. Five couples said that they won’t use any form of family planning methods as they want a boy child.

Myths regarding Intrauterine Contraceptive Devices (IUCD) are very strongly in the minds of females. The most common being generated through peer experiences 51% females said they will never use IUCD due to bad experiences by their peers. IUCD’s are one of the safer and effective (Pearls index-1-2%) method of contraception, awareness level regarding the same should be increased by undertaking one to one counseling and explanation of the advantages. Only 16% participants agreed to think about IUCD as an option and only 3 were using it already and 3 had used and removed due to bad experiences.

Healthcare delivery system needs strengthening and must be sensitive enough so that the couples themselves approach for guidance regarding family planning. Focus should be on one to one counseling to both male and female partner at the same time. We found that male partners are more aware about the contraceptive methods available in comparison to their female partners, this leads to inequality in choices that a female partner can have. So, offering a café teria approach in which an array of choices of contraceptive methods are provided to the couple for FP can help in reducing the gender discrimination that is visible especially in willingness to go for surgical contraception. Sensitization of the couple should be done in the antenatal care period itself and options of IUCD and injectable contraceptive should be offered in the puerperium and the period of lactational amenorrhea. We promoted injectable contraceptives in the puerperium and lactational amenorrhea period, it was found that the initial acceptance for injectable is very good but the women didn’t’ want to go for the second dose due to side effects like bleeding between periods and prolonged menstrual cycles. The married eligible couples should be targeted in the under five clinics for promotion on importance of family planning and family planning can be included as an integral part of pre conceptional care and education of adolescent girls as well as boys. Family planning can play a major role in improving the financial which in turn will improve nutritional, educational, social well-being of a family as a unit.

This study has some limitations. The myths and hesitancies of the participants were addressed to by counseling but the behavior change is a continuous and long term process, which needs to be assessed and addressed at regular intervals. The post counseling rise in the level of awareness and acceptance of family planning methods was not assessed.

CONCLUSION

Contraceptive acceptance in Maharashtra state of India as per NHFS-5 is 68%. The study tries to analyze well baby clinics as point of delivery for understanding and increasing contraceptive acceptance using personalized gender sensitive cafe-teria approach.Since our research finds contraceptive acceptance at 51.6% much lower than the state average, we look into components of gender dynamics and offer array of choices to couples so that they make well informed choices free of gender bias. We recommend well baby clinics as effective point of delivery for family welfare activities using gender sensitive cafe-teria approach. The continuity of personalized and dignified couple counseling from preconceptional, antenatal to postnatal period is emphasized to increase contraceptive acceptance.

ACKNOWLEDGEMENTS

We would like to thank the contribution of Ms. Rupali Gaikwad the Medical Social Worker who was instrumental in data collection, interview and counselling of the couples.

Funding: No funding sources

Conflict of interest: None declared

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

REFERENCES

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