Factors influencing acceptance of family planning methods among women coming to immunization OPD: a cross sectional study

INTRODUCTION

India has over 1.271 billion people (2015), containing 17.5% of the world's population, India is projected to be the world's most populous country by 2025, surpassing China, reaching its population; 1.6 billion by 2050.¹ India has more than 50% of its population below the age of 25 years and more than 65% below the age of 35 years.²

WHO defined family planning as way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitude and responsible decisions by individuals and couples, in order to promote the health and welfare of the family group and thus contribute effectively to the social development of a country.³ It is one of the ten great public health achievements of the 20^th century.⁴ Family planning also refers to practices that help individuals or couples to avoid unwanted births, to bring about wanted births, to regulate the intervals between pregnancies, to control the time at which births occur in relation to the ages of the parents and to determine the number of children in the family.⁵ It is essential in reducing poverty and achieving United Nations’ millennium development goal.⁶

Children were seen as gifts from God and any attempt at birth control was considered sinful. The opinion has now changed drastically in favour of family planning such that individuals, families and communities now advocate and seek for it publicly. Differences in the knowledge and usage of family planning methods may be due to social socio-cultural factors like marital status, culture and religion, and also those inherent in the individual’s environment found in one’s living and working conditions (such as the distribution of income, wealth, influence, power and cultural factors such as belief, custom and norms), rather than individual factors.^7,8

Child immunizations are one of the most equitable and widely used health services globally. By adopting family planning, couples can achieve healthy pregnancies through proper timing and spacing. The recommended vaccination schedule for children allows for multiple health care contacts with infants and their mothers during the first year of life. Using immunization program as a platform for the delivery of other services demonstrates the value of immunization while also encourage in potential additional support for strengthening delivery of quality health services.⁹

Family planning is one of the most cost-effective interventions available, but still there exists unmet needs for family planning. Unmet need for family planning reflects the gap between childbearing desires and contraceptive use.¹⁰ It is possible that different factors influence family planning service uptake and contraceptive use. Therefore, this study assessed factors influencing acceptance of family planning methods among the women coming to an immunization clinic.

Objectives

To determine extent of adoption of family planning practices by the study subjects. To identify the factors influencing acceptance/non acceptance of family planning practices.

METHODS

A cross-sectional study was conducted among women in immunization OPD of the urban health centre of tertiary care hospital, Mumbai during period of February to April 2017. The study was conducted after obtaining clearance from ethical committee. 190 women of aged 15 to 49 years who were attending immunization OPD during study period were included in study and women beyond reproductive age group, unmarried close relative accompanying children to immunization clinic and those who were not willing to participate in the study were excluded.

A sample size was derived by using the formula n =Z_α²pq\d² (Z_α =1.96 p = prevalence (68.4%) (12), q = (100 – p), d = precision (10% of p).

n = 4×68.4×31.6\6.8×6.8 = 186, so assuming 2% non-response rate, 190 sample size derived.

In urban health centre, immunization OPD is held once a week and on an average 50 children comes on every OPD day. A list of all the children attending immunization OPD was obtained. The sample size of children to be studied was selected from the list by using systematic random sampling method where every third child was selected from the list until we get 16 children from every OPD to achieve total sample size of 190. A semi-structured questionnaire was prepared in accordance to the study objectives and tested by conducting a pilot study in approximately 15 women. These women interviewed in the pilot study were not included in the final study. After preliminary self-introduction, purpose of the visit was explained to the study subjects. After obtaining informed consent, the pre-validated semi structured questionnaire was administered to the study subjects. Interviews were conducted in a separate room available at the urban health centre to maintain privacy and confidentiality. The collected data was analyzed using chi-square method, using SPSS 22.

RESULTS

Socio demographic profile was depicted in Table 1 shows that 59% women were in the age group 18 to 25 years, mostly were Muslim by religion (67 %), and followed by Hindu religion. 61% women were educated up to secondary school, 19% were educated up to higher secondary level and 7.3% were illiterate. Whereas most of women (60.47%) belonging to upper lower class, 39.53% were in lower middle class (Table 1).

Only 42.63% of women were using one or other type of contraceptives. Atleast 60% couple should use contraceptive, however only 42.3% were using. Average number of children per women varied from 1 to 1.33. Those woman who were above 28 years, their husband were using condom as preferred method of contraception, where average number of children was 2 or more. Among 81women who use contraceptive husband of 55.5% were using condom. 17.2% were using oral pills and 18.5% women used IUCD while TL had been adopted by only 9.87% women who had more than 2 children on an average (Table 2).

More educated women were use contraceptive methods compared to illiterate ones (Pearson Chi-square- 20.53, p value 0.001). Moreover, the uses of contraceptive methods were more in upper lower class as compared to lower middle class. The association was statistically significant (Chi square 5.02 p value 0.02). The knowledge about contraceptives had association with contraceptive use (Chi square 6.8 p value 0.01). Lesser number of women in the age group of 18 to 25 years were using contraceptives as compare to >25 years women (Chi square 10.21, p value 0.001). Religion and number of children did not have significant difference for contraceptive uses (Table 3).

Most common cited reason for acceptance family planning practices was spacing of birth 38.2%, completed family size 34.5%, to prevent unwanted pregnancy 19.7% and for health improvement 7.6% (Figure 1). However, for non-acceptance of contraceptive methods, the most common reason was fertility related (21.7%), followed by lack of knowledge (17.7%), opposition from family members (16.9%), low risk of pregnancy to breastfeeding (14.5%), not having intercourse (12%), fear of side effects (8.8%), for gender preference 3.5% and infertility (3.2%), while 1.6% were waiting for TL camp (Figure 2).

DISCUSSION

In the present study only 81 (42.63%) of women were using one or other type of contraceptive. A similar finding is observed by Mitkari et al that out of 234 married women of reproductive age group 98 (41.9%) women said that they were using some method of contraception, which was condom (6.8%), OC pills (4.3%), copper-T (4.7%) and female sterilization (26.1%).¹³ None of the women were using injectable contraception and none of the women’s husband has done male sterilization. According to NFHS4 data in urban population of India, use of condom, OC Pills, IUCD, female sterilizations and male sterilizations are 9%, 3.5%, 2.4%, 35.7% and 0.5% respectively. While in the present study the Among 81, women who used contraceptives, 55.5% were using condom. 17.2% were using oral pills and 18.5% women Used IUCD while TL had been adopted by only 9.87%. IUCD use was less preferred along with OC pills. Thus, there is need for promoting contraceptives with less pearl index and mostly terminal methods should be promoted in this marginal population.

Significant predicators for contraceptive method adoption were education and knowledge while with the religion there was no significant difference for contraceptive uses. Higher socioeconomic class was showing uptake of family planning services. A study by Mitkari et al found that education of women was significantly associated with contraceptive use.¹³ Contraceptive use was the maximum in women educated up to secondary school or above which is 55.7%. Religion and socio-economic status was not significantly associated with the contraceptive use. But SES shows that proportion of contraceptive use increases with the increase in socioeconomic status. It is minimum (38.24%) in women belonging to upper lower SES, while maximum (66.67%) in women belonging to upper socio-economic status. The similar finding was reported in a study by Katelyn.¹⁴ Statistically significant predictors of uptake of family planning services included: education (AOR=3.03, 95% CI 1.57-5.83), and religion was not significantly associated with the uptake of family planning. A study by Khan et al observed that religion and socioeconomic status and education of women were not significantly associated with contraceptive use.¹⁵ In the present study, females more than 25 years aged used contraceptive more than female age 18 to 25 years. Similar finding is observed in study by Mitakari.¹³ In the current study contraceptive use was significantly higher among those having lesser number of children than those having more number of children. This is contrary to the observations made by Khan et al.¹⁵

Most common cited reason for acceptance family planning practices was spacing of birth 38.2%, completed family size 34.5%, prevent unwanted pregnancy 19.7% and health improvement 7.6%. However, for non-acceptance of contraceptive methods, the most common reason was fertility related 21.7%, followed by lack of knowledge (17.7%) and opposition from family members (16.9%), low risk of pregnancy due breastfeeding 14.5%, not having intercourse 12%, fear of side effects 8.8%, for gender preference 3.5% and infertility 3.2%, while 1.6% were waiting for TL camp. Sajid et al has reported that 20.83% women were worried about side effects, 16.67% considered it as against religion, 11.67% wanted more children, 6.67% had no knowledge about source of information and 8.33% opposed to family planning because of their husbands influence in choosing the contraceptive method.¹⁶ Sudha et al has cited the most common reason for unmet need for contraception was fear of side effects.¹⁷ A study by Khan et al and Patel et al has reported lack of knowledge (18%) as the main reason for unmet need for contraception in their study.^15,18 A study by Genet et al found that 33%, 32%, 23.5% and 11.8% of women mentioned less perceived risk of pregnancy due to breast feeding, fear of side effects, partner opposition and religious prohibition respectively as reasons for not using contraceptives at the time of interview.¹⁹

CONCLUSION

Women in the age group 22 to 28 years had average number of children from 1.25 to 2.58, but they were using condom as the most preferred method of contraception. Instead, they should be using IUCD or TL as the preferred method.

Women who were illiterate as well as studied up to secondary school should be perused through ASHAs and ICDS workers for using contraceptives with better pearl index.

Health care workers visiting postnatal mother must stress upon ‘long term contraceptive’ use explaining the situations requiring HCW attention. BCG vaccination of babies should accompany injectable or IUCD contraceptives to mother in the PNC ward. Unless all concerns of mothers about side effects of contraceptives are addressed, reaching 60% CPR will be difficult.

The reasons for non-acceptance of FP methods should form the basis for qualitative as well as social research studies.

Funding: No funding sources

Conflict of interest: None declared

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

REFERENCES

1. 1. “India’s population ‘to be biggest’ in the planet”. 18 August 2004. United States Census Bureau-International Data Base (IDB). Available at: Population.un.org/wpp/publications/files/key_findings_wpp_2015.pdf. accessed on 1 September 2023.
2. 2. Demographics of India. Wikipedia. 2007. Available from: https://en.wikipedia.org/wiki/Demographics_of_India. Accessed on 8 January 2015.
3. 3. Park K. Family planning. In: Park’s textbook of preventive and social medicine. 23rd edn. Banarsidas Bhanot Publishers; 2015.
4. 4. Family planning, 2010. Available from: https://en.wikipedia.org/wiki/Family_planning. Accessed on 8 January 2015.
5. 5. Park K. Family planning. In: Park’s Textbook of Preventive and Social Medicine. 18th edn. Jabalpur, Indian: M/s Banarsidas Bhanot Publishers; 2009:3589.
6. 6. Bill and Melinda Gates Foundation. Family Planning Overview. 2012. Available from: http://www.gatesfoundation.org/familyplanning/Pages/overview.aspx. Accessed on 20 January 2012.
7. 7. Kelly MP, Morgan A, Bonnefoy J, Butt J, Bergman V. The social determinants of health: developing an evidence base for political action. National Institute for Health and Clinical Excellence, 2007.
8. 8. Social determinants of health. Wikipedia. 2012. Available from: https://en.wikipedia.org/wiki/Social_determinants_of_health#:~:text=The%20United%20States%20Centers%20for,populations%20effectively%20determines%20length%20and. Accessed on 21 November 2012.
9. 9. USAID. Fact sheet: Integration of Family Planning with Immunization Services: A Promising Approach to Improving Maternal and Child Health. fhi360.org/sites/default/files/media/documents/integration-family-planning-immunization.pdf. accessed on 1 September 2023.
10. 10. Tiwari S. Factors influencing unmet needs for family planning among currently married women in Nepal. Norway: University of Tromsø. 2012. www.unpopulation.org.
11. 11. Makade KG, Padhyegurjar M, Padhyegurjar SB, Kulkarni RN. Study of contraceptive use among married women in a slum in Mumbai. Nat J Community Med. 2012;3(1):40-3.
12. 12. Mitkari KK, Haralkar S, Sancheti P, Gokhale R. Study of contraceptive use in married women of reproductive age group in urban slum area of western Maharashtra. Int J Community Med Public Health. 2019;6(10):4499-504.
13. 13. Sileo KM, Wanyenze RK, Lule H, Kiene SM. Determinants of family planning service uptake and use of contraceptives among postpartum women in rural Uganda. Int J Public Health. 2015;60:987-97.
14. 14. Khan S, Verma R, Mahmood S. Correlates of use of family planning methods among married women of reproductive age group in Bareilly, India. Nat J Community Med. 2012;3(4):623-6.
15. 15. Sajid A, Malik S. Knowledge, attitude and practice of contraception among multiparous women at Lady Aitchison Hospital, Lahore. Ann King Edward Med Univ. 2010;16(4):266.
16. 16. Sudha V, Vrushabhendra HN, Srikanth S., Suganya E. Unmet need for contraception among urban women: a cross sectional study in Puducherry. Int J Community Med Public Health. 2017;4(5):1494-9.
17. 17. Patel SV, Patel DN, Pandit NB, Patel MV. A cross sectional study of contraceptive uses and unmet need for family planning among rural population of Vadodara. Int J Biomed Adv Res. 2015;6(11):765-7.
18. 18. Genet E, Abeje G, Ejigu T. Determinants of unmet need for family planning among currently married women in Dangila town administration, Awi Zone, Amhara regional state; a cross-sectional study. Reprod Health. 2015;12:42.