A qualitative study on determinants of choice of contraceptives in a rural

INTRODUCTION

Family planning is the decision-making process by which couple(s), jointly or individually; decide upon the number of children that they would like to have in their lifetime, and the age interval between children. Ideally both partners have equal rights to decide on their future fertility. It helps limit population growth and aids the development of the nation.

Family planning is a fundamental right of every human being. It is an important step toward breaking the cycle of poverty – for women, their families, and their communities. Yet much remains to be done before the right to self-determined family planning can be fully realized. According to National Family Health Survey-4 Karnataka survey, the rate of female sterilization is 48.6%, as compared to 57.4% in the NFHS-3 survey.¹ Further per NFHS-4 the rate of male sterilization is 0.1%, IUD/PPIUCD (expand) is 0.8%, pill use is 0.4%, and condom use is 1.3%. And in Bengaluru, the rate of female sterilization is 57.9% and IUD/PPIUCD use is 0.4%.

The decadal growth of population has slowed down to 17.64% in 2001-2011 as compared to 21.54% in 1991-2001.² According to DLHS-4 Karnataka survey, proportion of female sterilization was 57.6%, IUCD was 1.3%, OCP (expand) was 0.7%, CC (expand) 1.4%, and any traditional method was 0.9%.³ Despite this, unmet need for family planning was 21%, contraception prevalence was 55 %.⁴

The current programme with its “cafeteria approach” may confuse the beneficiaries instead of providing them specific recommendations. Additionally, in case of choice of contraceptive methods, which has largely been in line with Family Welfare programme, disproportionate skewing towards promoting nonreversible methods, particularly female sterilization, has been noticed – it continues to be used by the majority of contraceptive users in India.⁵

Hence it is time to relook at the strategies and services of the existing family planning programs and generate evidence to provide individual targeted and focused contraceptive interventions for different populations based on their specific needs.

Understanding the determinants of low uptake requires a newer method of evaluation combining both health and non-health factors. Hence focus group discussion was carried out investigating women’s experiences, to substantially improve our ability to understand the barriers they face and how to help them overcome these barriers.

METHODS

An interview guide was developed suitable for focus group discussion.

Conceptual framework was used to develop the leading questions for the focus group discussions after, macro level and micro level factors.

Macro level

At the service provider level, availability, acceptability, quality of care. Legislative measures taken, MTP Act & PC PNDT Act and another macro-level factor would be Information Communication and Technology.

Micro level

Social factors, cultural factors, Socio Economic Status of the family, family norms- influence by husband, mother-in-law, sister-in-law, sister, religion, knowledge, attitude and behavior of individual were considered.

FGD is a tool to assess the patient-based outcome. An FGD is an effective way to bring people from similar background or experience together to discuss a specific topic of interest. Responses in focus group are typically spoken, open ended, relatively broad, and qualitative.

Study setting, area, and population

The study was conducted in three groups under Ardesahalli primary health center, Rural Field Practice area of M S Ramaiah Medical College, Bengaluru. It covered a population of 11,362 with 1,634 couples in the Eligible Couples Register as of October 2014. Ardesahalli Primary Health Center comes under Devanahalli Taluq, under Bangalore Rural District.

An interview guide was developed for the focus group discussion using conceptual framework.

Focus groups

Two types of groups married women in reproductive age group and mother-in-law group, three sessions were conducted in Ardesahalli Primary Health Center area to assess the knowledge and attitude of the women with regards to use and determinants for choices of contraceptives. One focus group discussion with mothers-in-law (Group 1) was conducted at Jalige sub-center of Ardesahalli Health Center area and two focus group discussions were conducted with married women (15-49years) – (Group 2 & 3) in Ardesahalli area.

From the eligible couple register available at Ardeshanahalli Primary Health Centre currently married women in the reproductive age group of 15-49 years were invited which included women from all religions. Focus group discussions were conducted on two occasions with different participants among married women at Ardesahalli health center area. Focus group participants were recruited through a purposive sampling process.

From the eligible couple register available at Jalige sub-center area married women’s mothers-in-law were traced with the help of ASHA worker and were included in the third group.

Before initiating the discussion the interviewer and note taker were introduced to the participants. The purpose of the study was explained and participants were introduced. Good rapport was established with the participants. They were assured of maintaining confidentiality of their identity in the study. Following which focus group discussion guide was administered to the participants and in between probes was used to encourage discussion and active participation by all the participants. The discussion was recorded with the help of recorder. A siociogram was prepared and flow and dynamics of the session was ascertained.

After each FGD, a transcript of the discussion was made in English in patients’ own words. They were carefully analyzed, and important domains and sub domains were created.

Focus group discussion Analysis

Framework Approach

Framework analysis was used for analysis.

RESULTS

Self’s lack of knowledge was the common reason for using or not using any method in all the three focus groups in this study, followed by fear of side effect. Fear of side effect for accepting Intra uterine contraceptive device was a significant finding. There is high prevalence of concerns regarding side effects and health risks among women.

Mother-in-law’s lack of knowledge about contraceptive use and fear of side effects regarding contraceptive had an influence on daughter and daughter-in-law’s for using/not using any method. Awareness needs to be improved across all stakeholders to improve effectiveness of the program.

Quantitative component revealed that want of more children and particularly male children as the most common reason for not using contraceptives by the women.

Contraceptive acceptance increases with increase in number of living children owing to the adoption of permanent method of contraception as a final choice for completion of family. Birth of male child made a vast difference for accepting permanent method of contraception.

DISCUSSION

Sedgh, Hussain in their study on reason for non-use of contraceptives among married women found that fear of side effect is most common, followed by opposition from husband, in-laws and post-partum amenorrhea.⁶

In a study carried out by Patro et al in a resettlement colony in Delhi revealed the reasons for non-acceptance were either for an expectation of a male child (44%) or fear of side effects (29%).⁷

Glasier et al in their study revealed that women recognized the importance of using contraception but admitted to taking risks. Pills and condoms were familiar and acceptable despite undesirable side effects. Women were poorly informed about long acting reversible contraceptives (injections, IUCDs, implants) had firm but incorrect beliefs about their safety and side effects, disliked any method which involved an invasive procedure and/or vaginal examination, and had rather a low opinion of advice given by health professionals.⁸

Even in the present study fear of side effects was the most common reason for non-acceptance. Hence program should be geared to address these fears among the stakeholders to ensure greater acceptance.

A qualitative study exploring the determinants of maternal health service uptake by Che chi et al in their study revealed that the main negative effects on family planning service uptake related to the exposure to conflict were associated with a generally low level of appreciation of the importance of some services, due to low educational attainment.⁹

Rao et al found that the most important reason for lack of family planning practices was lack of awareness (57.2%) and 27.6% told most common reason for non-usage is want of more children.¹⁰

Lisa et al in a systematic review of qualitative research to assess the limitations for modern contraceptive use among young women in developing countries revealed that use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility and condom use was limited among disease and promiscuity together with greater male control.¹¹

Self’s lack of knowledge was the common reason for using or not using any method in all the three focus groups in this study. Awareness needs to be improved across all stakeholders to improve effectiveness of the program.

Sweeney et al in their study revealed out of 18 women interviewed it became clear that there were similarities and differences depending on socio-economic circumstances.¹² All of these women disclosed an unplanned pregnancy in their late teens as a consequence of poor adherence to the OCP, either due to forgetting to take their OCP, and/or using the OCP incorrectly. Women over 30 years of age from areas of higher social deprivation disclosed further unintended pregnancies at a young age as they were unaware of LARCs as a contraception option.

John et al in a study in Pakistan revealed that the two principal obstacles to using a contraceptive were the women’s perception that such behavior (of using contraceptive) would conflict with her husband’s fertility preferences and his attitudes toward family planning and her perception of the social or cultural unacceptability of contraception.¹³

Castle et al in their prospective study uses qualitative methods to examine the social and economic impact of family planning on women's lives in the district of Bamako, Mali.¹⁴ Fifty-five first-time users of contraceptives were interviewed, and 17 out of 55 had hidden their use of a birth-control method from their husbands. Substantial collusion is found to have occurred between sisters-in-law in assisting each other to gain and hide methods of family planning and to keep their use secret from their spouses and older marital relatives. The underlying causes of men's objections to contraceptive use need to be addressed so as to facilitate communication and joint decision making about family planning.

Mother-in-law’s lack of knowledge and fear of side effects regarding contraceptive had an influence on daughter and daughter-in-law’s for using/not using any method. It is imperative that the entire family is involved during the counseling sessions so that the misconceptions and irrational beliefs are addressed comprehensively.

Schuler et al in their qualitative study on women empowerment in rural Bangladesh revealed women’s participation in credit programs increases contraceptive use.¹⁵

Focus group discussions (FGDs) conducted by Rustogi et al to elicit the perception of Muslim women and their attitude towards family planning and currently available contraceptive methods and barriers to contraception.¹⁶ The findings revealed that majority of the women in the study did not favor early age marriage and prefer smaller family size. Many women stated that their husbands and other family members (especially mother-in-law) forbade them to use any family planning method.

Attitude (not encouraging the use) of mother-in-law’s influenced their daughter and daughter-in-law’s for using (not using) any method was reflected in the present study also.

Study by Sedgh and Hussain found that infrequent sexual activity and concerns regarding the side effects and health risks associated with contraceptive methods are the most common reasons for nonuse in many developing countries.⁶

Study by Ochaco et al among young women in Kenya revealed condoms were not considered as contraception by many users. Fear of side effects and adverse reactions were a major barrier to use. The biggest fear was that a particular method would cause infertility.¹⁷

Hoopes et al in a qualitative study to know the factors that influence contraceptive choice among adolescent school-based health center patients revealed that strong preferences about device-specific characteristics, previous exposure to information about LARCs (Long Acting Reversible Contraceptives) from peers, family members, or health counseling sessions and knowledge gaps about LARC methods that affect informed decision-making were the major three factors that influence LARC choice.¹⁸

Najafi et al in qualitative study revealed that there were personal, cultural, and health system barriers to modern contraceptive use.¹⁹ The women have been surrounded by fears, and misconceptions which serve as obstacles to initiation and continuation of contraceptive use. Strong socio-cultural norms and health services barriers including negative response of service providers, and low male family planning activities influence contraceptive use negatively.

An in-depth understanding of this reason as a strong determinant was revealed through focus group discussions with the mothers-in-law. Focus group discussions helped in understanding social norms like customs, traditions, and folkways of the study subjects and got variety of opinions and views regarding reasons behind use / non-use of contraceptives. An important finding of qualitative study was Mother-in-law’s lack of knowledge and fear of side effects would influence their daughters and daughter-in-law for not choosing any contraceptives.

The high prevalence of concerns regarding side effects and health risks among women having unmet need likely reflects a need for information and counseling to help women learn more about the methods available to them, better mechanisms through which women can switch methods when needed, and an expansion of method choices.

The findings from this study add novel and significant information about the reproductive experiences, including pregnancy intention and barriers to contraceptive use. Study described many barriers for using contraception and to accessing general reproductive health care services.

Implications

It is evident from the above that non-health determinants viz. social and cultural influencers have a greater role in non-acceptance of contraceptives. There is a predominant influence by mother-in-law on their daughters for accepting or not accepting a particular contraceptive. This indicates that the program approach should evolve appropriate mechanisms to address the important social as well as cultural beliefs and practices at the grass root level for achieving greater adoption of family planning practices. Also, sufficient thrust needs to be provided to the family as a whole and not just the couple when it comes to choices of contraceptives. Improvising the cafeteria approach and adding counseling sessions for primary influencers may have a greater benefit in addressing the unmet needs of the family planning program. Women tend to choose contraceptive methods with which they are familiar and/or that their mothers-in-law/ peers are using. Women want more information from their primary health care providers about the range of available contraceptives.

Qualitative research investigating women’s experiences and in-depth quantitative studies could substantially improve our ability to understand the barriers they face and how to help them overcome these barriers. Such research could help us better understand the reasons given, such as the nature of women’s or partners’ opposition and the specific side effects and health risks that most concern them.

Though family planning programme speaks about ‘cafeteria approach’, it is emphasizing on only few temporary methods like intrauterine device, oral pills, condom. The programme is also highly skewed towards female sterilization as incentives are given to Auxiliary Nurse Midwives, ASHA for promoting these methods.

Instead of providing multitude of choices and confusing the beneficiaries and not following any method, it’s better to provide guidelines that is acceptable or tailor made for that particular couple according to their circumstances. Example couple who is having a child and wants to use a spacing method can be advised to follow long acting reversible contraceptives (injections, IUCD, implants) based on their culture and acceptance in the family and not merely imposing what government is proving free of cost to the community.

Efforts have to be made for motivating males for using condoms in large numbers and accepting vasectomies, thereby sharing equally the responsibilities of planning the families along with their spouses.

To conclude, it is desirable to have a family centered approach rather than women centric approach in the family planning programme.

Data from the quantitative study also revealed that opposition from husband, lack of knowledge, want of more children followed by fear of side effects were the major factors influencing for not using particular method of contraceptive.

Limitations

More such sessions also involving male participants would yield better results.

Funding: No funding sources

Conflict of interest: None declared

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

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