KNOWLEDGE, ATTITUDE AND PRACTICE OF WOMEN TOWARDS FAMILY PLANNING METHODS IN TAFILA-JORDAN

Introduction

Fertility control has been used for thousands of years in different forms. Coitus interruptus is the oldest known method (1).

The early Greek, Egyptian, and Islamic physicians prescribed many recipes and instructions for contraception. According to the history of contraception, Arabs and Turks learned that inserting babbles through hollow tubes into the uteri of female camels prevented them  from conceiving during long trips across the desert (2).
 
Over the last 30 years, there has been a significant increase in the use of contraception worldwide (3-4).

 Demographic surveys indicate that at least 120 million couples like to limit their family size but are not currently using any form of contraception due to lack of information and means that they regard satisfactory to their needs (5).

  Therefore; it has been estimated that 20% of women were at risk of unplanned pregnancy and would be considered in need for family planning (6).

  Knowledge and use of contraceptives are the  indicators  most  frequently  used by the national and international  organizations to assess family planning (5-7).

 Changes of knowledge, attitude and practice (KAP) for both men and women are necessary to achieve the harmonious partnership (7). The extent of contraception use varies according to cultural factors, age, parity, education, occupation (of wives and husbands), family attitude, motivation, availability and acceptability of contraception (7). The prevalence of contraception is a widely used measure in the analysis of the proximate determinants of fertility.  Several world fertility surveys  (WFS) and contraception prevalence surveys (CPS) have been undertaken since 1960 (8), for example  the prevalence of contraception in Saudi Arabia varied between 26% -39 % of married women in 1999 (6,7).

 In Jordan, two studies were conducted.  The first study showed that the prevalence of contraceptive use was 56% and the rate of modern methods was 40% (9), while the other study showed that the prevalence of contraceptives was 32.1(10).
 
The proportions of couples who use some contraception methods in developing countries vary between 20-60% (3).  In Tafila, a city in the Hashemite Kingdom of Jordan, no previous study on KAP of contraception was conducted, so this study was carried out to assess KAP of women towards family planning methods among married women aged 16-44 years and to study the factors that could affect the use of family planning methods such as age, parity, occupation, education (of wives and husbands) family attitude and motivation.


Methods

This study included 600 married women with an age range between 16-44 years.  They had different educational backgrounds and they were all Tafila residents.
 
A semi-structured interview was developed by the researcher to fulfill the purpose of the study. It consisted of demographic data, and questions related to knowledge, attitude and practice of contraception. Also, it included questions related to factors that influenced the use of contraception methods and family planning such as education, parity and age. All participants were interviewed at the family planning unit at Prince Zaid Hospital. The duration of each interview was around 20 minutes.

 The chi square (X2) test was used as a test of significance at a level of 0.05.


Results

Table I shows the different socioeconomic conditions of the participants including age, education, occupation, husband’s education and parity among the studied sample and those who use contraceptives.

Prevalence of the methods of contraception
Out of 600 interviewed married women between the age of 16 -44 years, 530 (88.3%) had used one or more methods of contraception at some time, and 38% were using contraception at the time of the study as shown in Table II.  More than half of users were between the ages of 25-34 years, who had four or more children as shown in Tables III & IV, respectively.

Interuterine contraceptive device (IUCD) was the commonly used method (38.3%) followed by coitus interruptus and safe period, 16.8% and 14.1%, respectively, and only 2.3% had tubal ligation.

Knowledge, practice and attitudes towards contraception
Regarding knowledge related to contraceptive methods, results showed that 560 (93.3%) of the currently married women recognized at least one method of family planning, 412 (69.5%) knew two methods, and only 260 (43.3%) knew three or more methods. IUCD was the most frequently mentioned method (85 %) followed by coitus interruptus (51.4%) and oral contraceptive pills (OCP) (46.5%), safe period (45.3%), sterilization (43.3%) and condom 219 (36.5%). The least mentioned method was injections: 141 (23.5%). Nearly two thirds of users took their contraceptive apart from the family planning center.

The results of attitudes indicated that 357 (67.4%) showed a positive attitude towards using contraception, which was approved by husbands.  In contrast, 127 (22.8%) showed negative attitudes by disapproving their use (Table II).

Reasons for choosing different methods of contraception:
The reasons for contraception use were; self-motivation 187 (33.6%), husband preference 170 (32.1%) doctor recommendations 86 (16.2%).

Almost 43% of women used the method that they thought easy or safe or had less complications than others methods. About 381 (71.9%) women used contraception for spacing between births and 117 (22.0%) did not want more children. Only 6% used contraceptives for medical reasons. Nearly one third of users, 166 (31.3%) had used contraception for two years and only 14.3% for five or more with a mean of 2.89+1.54 years. Women stopped contraception because they wanted to conceive  (64.9%), or because for medical complications (35.1%), while 180 (34%) were still using 70% (TableV).

The effect of age on contraception methods
Using the chi square test, results showed significant differences among different age groups of women with different types of contraceptives (P<.05), where younger women preferred IUCD (44.5%) and its use was increasing with age reaching the peak at 25-29 years (51.4%), while OCP was less likely to be used by younger women  (9.1%) and its peak was at (30-34) years (16.8%), (Table III) 

The effect of parity on the use of contraceptive methods
Results indicated that mothers who had two or more children preferred IUCD, and its use was decreasing with the increased number of children (39.2% and 51.2%) at para two and three compared to (23.1%) at para five or more, while the use of coitus interruptus increased with the increasing of parity p<0.05, (Table IV).

A comparison of the effects of different levels of education on the use of contraceptives
There was a difference in the levels of education among couples, where the majority of wives were illiterate (26.6%) compared to their husbands (13%).  Well-educated women were more likely to use OCP compared to the less educated who preferred the use of IUCD.   Highly educated users of contraceptives were only 14.8%.  Results using Chi square showed significant differences p< 05, (Table VI).


Discussion

In Islam, abortion and sterilization are prohibited except on medical grounds. However, the use of contraception is allowed for child spacing to ensure the health of the mother and child rather than to restrict the family size (11).

 The desire of Tafila community of a large family was clear in this study where a quarter of the studied women (24.6%) had five or more children and only 2.2% were sterilized, and 61.9% stopped contraception to achieve pregnancy, a finding similar to other studies (11).

The present study showed that women had positive attitudes and awareness of the different methods of contraception, and were using it for spacing. This fact is well supported by the observation that 88.3% of studied women had used contraception, which is slightly higher than women in other countries i.e. Saudi Arabia (78.24%) (1).

 This may be due to the economic hardships and awareness of the benefits of small families. Nearly two thirds of users received contraception from the family planning centers. The preference for a particular type of contraception used by women varies from one country to another (4).

 In this study, IUCD was the most commonly used method followed by coitus interruptus, safe period and other methods, which were different from those in other studies (7).

Their preference was based on their belief that it was a safe and easy method. On the other hand, nearly one third of our sample were using natural methods i.e. safe period or coitus interruptus, which accounted only for 0.4% in Aved's study (12).

 More than one third (35.1%) of users stopped contraception use because of complications, which is slightly lower than that in other studies (1).

 In this study, the prevalence of contraception  use  was (38.3%) which is nearly equal to that found in Iraq  (28.40%) (13).

Our study shows that the use of family planning methods was generally the highest among women in the child bearing age (25 – 34 years) which is similar to that found in other studies (6,7).

A difference in the contraceptive use by age reflects changes in the need for contraception over life cycle. A woman need for contraception changes as she passes from her initial child bearing years, during which she may welcome a pregnancy in her 30s when she is still fertile but may wish to prevent or space additional pregnancies, and then to her 40 s, when her fertility declines and she has less need of contraception. In this study, women with five or more children were most likely to use contraception, while in North Africa, Latin America and Asia women had only 2 or 3 children which reflects their preference of smaller families (8).

The difference in contraception prevalence between women with the different levels of education is that, well-educated women are more likely to use OCP compared to the less educated women who preferred the use of IUCD. It is clear from this study that health education is needed in the field of family planning. Primary health care centers can play a major role in health education, counseling and service for family planning and giving advice on contraception and provision and increase availability of different methods. No primary care service can claim to be comprehensive if it does not provide adequate family planning (7).

It is our hope that our findings will help in planning a strategy to improve services, make contraception more acceptable, reduce the number of unplanned pregnancies and also form a base for future trends in contraception practice in our community. There is a need to increase the awareness of the people regarding all aspects of family planning, which can be achieved by antenatal, postnatal, and well baby clinics.  In addition, further studies to establish the relative incidence of various complications due to the use of different methods, are needed.

 
Table I: Sociodemographic characteristics among  contraceptive users.

Variable	Studied sample	Contraception users
	No. (%)	No. (%)
1- Age (years) §        16-19 §        20-24 §        25-29 §        30-34 §        35+ Total	56 (9.33) 129 (21.5) 161 (26.8) 152 (25.3) 102 (17.0) 600	3 (6.23) 108 (20.4) 146 (27.5) 149 (28.1) 94 (17.7) 530 (88.3)
2- Education §        Illiterate and just literate §        Primary and intermediate §        Secondary §        High education Total	152 (25.3) 249 (41.5) 111 (18.5) 88 (14.7) 600	141 (26.6) 209 (39.4) 102 (19.2) 78 (14.8) 530
3- Occupation §        Housewives §        Working Total	455 (75.8) 145 (24.2) 600	409 (77.2) 121 (22.8) 530
4- Husband’s education §        Illiterate and just literate §        Primary and intermediate §        Secondary §        High education Total	139 (23.2) 190 (31.6) 153 (25.5) 118 (19.7) 600	69 (13.0) 181 (34.1) 139 (26.2) 141 (26.4) 530
5- Parity §        1 §        2 §        3 §        4 §        5+ Total	60(10.0)          121(20.0) 133(22.2) 138(23.0) 148(24.6) 600	23(4.30) 97(18.3) 129(24.4) 125(23.6) 156(29.4) 530

Table  II:Distribution of the studied sample according to their knowledge and practice of contraception methods

Contraception methods	Knowledge %	Practice (current users %)
* IUCD	510 (85.5)	203 (38.3)
Coitus interruptus	314 (51.4)	89 (16.3)
Safe period	272 (45.3)	75 (14.1)
Oral contraceptives	279 (46.5)	73 (13.8)
Condom	219 (36.5)	45 (8.49)
Injection	141 (23.5)	35 (6.60)
Sterilization	205 (34.3)	10 (2.26)

*IUCD: Intrauterine Contraceptive Device

Table III:  A comparison of the effects of age on contraception methods among the study sample
X2 = 28.135                DF = 16                P<0.05


Table IV.  A comparison of the effects of parity on contraceptive methods among the study sample
X2 = 4.683                DF = 4                 P<0.05

Table V: Reasons for choosing a particular contraception

Reasons	IUCD %	Coitus Interruptus	Safe period	* OCP	Condom	Injection	Sterilization	Total
Safe and easy	110 (54.2)	2 (2.20)	45 (60.0)	45 (61.6)	9 (20.0)	18 (51.4)	1 (10.0)	230 (43.4)
Husband preference	14 (6.9)	1(1.16)	5 (6.70)	9 (12.3)	2 (4.40)	7 (20.0)	2 (20.0)	40 (7.50)
Had complications with other methods	56 (27.6)	70 (78.7)	25 (33.3)	7 (9.60)	30 (66.7)	5 (14.3)	1(10.0)	194 (36.7)
Advised by doctors or friends	20 (9.90)	16 (18.0)	0	8 (11.0)	3 (6.70)	3 (8.60)	6 (60.0)	65 (10.6)
Not known to the women	3 (1.48)	0	0	4 (5.50)	1 (2.20)	1 (2.20)	0	10 (1.9)
Total	203 (38.3)	89 (16.8)	75 (14.1)	73 (13.8)	45 (8.90)	35 (6.60	10 (2.3)	530 (100)

* OCP: Oral contraceptive pills

Table VI: A comparison of the effects of different levels of education with contraceptive methods among the study sample
X2 = 14.926                DF = 12               P<0.05

 
References

1. Farrag OA.  Attitude towards fertility control in Eastern province of Saudi Arabia. Saudi Medical Journal, 1983; 4(2): 111-116

2. Cauvet G. Le chameu. Balliere, Paris 1995.

3. Glasier A. Contraception, Sterilisation and Abortion In: Shaw R W. Soutter, WP, Santol SL. Gynecology. Edinburgh: Churchill Livingstone, 1997; 393-404.

4.  World Health Organization. The world health report, 1998.

5. World Health Organization. Reproductive health research: The new directions.  Biennial report 1996-1997, 25th anniversary issue.

6.  Al-Sekait MA.  Prevalence of contraception used among Saudi Arabian women. Saudi Medical Journal 1999; 20(9): 687-690.

7.  Ogbeide DA. Profile of acceptors of contraception in a family practice clinic. Saudi Medical Journal 1999; 2(10): 817-818.

8. World Health Organization. Population report, series M, 1981 (5): M-163.

9.  Jordan population and health survey. Department of statistics. Amman-Jordan, 1997

10. El-Yahya M. Reports on an agency-wide study on current practices of contraceptive use among mothers of children 0-3 years of age who attend UNRWA MCH clinics. Amman-Jordan UNRWA. 1997

11. World Health Organization. Population report, Series J, 1984; (27): 60-66.

12. Aved B. Trends in contraceptive methods of use by California family planning clinic clients aged 10-55, 1976-79. American Journal of Public Health 1981; 71:1162.

13. Hussain H. Field survey on maternal health of Al-Rashadia villages in Baghdad. J Com Med Iraq 1995; 9(2): 93-95.