Journal of Reproductive Health and Contraception

Keywords

Pregnancy; Contraceptive; Intra uterine device; Sterilization; Illiterate

Introduction

Globally low and inconsistent use of contraceptives by young people due to various reasons contributes too many unintended pregnancies. Ensuring quality contraceptive use by sexually active young people is a global concern and of India too. The results are high rates of teenage pregnancy (25%) and unintended pregnancy (46%) [1]. In addition to population problem of many pregnancies, maternal ill health, short birth intervals (<24 months) have been linked to low birth weight, preterm births, small for-gestational age babies and childhood stunting, and mothers suffer with more chances of morbidities mortality [2-10]. There is persistent dominance of sterilization in the Indian family planning program because of various reasons [11]. In a study by Prusty [12] it was revealed that knowledge and use of temporary contraceptive methods were considerably lower among tribal women compared to non-tribal counterparts in the Jharkhand, Madhya Pradesh, and Chhattisgarh. Low acceptance was due to phobia of adverse health consequences, accessibility to and lack of sound knowledge of contraception the unmet need for family planning among them was quite high. Researchers suggested that educating women and their husbands about proper use and benefits of modern contraceptives was essential.

Objective

Present study was undertaken to know contraceptive use for postponement of first pregnancy or spacing between two pregnancies or limitation of pregnancies in young women, especially rural.

Materials and Methods

A facility-based cross-sectional study was done in outpatient of a rural medical institute over 6 months. One thousand married non pregnant women between 18 and 34 years were interviewed. The study subjects were neither cases of infertility nor had undergone sterilization. Their husbands had not undergone vasectomy. They had not undergone hysterectomy and had not attended premature menopause. On any given day 5 to 8 women could be interviewed, one after another keeping in mind women’s reasons for visit to the hospital (acute illness or seriously illness) and other aspects like returning back to their villages as institute was rural. They were asked whether they were using any contraceptives for prevention of first pregnancy, or between two pregnancies or for limitation of pregnancies. Interviews were done with the help of a predesigned questionnaire in local language. Consent was taken before inclusion in the study. While most of the women had higher secondary education (84.8%), 2.3% were illiterate too (Table 1).

Table 1: Demography of study subjects.

Results

It was revealed that reported temporary contraceptive use was by 78.8%. There were more than 21% young women who did not want to have a baby and were at risk of unintended pregnancy but were still not using any contraceptives, real unmet need. Also quite a few used methods infrequently, oral contraceptive pills as well as condom. Those who were using temporary contraceptives were asked about the timing of use of contraceptives. Of 283 women under 20 years of age 113 (39.92%) used contraception before first pregnancy and 77 (27.20%) after abortion, but ninety three (32.86%) did not use any contraceptive though they did not want to have a baby. Between 272 women of 20-24 years, 101 (37.13%) used contraceptive before pregnancy, 35 (12.86%) after delivery, 82 (30.14%) post abortion and 45 (16.54%) did not use any contraceptive though pregnancy was not desired. However, this number was significantly less than teenagers not using contraceptive (P value 0.05%). Of 274 women of 25-29 years 94 (34.30%) used contraceptive before their first pregnancy, 45 (16.42%) after delivery and 96 (32.98%) after abortion. Analysis of differences between rural and urban women of this region revealed not much of difference in overall use of temporary contraceptives, 31.05 % of rural teenagers did not use contraceptive and 35.24% urban women (Table 2). When they were asked about contraceptive methods used, 113 (39.92%) of 283 teen agers said their husbands used condom infrequently and 77 (27.20%) women themselves used oral contraceptive pills (OCP ), but not on continuous basis. Between 20-24 years, 101 (35.68%) of 262 said their husbands used condom infrequently and 72 (27.48%) women used OCPS, but not on continuous basis. Between 25-29 years of age, 124 (43.66%) of 284 said their husband used condom infrequently and 56 (21.37%) of 262 women used OCPS infrequently. Very few women had intrauterine device (13%) where chances of regularity were more. Further rural urban relation was looked into. It was revealed that more of urban couples used condom compared to rural. But there was no statistically significant difference in overall temporary contraceptive use by rural and urban women (Table 3). When analysis was done in relation to education, Illiterate women did not use any contraceptive and no postgraduate studied had Intra uterine device (IUD). Primary school educated 26 (34.66%) out of 75 used contraception and 240 (28.30%) of 848 who were educated up to higher secondary school used contraceptives. Of 43 undergraduate studied 9 (20.93%) women’s husbands used condom and 18 (41.86%) of 43 undergraduate studied used OCP. All the IUCD were used by higher secondary school studied women.

Table 2: Age, locality and use of contraceptive.

Table 3: Age, locality and method of contraception.

Discussion

Historically, the family planning program in India focussed heavily on the promotion of permanent methods of prevention of pregnancy in response to the need for controlling rapid population growth [13,14]. Women with secondary school or higher education are likely to prefer temporary methods over sterilization. Working women also generally prefer sterilization instead of modern temporary methods and the same is true when the women consider themselves as responsible for their healthcare decisions. An informed choice model of service delivery was introduced in 1998, emphasizing individual reproductive and family planning needs and rights, and offering quality services without any form of coercion or discrimination with cafeteria approach in family planning, a coercive target approach [15]. Although the impact of informed choices cannot be directly measured, evidence showed changes in method mix among users [16]. Also the bio-social gap, (the period between menarche and marriage) has increased and so the time period during which young people need contraceptives has widened. It has hardly been taken care in India and is an area which needs research. Overall reproductive health programs should address various economic sociocultural barriers and use cost-effective strategies such as mass media for awareness promotion of spacing methods of prevention of pregnancy. Recent evidence revealed inequalities in the provision of family planning and reproductive health information, particularly women from communities who are disadvantaged in terms of resources, infrastructure [17]. Study by Oliveira et al. [13] revealed modern temporary methods were used by 34% and traditional methods constituted about 23% of overall method use, a total of 57 % using spacing methods in a scenario of high level of unmet need for spacing contraceptive methods. For abolishing the unmet need for modern spacing methods completely, the number of couples which needed to be served modern spacing methods was 53 million in the study by Ram et al. [17].

In a study the demand for contraceptives among Ugandian young people was 45 percent and 57 percent respectively for 15-19 and 20-24 age groups, however only 11 percent and 21 percent used contraceptives [1]. Despite an apparent high level of awareness of contraceptives, the use of contraceptives remained low and inconsistent among young people due to various reasons. The low quality of contraceptive services may be one of the many contributing factors to non-use of contraceptives among young people. A recent qualitative study recounted changing perceptions and behavioural shift towards contraceptive use among young people, but noted service level barriers for those who had overcome all other obstacles and tried access contraceptive services. Health system factors that deter contraceptive use include: shortage of skilled providers, limited supplies, poor service organization, and provider imposed restrictions imply barriers to quality services [18,19]. Demographic health surveys have only modest information on facility operations, infrastructure and providers' behaviour. The framework proposed six aspects of assessing quality which were technical competence of providers, information given to users, choice of contraceptive methods provided, interpersonal relations, continuity mechanisms, and appropriate constellation of services. These six aspects reflected attributes of the services, clients experience as critical for contraceptive adoption and continued utilization. Studies which used this framework have shown that quality of care can impinge on individual’s decision to use or not use modern methods and also the choice of method [20]. A round of the District Level Household Survey (2007-2008) of India revealed that 6.7 percent married women were using traditional contraceptive methods in India. It revealed that more than half of the married women (56%) had used these methods [21]. It is believed that the family planning scenario in India is dominated by the use of sterilization in almost all states and use of spacing methods is limited [12,22,23]. The three National Family Health Surveys (NFHS) 21 showed that female sterilization was on rise and male sterilization was on constant fall [24]. In a study of women in the low resource outskirts of townships, cities and villages in Maharashtra, male dependent methods accounted for less than 10 percent of total contraceptive prevalence [25]. In the present study young women were asked about use of contraceptives by those who did not want to have a baby and 32.86% teenagers did not want to have pregnancy but still did not use any contraceptive and whatever methods were used were used infrequently. There are other reports of greatest unmet need in teen agers. Several studies showed that unmet need for family planning was greatest in the 15-19 year olds, in the less educated and in the poorest households [26-29]. In a community based survey it was revealed that a considerable number of women between 25-28 years opted for sterilization with the unique preference for female sterilization when the family size was complete showing the predominant reliance on female sterilization even among young women rather than temporary contraception [29]. Higher education delayed sterilization in young women due to delayed marriage and childbirth. Women empowerment, proper information and assuring availability and accessibility to different methods can gradually change the dominant preference for female-oriented permanent method of contraception. In our study we did not include sterilization cases. Of 284 women of 25-29 years 124 (43.66%) said their husbands used condom infrequently and 56 (19.71%) women used OCPS but not on continues basis. Further rural urban relationship was looked into and it was revealed that, 56.89% rural women of less than 20 years and 48.52% of 262 rural women of 20 to 24 year had used contraception compared to 43.10% less than 20 years age of urban and 49.61% of 262 urban of 20 to 24 years. More of urban women’s husbands used condom compared to rural. Mcguire and Stephenson [30] did a study and found that women living in communities with greater levels of unmet need for modern contraception and lower rates of contraceptive use were more likely to have shorter birth intervals, demonstrating an important synergy in reproductive health outcomes.

Present study has weakness that study subjects were those who had come to hospital for various disorders, though not seriously sick. It is not community based study. So the figures of users may be higher. Also it was not possible to go in depth as interviews were conducted in outpatient where women were waiting for therapy of their ailments which brought them to the hospital. Their economic status also could not be studied.

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