ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10006-1994 |
Unmet Needs of Contraception among Married Women: A Rural Qualitative Study
1Department of Community Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, India
2–4Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
Corresponding Author: Mercy M Jafrin, Department of Community Medicine, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, India, Phone: +91 9487132393, e-mail: dr.m.mercy@gmail.com
How to cite this article: Jafrin MM, Konduru RK, Natesan M, et al. Unmet Needs of Contraception among Married Women: A Rural Qualitative Study. J South Asian Feder Obst Gynae 2022;14(1):6–10.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Aim and objective: To identify the factors influencing the unmet needs of contraceptive use by Qualitative research methods.
Materials and methods: A community-based qualitative study with the help of focused group discussions (FGD) and an interview guide was formulated after assessing micro- and macrolevel factors for not using contraceptive methods. A sociogram was used to visually depict the flow of information in the discussion.
Results: From the FGD the hindering factors to practice contraception were found to be lack of knowledge in selecting a method, fear of side effects, and hesitancy to seek help from care providers. Some stated that they have self-control and they lack co-inhabitation with the spouse. Also the utility of family planning services is also unacceptable and inaccessible and unaffordable. The facilitating factors for practicing the contraceptive practices were women who wanted to prevent unwanted pregnancy. Some expressed their views as practicing contraception will take care of population explosion. After the session women also expressed their interest in knowing and practicing the different methods of contraception as a behavior change.
Conclusion: It was found that factors contributing toward the unmet needs of contraception were client factors, family factors, and health system factors.
Clinical significance: This study brought out the factors responsible for the unmet needs of contraception and paved the way to prevent unwanted pregnancies and providing a platform for improving the health status of women by following contraception methods.
Keywords: Contraception, Focused group discussions, Qualitative study, Unmet needs.
INTRODUCTION
India being the second most populous country with 17.5% of the world’s population contributing to only 2.4% of the global land mass. India accounts for about 20% of world’s eligible couples. India was the first country in the world to launch the National Programme For Family Planning in 1952 and to adopt and an official population policy as per the India’s vision of family planning 2020 which pledged to provide family planning services and to sustain the coverage of these services.1 As per the census 2011, the decadal growth rate of India had declined from 21.54% in 1991–2001 to 17.64% in 2001–2011, which showed a consistent decline in birth-rate with a total decline of 16% from the year 2000 to 2012. The birth rate at all India level has declined drastically over the last four decades from 36.9 in 1971 to 20.2 in 2017.2 Even though there was a decline in decadal growth rate, there had been a lot of ill effects due to over population, mainly the social and economic problems affecting the society.3 Many other important concerns were the quality of life and the employment of huge labor force which has to be addressed.4,5 Various factors play a role in influencing the practice of family planning wherein reproductive health plays a vital role and a comprehensive approach including awareness on various methods of contraception and maternal health.6,7 The myths and misconceptions regarding contraception have to be tackled to improve the maximum utilization of these family planning services. As per the NFHS-4 Tamil Nadu Fact sheets 2015–2016, current prevalence of contraception (any method) is 53.2% with female sterilization of 49.4%. The total unmet needs of contraception are 10.1%, out of which the unmet needs for spacing contributing to 4.8%. About 76.7% of the women who were using contraception were told about the side effects and only 30.2% of nonusers were reached and counselled by a health worker. The extent of acceptance of these contraceptive methods differs in urban and rural settings and also at the individual, family, and community level.8,9 In the field practice area of the Rural Health Training Centre of Pondicherry Institute of Medical Sciences, there was no study with the qualitative approach done to find out the factors influencing the contraceptive use and unmet needs of contraceptive use. Hence this study was taken up to determine the prevalence of contraceptive use among married women aged 18–45 years and to identify the factors influencing the unmet needs by focused group discussions. This will provide a holistic picture of contraceptive use in the selected rural area.
MATERIALS AND METHODS
Study Area
The study was conducted in the field practice area of the Rural Health Training Centre (RHTC) of the Department of Community Medicine, Pondicherry Institute of Medical Sciences. The field practice area comprises 20 villages with a total cumulative population of 15,067 (3,947 families) and is geographically located in Cheyyur Taluk of Kanchipuram district of Tamil Nadu.
Study Design
This study was a community-based qualitative research using focused group discussions.
Study Population
The study subjects were married females aged between 18 and 45 years who had been residing in the randomly selected villages, at least for the past 1 year.
Inclusion Criteria
The women in the reproductive age group of 18–45 years who were married.
Those women who were permanent residents of the study area.
Exclusion Criteria
Those married women who were aged between 18 and 45 years but were either divorced, separated, or widowed at the time of the study.
Married women who had undergone hysterectomy for any predisposing obstetrics or gynecological conditions.
Study Period
The study was conducted between January 2018 and March 2019. The data were collected over a period of 4 months from December 2018 to March 2019.
Ethical and Human Considerations
The study was approved by the institutional ethical board. After informing the study participants about this research, and getting prior consent using the participants information sheet and consent form, they were interviewed.
Sampling Technique
For collecting the information using qualitative technique, the sampling method followed was purposeful sampling. In this technique all the married women in the age group of 18–45 years who had unmet needs of contraception were identified from the quantitative study. The women who had unmet needs were selected from randomly selected villages. Totally two focused group discussions (FGDs) were conducted among the women comprising of eight individuals in each group. These women who were selected belonged to diverse sociodemographic background. The FGDs were audio recorded with the help of a note keeper. The discussion was moderated by the principal investigator (P.I).
Study Tool
After getting the informed consent from the participants, the topic of the study was introduced to the participants by the principal investigator and the participants were allowed to express their views, and probing was done in-between to extract more in-depth information about the topic. The deductive approach was followed in formulating the interview guide by using a conceptual framework. The session proceedings were audio recorded. The information given by the participants were summarized and read to them after the session was complete. They were also informed that they were free to share any of their experiences at the end of the discussion, which would also be documented.
Data Analysis
The data were analyzed by thematic or framework analytical approach. These were followed by transcribing the recordings into verbatim and these were presented into hybrid codes using highly interconnective iterative process beginning with data immersion. This was followed by a series of other thematic framework wherein shifting through the data and identifying various meaningful and relevant quotes without hierarchy. Finally thematic categories were derived and organized into themes with the help of mapping of data into relevant information from the transcripts for interpretation. This technique was done by the P.I. and Co P.I. and independent coding schemes were derived, which was finalized into common themes after comparing and pile-sorting the various themes. The final themes were derived by compiling together all the emergent information using inductive approach.
RESULTS
Themes of Analysis
I. Client related factors influencing the unmet needs of family planning services
Client factors:
– Fear of side effects/accusation
– Lack of motivation/awareness
- Self-control
- Lack of co-inhabitation
- Lack of decision-making power
- Ill-health
II. Family-related factors influencing the unmet needs of family planning services
Family factors:
– Lack of support
– Lack of awareness
– Imposition
– Financial constraints
III. Health system related factors contributing to the unmet needs of family planning services
Health system factors:
– Availability
– Acceptability
– Affordability
Client Factors
Fear of Side Effects/Accusation
From the focused group discussion the fear of side effects such as bleeding, irregularity in menstruation, Cu T getting rusted, and pain while using emerged as the major factors contributing to the unmet needs of contraception. Following are the responses given by the respondents.
“Also if Cu ‘T’ is used, it gets lodged in the abdomen.”
“When I use Cu ‘T’ I don’t know how many days it can be used and frequently it has to be changed. Feeling afraid because it may get rusted.”
“My husband doesn’t want me to use because I am weak.”
They also had a fear that they may be blamed for secondary infertility, if they use Cu T for spacing. If they use a wrong method and finally end up in worst consequences like ill heath due to bleeding and pain abdomen, they would be accused by their husband and in-laws for following that method. The following responses were shared.
“The freedom of choosing the contraceptives is not allowed, because if we face side effect, they will blame us. So better to consult husband and in-laws before using the methods.”
“After 10 months of age of the first child I conceived, but my husband advised abortion, my mother told not to abort and deliver the child and do female sterilization. If we take abortive pills, the next baby may not form.”
Lack of Motivation
Participants felt that they lack motivation to follow the contraceptive methods mainly because of lack of interest to know about the methods. And also the fear factor which proved to be the hindrance in having a motivation to follow. They did not have adequate knowledge of what are the methods available and how to follow those, with better understanding about the benefits and limitations. Their belief that they had reduced chances of getting pregnant again after they completed their family even when they are sexually active prohibited from using he contraception. Some felt that they had self-control over intercourse and why was there a need to practice the methods. Also the husband living in far-off places and occasional visit would not make them pregnant.
“My husband works in a faraway place and comes once a month.”
“I have self-control and I avoid intercourse, if I don’t want.”
Lack of Decision-making
Some said they were able to choose the methods of contraception but they need the consensus of their husbands in practicing a particular method of contraception. They expressed that they cannot use it independently.
“Freedom to choose the contraception is there, but has to consult the husband.”
“Both husband and wife have to take the decision.”
“Better to consult husband and in-laws before using the methods.”
Health
Some said that the health of the mother was also very important while practicing certain methods because it can affect the normal functioning of the individual due to the side effects that the particular method can produce.
“After my first child, I was advised with Cu ‘T’ but I did not use it because of side effects and my husband did not accept to use it because I am weak.”
Family Factors
Lack of Support
Many felt that the family in which they live need to support them while following a particular method, because if any adverse event happened, they should not be blamed for it.
“If we face side effects they will blame us.”
Lack of Awareness
Also males have to be motivated for male sterilization because it was easy for them to carry out the day-to-day activities after the operation and they can be convinced if family support was there for them.
“If males are convinced about sterilization they will do, and they can be in their routine life like cycling immediately after operation.”
“But for females it takes 5–6 days for removing stitches and come back to normal life.”
Imposition
Women expressed that even if we were able to choose the methods of contraception and follow them, they are unable to implement as they were being compelled not to follow the methods, as it might affect the normal functioning of their body. They also expressed that the chances of getting the next baby after following a particular method were also diminished.
“If we take abortive pills, the next baby may not form.”
Financial Constraint
The participants expressed that if they want to get the contraception at times, they were unable to afford it because of financial constraints.
“To get oral pills from the private practitioner we are not having the financial support.”
Health System Factors
Availability
Participants told that they were not sure whether the family planning methods are available in the nearby heath facility.
“Family planning methods are not available in Primary Healthcare Center. We have to go to Maduranthagam GH and Chengalpet GH for female sterilization.”
Acceptability
Participants also expressed that they were willing to accept some of the methods if they were told about it in detail. But family support was very essential to practice and follow any method according to the convenience of both the partners. It was the constraint they faced while following a method. They also felt that lack of knowledge and lack of interest in knowing the methods proved to be hurdles in their way. Indecisiveness as they cannot choose any method solely by their will, as husband and in-laws also have to abide by their decision. So they felt that they lack the decision-making power in deciding the method that they want to use.
“Did not use any methods because we had self-control.”
“We frequently have to change Cu ‘T’.”
Affordability
Participants told that even if the services are available and acceptable, they are not economically strong to avail those services, if they want to seek a private practitioner for help in this regard.
“To get oral pills from the private practitioner we are not having the financial support.”
DISCUSSION
From the data of the qualitative research several points regarding the factors influencing the unmet needs of contraception that came up during focused group discussions were categorized under broad themes like client factors, family factors, and health system factors. In this study client factors like fear of side effects and accusation and lack of motivation due to self-control on intercourse and lack of decision-making power among the study participants were highlighted. Similarly in the study done by Bandri et al.10 in a rural area of Maharashtra, various client-related factors like the knowledge about female sterilization, decision-making power for practising the contraception, communication with the spouse about contraception, and source of information about the family planning methods were brought out. Also in a study by Sweeney et al.11 it was found out that the adherence of any contraceptive method is essential to lead a healthy reproductive life. It was stated in studies. Similar findings were observed in the study done by Fatima et al.12 in a family welfare clinic in Pondicherry. To solve this pitfall, the Village Health Nurse (VHN) and the medical officer of the nearest health facility should take initiatives like health education programs addressing the availability of contraceptives in the Primary Health Centre at free of cost, motivation of spouses to undergo male sterilization, and thereby adopting small family norm. Same scenario was observed in the study by Kalra et al.13 where most of the decisions were joint decisions of husband, wife, and in-laws. The awareness level varied among nations in the study by Dalaba et al.14 done in Ghana and showed that women were well informed about the methods but family members were worried about the side effects. Also the health system factors like availability, acceptability, and affordability formed a main hindrance in usage that was highlighted in this study. This has to be sorted out to increase the usage of contraceptive methods among both the partners. In the present study, with respect to health system factors the accessibility for permanent sterilization was difficult for the women, because they had to go to government hospital which was about 30 km from their residence to avail the services. Hamsa et al.15 in their qualitative study by focused group discussions on determinants of contraceptive use among women in Ardesahalli was able to find that the fear of side effects and lack of knowledge were the root causes for not adopting any methods of contraception. Nirmalaya et al.16 in a qualitative study on the nonacceptance of contraceptives was able to find that that primary source of information regarding the contraceptive methods was from healthcare providers. They were also informed by the health worker that contraceptive methods were available free of cost at the health centers. The main reasons for the nonpreference of injectables were unwillingness from family, husband, and fear of side effects. They also felt that if the duration of action of a particular method was long, it may affect their fertility. Aengest et al.17 in a mixed method qualitative study by in-depth interviews in New Delhi revealed that women were comfortable in using Cu-T but their husbands did not allow her for practicing that method. The preference for permanent methods was suppressed due to the fear of pain in the postoperative period. Majority of the women expressed that if permanent method of contraception was followed, it was inconvenient for them because of pain due to surgery in the postoperative period.17
CONCLUSION
Thus the focused group discussions helped in bringing out various intricate factors that determined the usage of contraception and the unmet needs of contraception. It was found that factors contributing to unmet needs of contraception were client factors, family factors, and health system factors. Provider’s perspective was not brought out in this study due to some limitations. This would be taken into account and would be incorporated in future studies.
ACKNOWLEDGMENTS
Authors would like to thank the study participants who took part in the study.
CLINICAL SIGNIFICANCE
More research studies using the qualitative research methods are to be conducted in different communities with extensive health education programs about the myths and misconceptions and also increase the awareness about the male sterilization techniques. This study brought out the factors responsible for the unmet needs of contraception and paved the way to prevent unwanted pregnancies and providing a platform for improving the health status of women by following contraception methods.
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