|Year : 2013 | Volume
| Issue : 3 | Page : 181-186
Contraceptive uptake and its determinants and unmet need for contraception amongst women in an urban Muslim community: A cross-sectional study
Bishwalata Rajkumari, Polly Nula, Usharani Longjam
Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Imphal, Manipur, India
|Date of Web Publication||19-Feb-2014|
Assistant Professor, Department of Community Medicine, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur - 795010
Source of Support: None, Conflict of Interest: None
Context: An estimate of the determinants of contraceptive usage and the extent of unmet need for contraception is necessary to determine the maximum potential demand for family planning services to achieve the targeted Total fertility rate of 2.1 in our country. Aims: To assess the contraceptive uptake and its determinants and to estimate the unmet need of contraception. Materials and Methods: A cross-sectional study was conducted amongst 728 married women of an urban Muslim dominated community in the age group 15-45 years at Khetrigao, Imphal East, Manipur, during April-June 2012. A semi-structured proforma was used to collect the respondents' characteristics. Chi-square test and multiple logistic regression analysis were used to test for association. Results: Contraceptive prevalence was found to be 55.5%, but only 351 respondents were effectively protected and were using modern methods (Couple Protection Rate 48.2%). The total unmet need calculated was 23.9%. Fear of side effect (29.9%) was the major reason for not using family planning methods. Almost half of the respondents [345 (47.4%)] gave history of undergoing abortions. Multiple logistic regression analysis showed that having access to health facility [odds ratio (OR) 1.989, 95% confidence interval (CI) 1.083-3.665], husbands having a favourable attitude toward family planning (OR 3.224, 95% CI 1.268-8.199), women who had undergone an abortion (OR 2.471, 95% CI 1.707-3.576), and women who discuss with their husbands about using contraceptives (OR 3.069, 95% CI 1.696-5.551) were significantly more likely to be users of modern contraceptive methods. Conclusion: Education of women and increased accessibility to family planning services in this community will empower them to take decisions regarding adoption of contraception.
Keywords: Contraception, Limiting, Spacing, Unmet need
|How to cite this article:|
Rajkumari B, Nula P, Longjam U. Contraceptive uptake and its determinants and unmet need for contraception amongst women in an urban Muslim community: A cross-sectional study. J Med Soc 2013;27:181-6
|How to cite this URL:|
Rajkumari B, Nula P, Longjam U. Contraceptive uptake and its determinants and unmet need for contraception amongst women in an urban Muslim community: A cross-sectional study. J Med Soc [serial online] 2013 [cited 2020 Oct 30];27:181-6. Available from: https://www.jmedsoc.org/text.asp?2013/27/3/181/127388
| Introduction|| |
Uncontrolled population growth has been viewed as the greatest barrier to the socioeconomic advancement of a majority of people in the developing countries. Although India has the distinction of initiating an official Family Planning Program way back in 1952 and a considerable amount of resources has been spent on the program during the last five decades, the achievements are far from satisfactory.  With over 1.2 billion people, our country is yet to achieve population stabilization target total fertility rate (TFR) of 2.1. ,,,
The acceptance of contraception by a couple is governed by various socio-cultural factors such as religion and education of husband and wife. , Many women who are sexually active would prefer to avoid conception, but are actually not using any contraceptive method, as well as their partners. These women are considered to have an unmet need for family planning (FP).  These unmet need for contraception can lead to unintended pregnancies, which pose risks for women, their families, and societies. In less-developed countries, about one-fourth of pregnancies are unintended,  that is, either unwanted or mistimed, which may lead to unsafe abortion. An estimated 18 million unsafe abortions take place each year in less-developed regions, contributing to high rates of maternal death and injury in these regions.  An estimate of the unmet need for contraception in a population is necessary to determine the maximum potential demand for FP services.  In many countries, established national targets for increases in contraceptive prevalence and declines in fertility could be achieved by eliminating unmet need. ,, The National Population Policy (2000) has set the task of addressing the unmet need for contraception as its immediate objective.  Assessing people's perceptions, particularly that of women, and the level of adoption of FP may be helpful in getting an insight of the problem.
Studies have revealed that a range of obstacles other than physical access to services prevents women from using FP, ,, religion being a strong predictor for taking decision on adopting contraception, especially sterilization. , Muslim society has its own religious beliefs regarding the usage of contraceptive methods.
The population of Manipur has increased from 22.9 lakhs (2001 census) to 27.2 lakhs (2011 census) with a TFR of 2.8. , The extent of acceptance of contraceptive methods still varies within societies and among castes and different religious groups.
Keeping in view the above points, the study is designed to assess contraceptive prevalence and its determinants, and the unmet need of contraception in an urban Muslim community of Imphal East district of Manipur, India.
| Materials and Methods|| |
This cross-sectional study was conducted in Khetrigao, Imphal East district, during April-June 2012. The area has a predominantly Muslim population from the lower socioeconomic group. The area comprises 13 villages with a total population of 11,396 according to 2001 census. 
Sample size was calculated based on a contraceptive prevalence of 44.1% (DLHS 3),  with a precision of 10% at 5% significance level. Using the formula for single proportion, a sample size of 518 was obtained. Assuming a little more than 10% non-responders, the sample size was increased to 570, rounded off to 600. Five villages were selected using simple random technique. The estimated number of eligible couples in each village ranges from 120 to 150 approximately according to 2011 line listing data. All the eligible couples in the sampled villages were included to reach the required sample size. Our respondents comprised currently married women within the age group of 15-45 years residing in the sampled villages since the last 1 year. Women who have undergone hysterectomy, who have attained early menopause, those who were not available on two visits, and those who refused to participate in the study were excluded from the study.
Contraceptive prevalence rate is defined as the percentage of currently married women in the age group 15-45 years who are practicing or whose husband is practicing any form of contraception. Unmet need for contraception is the percentage of currently married women within the age group of 15-45 years who does not want any further pregnancies or who wants to postpone the next childbirth for at least 2 years, but is not using any of the approved methods of contraceptives and is still fertile. Calculation of unmet need also includes the currently married pregnant women in the age group 15-45 years in which the pregnancy was unwanted or mistimed. Calculation of unmet need was further subdivided into unmet need for spacing and unmet need for limiting.
A predesigned pretested semi-structured questionnaire consisting of the respondents' socio-demographic profile and questions relating to knowledge of FP methods, attitude toward FP, use of contraceptives, intent to use, reasons for not using, history of abortions, desire for male child, etc., was used for data collection after obtaining informed consent from the participants.
Data were entered into Microsoft Excel spreadsheet and cross-checked daily. Any missing data were identified and verified on subsequent visits. Data analysis was done using SPSS version 11.5. Crude and adjusted odds ratios (ORs) and their 95% confidence interval (CI) were generated by univariate and multiple logistic regression analyses, with the respondents' age, type of family, desire for male child, access to health facility, history of abortion, etc., as the main independent variables and being the user or non-user of modern methods of contraceptive as the dependent variable. A P-value <0.05 was considered as significant.
Since the institution has not constituted an ethics committee yet, permission for the study was obtained from the head. Verbal informed consent was taken from each respondent. Individual data with identifiers were kept confidential.
| Results|| |
Of the 780 eligible couples identified in the five villages, 52 (6.6%) were excluded as 3 women had undergone hyterectomy, 2 had premature menopause, and 47 were not available even at the 2 nd visit. There were no refusals to participate. A total of 728 respondents were eligible for the study. The age of the respondents ranged from 16 to 45 years, with a median [interquartile (IQ) range] age of 28 (24-35) years, whereas the husbands' age ranged from 18 to 78 years, with a median (IQ range) age of 33 (28-40) years. Majority of the respondents belonged to the 26-35 year age group [334 (45.9%)]. Nearly one-fourth of the respondents were illiterate [181 (24.9%)], but majority of them had studied till middle school [310 (42.6%)]. Almost three-fourth of the respondents were housewives [536 (73.6%)]. The approximate monthly income ranged from `1000 upto `50,000, but more than half of the respondents [432 (59.3%)] belonged to families whose monthly income was below `5000. Majority of the respondents were from nuclear families [409 (56.2%)].
Husband was the decision maker for majority of the families [532 (73.1%)]. Knowledge of FP was almost universal [720 (98.9%)]. Majority of the respondents got the knowledge from mass media (72.8%), followed by friends/relatives (49.4%) and health centers (45.7%). More than three-fourths of the respondents [646 (88.7%)] said they had access to FP center/health center. Intrauterine contraceptive devices (IUCDs) were the most commonly known method of contraception (94.5%), followed by condoms (90.1%) and oral pills (89.5%), while injectable contraceptive method was least known (19.5%).
Nearly all of the respondents had a favorable attitude toward using some form of contraceptive [697 (96%)]. Similarly, most of the husbands had a positive attitude toward the use of FP, constituting 672 (92.3%). Majority of the respondents (87%) discussed with their husbands about FP. It is observed that most of the respondents felt that one to two children (39.15%) is the ideal number. The ideal gap between two child births, according to the respondents, ranges from 1 to 10 years, with an average of 3.9 years and a median of 4 years.
[Table 1] shows the percent distribution of the respondents by the current use of contraception and the type of unmet need according to background characteristics. More than half of the respondents (404) were using some form of contraceptive measure, giving a contraceptive prevalence rate of 55.5%. Intrauterine devices (IUDs) were the most commonly used method [169 (39.1%)], followed by condom [64 (14.8%)], and injectable contraceptive was the least practiced method [4 (0.9%)]. Majority of the respondents were using contraceptives for spacing of child birth [255 (59%)] and most of the respondents (44.9%) were motivated by their husbands to use FP methods. Of the 404 (55.5%) contraceptive users, 53 (7.2%) were using traditional methods or non-approved methods, so the number of respondents effectively protected and using modern methods is 351, giving a Couple Protection Rate of 48.2%.
|Table 1: Percent distribution of the respondents by the current use of contraception and type of unmet need according to background characteristics|
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Among the non-users, 77 (10.6%) of the respondents were pregnant. The pregnancy was mistimed for 16 (2.2%) of them and unwanted for 5 (0.7%) of the respondents. Out of 377 (51.8%) women who were not pregnant and not using any approved method of contraception, 154 (51.3%) had the intention to use whereas 146 (48.7%) did not have any intention to use contraception. Of those who intended to use, 79 (10.8%) had intended for spacing whereas 75 (10.3%) had intended for limiting childbirth. The total unmet need is calculated as the sum of the need for spacing (10.8%) plus need for limiting (10.3%) plus mistimed pregnancy (2.2%) plus unwanted pregnancy (0.7%), giving a total unmet need of 23.9% [Figure 1].
It is observed that fear of side effect (29.9%) is the major reason for not using FP methods. Only 4 (1.0%) of the respondents gave religious beliefs as a reason for not using any method. Almost half of the respondents [345 (47.4%)] gave history of undergoing abortions. The number of abortions undergone ranges from 1 to as many as 8 times, with a mean of 1.72 and a median of 1. Majority of the respondents had to undergo an abortion due to miscarriage [168 (48.6%)], but in 101 (29.2%) cases, the reason was unwanted pregnancy, and 59 (17.1%) said that the pregnancy was mistimed.
[Table 2] shows the crude and adjusted ORs of the odds of being a user of a modern method of contraceptive relative to the odds of not using. Women in the higher age category, those belonging to nuclear family, those having desire for male child, and those having a favorable attitude toward FP were significantly more likely to be users of modern contraceptive methods, as seen in the univariate analysis. But this relation is no longer seen in the multiple logistic regression analysis. Women having access to health facility, women whose husbands have a favorable attitude toward FP, and those who discuss with their husbands about using contraceptives were significantly more likely to be users of modern methods, and women having desire for more children were less likely to be users of modern contraceptive methods.
|Table 2: Multiple logistic regression analysis with modern contraceptive users as dependent variable with selected independent variables|
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| Discussion|| |
The study is the first to quantify the unmet need of contraceptives and the determinants of contraceptive use exclusively amongst Muslim women in the state. The characteristics of women belonging to Muslim community in the state are more or less similar and our results can probably be generalized to all Muslim women in the area.
Although the contraceptive prevalence of 55.5% in our study population is higher than that reported in NFHS 3 (49%), the prevalence of unmet need is still very high (23.9%). In many countries, the established national targets for increases in contraceptive prevalence and declines in fertility could be achieved by eliminating unmet need. Meeting the unmet need of FP is one of the immediate objectives of the National Population Policy of the Government of India also.  Existing policies and programs in relation to FP services need to be strengthened to reach out to both urban and rural illiterate women from the lower socioeconomic strata, so that they can avail the services easily and effectively without any barriers.
Fear of side effect (29.9%) was one of the major obstacles among the women for using contraceptives. Misbeliefs and fears about IUDs need to be overcome with the supportive behavior of health personnel. More than 94.5% of the respondents had knowledge about IUCDs, condom, and oral pill, but knowledge on injectable and emergency contraceptives was low. Increased awareness and availability of methods that do not involve partner consent must be prioritized. Education of women in this community will also empower them to take decisions regarding adoption of contraception. Other studies also reported that low level of education, particularly among women, is one of the major reasons behind high fertility and low contraceptive use. , A community-based study carried out in rural Bangladesh revealed that husbands' preference for additional children diminishes as the level of education of wives increases.  Therefore, special efforts are to be made toward promotion of girls' education in the community for ensuring reproductive health in the long term.
As having access to health facility is significantly associated with higher proportion of usage, there is a need to improve the condition of health care centres located in the area to facilitate user-friendly service and ensure the availability of contraceptives which these women can use confidentially as per their informed choices.
In the study, a sizable proportion [160 (21.9%)] of the respondents gave history of undergoing an abortion due to unwanted or mistimed pregnancies. It has been estimated that of the 210 million pregnancies that occur annually worldwide, about 80 million (38%) are unplanned and 46 million (22%) end in abortion. , During the past few decades, there has been worldwide liberalization of abortion laws. To reduce the maternal morbidity and mortality associated with illegal abortions, abortions are legalized in India from 1971.  Promoting the use of contraceptive methods is needed to decrease the number of abortions, some of which are of high risk and unsafe.
In a survey pertaining to reproductive health events, the wife's response can be taken as a proxy for the couple's response; thus, to some extent, our present study helps in assessing the level of public awareness about FP. But to get a precise idea about FP attitude and intention, there is a need to collect information from husbands and wives separately.
We were able to refresh the knowledge of FP after conducting the interview and also had the chance to inform the respondents about the benefits of adopting small family norm and to make clear some of the false beliefs and myths regarding contraceptive use.
Policymakers and program managers can strengthen our National Family Planning Program by understanding and using data on unmet need, considering the characteristics of women and couples who have unmet need and working to remove obstacles that prevent individuals from choosing and using an FP method.
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[Table 1], [Table 2]