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Table of Contents
PUBLIC HEALTH AND COMMUNITY MEDICINE
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 155-163

Contraception and family planning: knowledge, attitude, pattern of use, and barriers among females in Gharbia Governorate, Egypt


1 Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission21-Oct-2021
Date of Decision03-Dec-2021
Date of Acceptance17-Dec-2021
Date of Web Publication09-Aug-2022

Correspondence Address:
Salwa A Atlam
Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, El-Gaish Street, Tanta
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmisr.jmisr_69_21

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  Abstract 


Aims
Most contraceptive methods are designed to be used by women due to the paucity of effective contraceptive options for men. This study aimed to assess knowledge, attitude, and family-planning (FP) practice among women of reproductive-age group in Gharbia Governorate, Egypt.
Materials and materials
A self-administered questionnaire was developed and adapted from previous studies. Scores were used to assess the levels of knowledge, attitude, and practice concerning FP.
Results
The questionnaire was answered by 430 women. Current use of contraceptives was stated by 81.9%. The commonest methods included intrauterine device (44%), oral pills (20.7%), and injectables (8.4%). Knowledge was good, fair, and poor in 34.2%, 60.2%, and 5.6% of participants, respectively. Attitude was positive in 95.3%. Practice of FP was good in 67.9%. The most common barriers included fear of side effects (27.2%), lack of knowledge (23.3%), husband's refusal (13%), and for religious reasons (6.5%). Good knowledge was significantly associated with full-time job of women (P < 0.001), professional job of husband (P = 0.002), and high income (P = 0.004). Attitude was not significantly associated with sociodemographic characteristics (P > 0.05). Good practice was significantly associated with age ≥30 years (P = 0.037) and family size above 4 (P = 0.002). Knowledge and practice scores were significantly and positively, though weakly, correlated with the attitude score (rs < 0.3, P < 0.05).
Conclusion
The overall knowledge and attitude of respondents was good, but practice needs to be improved. Future campaigns and FP counseling should address the misconceptions about contraception, particularly side effects. Other barriers should be approached to ensure meeting of FP needs of couples.

Keywords: Contraception, questionnaire, survey, women


How to cite this article:
Atlam SA, Borg HM, Daoud WM. Contraception and family planning: knowledge, attitude, pattern of use, and barriers among females in Gharbia Governorate, Egypt. J Med Sci Res 2022;5:155-63

How to cite this URL:
Atlam SA, Borg HM, Daoud WM. Contraception and family planning: knowledge, attitude, pattern of use, and barriers among females in Gharbia Governorate, Egypt. J Med Sci Res [serial online] 2022 [cited 2024 Mar 28];5:155-63. Available from: http://www.jmsr.eg.net/text.asp?2022/5/2/155/353589




  Introduction Top


Contraception has become a focus of interest in medical practice to ensure good health of mothers and children by spacing pregnancies and avoiding unwanted pregnancies [1]. Social studies have demonstrated underuse of contraceptive methods in several countries [2],[3].

Most contraceptive methods are designed to be used by women [4]. Therefore, assessment of women's knowledge, attitude, and practice is pivotal for health organizations for developing and implementing the strategies of family planning (FP).

The Egyptian FP program started in the late 1960s but began to show real impact in the 1980s, when contraceptive use reached ~30% in 1984 and then increased to 45% by 1992 [5]. A FP campaign was released in Egypt with the slogan “Two is enough.” The population of Egypt is currently about 102 million and is expected to double by 2078 [6].

Assessment of women's knowledge offers insight into the misconceptions that may negatively impact their attitude and practice. Moreover, identification of barriers that hinder the use of contraceptive methods helps reaching the goals of stabilizing population growth. Therefore, the present study was conducted to assess knowledge, attitude, and practice of FP among women of reproductive-age group in Gharbia Governorate, Egypt.


  Participants and methods Top


Study design, settings, and ethical considerations

This was a cross-sectional study conducted during September 2019 through September 2020.

Sample-size calculation

Using Epi-Info statistical software package created by World Health Organization and Centre for Disease Prevention and Control, Atlanta, Georgia, USA, in 2002, the sample size was calculated at N >384 with 95% confidence level and a margin of error 5%. Adding a 10% attrition percentage to account for incomplete responses yielded a final sample size of 422 participants.

Eligibility criteria

We included married females within the childbearing age (18–49 years) residing in Gharbia Governorate, Egypt, and attending family health unit (FHU) or Tanta University Hospital (TUH).

Methods

A self-administered questionnaire was adapted from previous studies [5],[7],[8],[9],[10],[11],[12], translated into Arabic, and validated. It was tested on a pilot sample (40 women, not included in the final analysis) to ensure clarity and understanding of questions.

It consisted of 41 questions arranged into four parts: (a) sociodemographic data and sources of information, (b) knowledge, (c) attitude, and (d) practice of participants.

The sociodemographic data included the age, weight, height, woman's level of education and husband's level of education, employment status of the wife and husband, and annual income of the family. Questions about knowledge sources were asked about both the first source of information and the preferred source.

For exploring knowledge, attitude, and practice, ten questions were used for each domain. A scoring system was developed for knowledge by assigning one point for each correctly answered question (questions 9–18) and zero for incorrect answers or “do not know” response. The total score of knowledge ranged from zero to ten: eight points and above indicated good knowledge, five to seven indicated fair knowledge, and below five indicated poor knowledge.

A similar score was used to assess attitude (questions 19–30, except for questions 27 and 28). A total score of five or above was considered positive attitude, whereas a total score less than five was considered negative attitude.

For assessment of practice level, a score was also used that included questions 31–40 (excluding question 38). Two points were assigned for answers of good practice, one point for poor practice and zero for no practice. The total practice score ranged from 0 to 18. A score of nine or above indicated good practice, whereas a score below nine indicated bad practice.

Statistical analysis

The participants' responses were analyzed using SPSS for Windows, version 26 (IBM Corp., Armonk, NY). The qualitative variables were summarized as frequencies. Pearson's χ2 test or Fisher's exact tests were used to examine the association between two categorical variables as appropriate. Spearman's ranked-order correlation was used to assess the correlation between scores, considering the level of significance as P < 0.05.


  Results Top


Characteristics of the participants

The present study included 430 participants. A slightly higher percentage of participants were recruited from TUH compared with FHU (59.5% vs. 40.5%). Women aged 18 to less than 30 and those above 30 years constituted 44.9% and 55.1% of respondents, respectively. About two-thirds resided in rural regions. Most women had body mass index (BMI) above the average (79.4%). Approximately one-fifth of the respondents had primary or higher education, whereas those with middle/secondary educational degree accounted for 56.5%. About two-thirds of husbands had high educational level. Only 18.5% and 16.1% had primary or middle/secondary degree, respectively. Most respondents were housewives (68.8%), and only 16.7% had full-time job. Husbands worked in skilled jobs in 40.9%, professional jobs in 29.8%, and unskilled jobs in 29.3% of cases. Most respondents (63.3%) had a family consisting of four or more members. The income was stated to be enough, not enough, and more than enough in 61.2%, 27.9%, and 10.9% of cases, respectively [Table 1].
Table 1: Sociodemographic characteristics of the participants

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Knowledge about contraceptive methods

The main source for knowledge was healthcare providers (43.6%), followed by family/friends (31.9%), media (17.2%), and school education (7.2%). The preferable source for knowledge followed the same order but with a higher percentage preferring healthcare providers and lesser percentage in all other sources.

School education about reproductive health or contraceptive-related issues was received by 24.9%, whereas educations concerning these issues were received before marriage by 39.2% of participants. The difference between birth spacing and limitation and the ideal interpregnancy interval was known by 60.1% and 40% of respondents, respectively. The indications and contraindications of FP methods were known by 20.5%. The side effects and failure rates of contraceptive methods were known by 42.3% and 47%, respectively [Table 2]. Most (97.7%) participants heard of one or more FP method, whereas only 2.3% did not hear of any of the methods listed in the questionnaire. The most known methods were intrauterine device (85.1%), oral contraceptive pills (81.6%), injectable (58.8%), skin patch (18.6%), cap/diaphragm (17.4%), female sterilization (7%), withdrawal (3.5%), spermicidal jellies (2.3%), condom (1.9%), lactational amenorrhea (1.4%), and rhythm method (0.2%) [Figure 1].
Table 2: Knowledge about contraceptive methods among participants (total n=430)

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Figure 1: Methods of contraception heard about among the participants.

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Attitude of participants toward the use of contraceptive methods

Nearly two-thirds of participants agreed of enlightening unmarried girls regarding reproductive health and FP. Discussing these matters with unmarried girls was considered common in society (44.4%), uncommon (30.7%), and embarrassing (18.6%). The preferred number of children to have was 2–3 in 83.7% of responses. Seventy percent of respondents stated that they do not want more children now. Most participants were positive toward discussing contraceptive methods with their husbands or surroundings, whereas the remainders were embarrassed (7.2%) or avoided discussion (16.7%). Similar attitudes were reported concerning the husband's or acquaintances' attitude when discussing these issues. Most (72.3%) respondents used contraceptives without or despite adverse effects, whereas 10.7% never used them. Bad experiences were reported by 127 (29.5%) participants with one or more methods. Participants considered having a male child in their family very important (31.9%), somewhat important (30.5%), and of low importance (37.5%). Larger families were considered happier than small families by 40.5% of participants, similarly happy by 14%, and less happy by 40.5%. The bad experiences of contraceptives as reported by participants were bleeding (14.4%) and pregnancy while using the method (6.5%) [Table 3].
Table 3: Attitude of participants toward the use of contraceptive methods (total n=430)

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Pattern of use of contraceptive methods and barriers of family planning

The methods used by participants of this study included intrauterine devices (44%), oral pills (20.7%), hormonal injectable (8.4%), condom (1.9%), lactational amenorrhea (1.4%), and others (3%). Those who did not use any method constituted 20.7% of participants [Figure 2]. The mean age of the participants when having their first child was 21.6 ± 3.4 (range: 16–36 years).
Figure 2: Types of contraceptive methods used by participants.

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Only 4.9% of participants used contraceptive methods before their first child. About 27% of respondents stated that they would not use contraceptives even if they do not want more children. Current use of contraceptive methods (either by the woman or the husband) was reported by 352 (81.9%) participants, whereas 78 (18.1%) did not use methods at the time of survey. Only 25 of women not using contraceptives attributed this for wanting to get pregnant. The preferred places to seek medical services were gynecologist clinics (38.8%), health centers (28.8%), university hospitals (13.7%), governmental hospital (11.4% attend), pharmacies (3.5%), and general practitioners (3.3%). Only two participants chose nowhere. The barriers to FP were recognized by 27%, whereas 66.7% stated that no barriers exist and 6.3% were unsure. The most commonly reported barriers were fear of side effects (27.2%), lack of knowledge (23.3%), refusal of husband (13%), religious reasons (6.5%), social stigma and pressure (5.1%), lack of affordability (4.9%), and lack of access (2.3%), besides other miscellaneous unspecified barriers (17.7%) [Table 4].
Table 4: Pattern of use of contraceptive methods and barriers of family planning (total n=430)

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Knowledge, attitude, practice, and their determinants among the participants

Knowledge was good in 147 (34.2%), fair in 259 (60.2%), and poor in 24 (5.6%) participants. Lower level of knowledge was significantly associated with urban residence (P = 0.029), whereas high and fair levels of knowledge were significantly associated with the woman having full-time job (P < 0.001), husband having professional job (P = 0.002), and earning more-than-enough income (P = 0.004) [Table 5].
Table 5: Determinants of knowledge of the participants

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The attitude toward contraceptive methods was positive in 410 (95.3%) and negative in 20 (4.7%) respondents. In addition, no significant association with any of the sociodemographic characteristics of the participants was found. The level of practice was good in 67.9% and bad in 32.1% of cases. The good practice was significantly associated with being recruited from FHU (P = 0.023), being 30 years old or above (P = 0.037), and having a family size above 4 (P = 0.002) [Table 6].
Table 6: Determinants of attitude and practice of the participants

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Correlation between the total scores of knowledge, attitude, and practice

The total knowledge and practice scores were significantly and positively, though weakly, correlated with the attitude score (rs < 0.3, P < 0.05) [Table 7].
Table 7: Correlation between the total scores of knowledge, attitude, and practice

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  Discussion Top


The present study was conducted to assess the knowledge, attitude, and practice of FP among women of reproductive age in Gharbia Governorate, Egypt.

The overall level of knowledge was good in 147 (34.2%), fair in 259 (60.2%), and poor in 24 (5.6%) participants. Lower level of knowledge was significantly associated with urban residence (P = 0.029), which is in line with Abd-el-Rahman et al. [8] who surveyed 550 postpartum women in Minia, Egypt, and found that knowledge level was higher in rural areas (77.2%) than in urban areas (52.5%). High and fair levels of knowledge were significantly associated with the woman having full-time job (P < 0.001), her husband having professional job (P = 0.002) and earning more-than-enough income (P = 0.004). The knowledge level was not significantly associated with place of recruitment, age, BMI, educational level of the woman or husband, family size, and first or preferred source for information.

The main first source for knowledge about contraception was healthcare providers (43.6%), followed by family/friends (31.9%), media (17.2%), and school education (7.2%). The preferable source for knowledge followed the same order but with higher percentage preferring healthcare providers and lesser percentage in all other sources. Similarly, previous studies in Egypt reported healthcare professionals as the main source of contraceptive knowledge [5],[8].

In the present study, the attitude toward contraceptive methods was positive in 95.3% but negative in 4.7% of respondents. This percentage of positive attitude is higher than the rates reported by Ibrahim et al. [13] in Assiut, Egypt (72.6%), Gupta et al. [14] in Haryana, India (83.1%), and Semachew Kasa et al. [15] in Northwest Ethiopia (58.8%). These variations in the attitude of women reflect probably differences in cultural values, baseline characteristics of participants, and tools used to assess attitude.

We found a lack of significant association between women's attitude and the sociodemographic characteristics of the respondents. Ibrahim et al. [13] found that positive attitude was significantly associated with younger age, being employed, residing in urban areas, and having high education. These differences may be attributed to variations in baseline characteristics of participants and tools used to assess attitude.

In this study, the level of practice was unsatisfactory, with only 67.9% of respondents showing good practice. As 70% of participants admitted that they do not want to have more children, this indicates the presence of unmet needs of FP, particularly if we took into consideration those wanting more children but require spacing pregnancies.

The rate of contraceptive-method use among our participants was 81.9%. In about one-third of those not using contraception, the cause was their desire to get pregnant. About 27% of respondents stated that they would not use contraceptives even if they do not want more children. Such a finding raises alarm that barriers exist that prevent women who need FP from using contraception. This rate is higher than that reported by Ibrahim et al. [13] of women who used before or intended to use contraception in the future (59.2% and 77%, respectively).

Good practice in our study was significantly associated with being recruited from FHU (P = 0.023), being 30 years old or above (P = 0.037), and having a family size above 4 (P = 0.002). The association of good practice with large family size could be explained in light of that a large family needs the services of FP and the woman becomes motivated because more children would pose a burden on the family. There was no significant association between the educational level and practice. Similarly, Nansseu et al. [16] in Cameroon reported the absence of a significant association between educational level and practice of FP.

Barriers to FP were recognized by 27% of our participants, whereas 66.7% stated that no barriers exist and 6.3% were unsure. The reported barriers were fear of side effects (27.2%), lack of knowledge (23.3%), refusal of husband (13%), religious reasons (6.5%), social stigma and pressure (5.1%), lack of affordability (4.9%), and lack of access (2.3%).

Lack of knowledge and fear of serious side effects (such as womb damage, disease, and death) represent major barriers to the use of contraceptive methods as reported by previous studies. Ibrahim et al. [13] reported that 14.6% of their participants feared side effects of contraceptive methods and viewed these as barriers to use. Similar concerns were reported by studies from Democratic Republic of Congo [17], Kenya [18], Nigeria [19], and Zambia [20].

Refusal of the husband to use of contraceptives was cited among the barriers in several studies conducted in various Islamic and African countries [13],[19],[21],[22],[23],[24],[25], where the husband is regarded as the head of the family and has the right to be obeyed by his wife. Therefore, women cannot use contraceptives without permission of their husbands in these communities.

Religious and cultural beliefs were reported as barriers to the use of contraceptive methods in some African countries where they condemn birth control as “children are gifts of God” [11],[21],[25],[26],[27].

Accessibility and affordability of different contraceptives are important factors in determining the use of FP methods. In Egypt, both public and private health sectors provide FP services. Inaccessibility may arise if some methods of contraception require certain level of skill and equipment such as vasectomy and tubal ligation, so, they may not be available in a certain location for all couples who are in need [20]. It may result from noncooperation of healthcare providers and failure to provide adequate counseling for couples [11],[17],[20],[22],[24].

Both total knowledge and practice scores were significantly and positively, though weakly, correlated with the attitude score (rs < 0.3, P < 0.05). The lack of significant correlation between knowledge and practice on one hand, and the weak correlation between attitude and knowledge on the other hand, reflects the presence of barriers other than lack of knowledge. These barriers may include fear of side effects that was defective in most participants, husband's refusal, or religious causes. Other barriers may exist and deserve dedicated research to explore them, such as cultural beliefs of the stability of marriage when the number of children is increased, the desire to have male children, and childwork that may drive families to have more children in order to improve their income.

The present study included several points of strength. The questionnaire covered many aspects of knowledge, attitude, and practice, and explored many potential barriers to FP. However, the study was subject to some limitations. The nature of survey studies bears some risk of recall bias, particularly when women discuss the bad experiences or sources of knowledge. Moreover, the accessibility and quality of FP services, as rated by the participants, deserve more investigation as they represent potential barriers.


  Conclusion Top


The overall knowledge and attitude of respondents were good, but the practice of FP needs to be improved. Future campaigns and FP counseling should address the misconceptions about contraception, particularly side effects. Other barriers should be studied and approached to ensure meeting of FP needs of couples.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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