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Indian Journal of Medical Sciences, Volume 57, Number 7, July 2003, pp. 303-310 Contraceptive knowledge, practices and utilization of services in the rural areas of India (An ICMR Task Force Study) N Chandhick,* B S Dhillon,* I Kambo,** N C Saxena*** *Assistant Dir-General, **Deputy Dir-General (SG), ***Deputy Dir-General (SG)
and Chief; Division of
RHN, ICMR, New Delhi.
Accepted on 13-3-2003. Code Number: ms03005 Information or knowledge, practices and utilization of family planning services is crucial to planning. Indian Council of Medical Research (ICMR) has been engaged in studies focusing at developing strategies for improving Maternal and Child Health (MCH) and family planning (FP) services at grass root level for over a decade. With a shift in focus from MCH and FP towards comprehensive reproductive health care, ICMR initiated a project on Integrated Reproductive Health Care Delivery through its network of Human Reproduction Research Centres (HRRCs) located at medical colleges in various regions of the country. This paper is based on observations related to Contraceptive Knowledge, Practices and Utilization of Services during a large reproductive health survey of eligible married women. MATERIAL METHODS A multi indicator cluster survey of eligible women (married women 15-45 years of age), covering various reproductive health issues including family planning was conducted in 28 districts from 14 states of the country between January 1996 to February 1997. A three stage stratified random cluster sampling was adopted for selection of villages from the rural areas for the survey. Selection of districts was done by the HRRCs in consulation with the district health authorities. Stratification for sampling of villages was done at two stages on the basis of distance from the health facilities. In the first stage blocks were stratified into two groups based on distance from the District Hospital and one block was selected randomly from each group. In the second stage villages in the two selected blocks were stratified into three groups on the basis of distance from Primary Health Centre (PHC) and presence of subcerntre (SC) in the village thus forming six strata. At the third stage random clusters (villages) were selected from each stratum to provide coverage of about 4000 eligible women from the district. Questionnaires for the survey were prepared centrally in English and were translated into regional languages at the respective HRRCs. The questions pertaining to women's perceptions. opinions, knowledge, attitudes etc. were open-ended and the probable responses were listed to facilitate recording and minimizing interview time. No leading or suggestive questions were asked to avoid courteous responses and over estimation. Women were interviewed at their homes by female interviewers. Only volunteered responses were recorded. Necessary instruction manuals were prepared and regional workshop of HRRC medical officers were held for discussing conduction of the survey. Selection of the interviewers was done locally by the HRRCs. Training of interviewers was carried out by the HRRC medical officers. From among the current contraceptive users, all users of IUD, OC and acceptors of a permanent method during the one year (14,276) were interviewed in detail regarding source, services, family support, need realization and first time use of any family planning method. In addition a systematically selected sample of 17,082 non-pregnant women who were not using any family planning method were interviewed to asses their knowledge about available family planning methods, services and reasons for non utilization of any method. Data analysis was carried out at the ICMR Headquarters. Statistical analysis includes simple percentage distribution, rates and comparison of rates by `students' test. OBSERVATIONS A total of 1,17,465 eligible women were covered in this survey from the selected 28 districts. The mean age of the women, age at marriage and age at 1st conception was 29.5+6.8, 17.7+2.8 and 19.4+2.7 years respectively. Overall contraceptive prevalence including permanent, spacing and barrier method was 45.2 percent. This varied between 13.8 percent is Barabanki District, U.P. to 70.7% in District Yamuna Nagar, Haryana. Majority of these couples (34.2% including 0.6% vasectomy acceptors) had utilized a permanent method-mainly female sterilization. Use of spacing methods was reported by less than 5% of women in majority of the districts except from the study district in Haryana, Rajasthan, West Bengal, Assam, Goa and Meerut, U.P. (Table 1). Among the 14,276 current contraceptive users, 26% and 74% of women were using spacing or a permanent method respectively. The source of method was PHC (31.5%) or hospital (42.1%) in majority of the users. Sub-centre was the source of family planning services in 7.5% of the women. Only 9.2% availed these services from the private sector. Information on other services provided at the time of contraceptive acceptance was also obtained. Around half of the women (53.1%) had received counseling and 20.3% information about other methods. Pelvic examination was reported by 39.1% (Table 2). However, there were wide variations between district. This was not mentioned by any women from Yamuna Nagar, district where 60% of the women had received a contraceptive method at the camp. In contrast, 90% of women from one of the study districts in Tamilnadu expressed having a pelvic examination done. On asking direct question, most of the women (>97%) expressed satisfaction with the method, provider and services. In addition 75.4% also expressed that they had free discussion with the provider. Almost all women (98.8%) were using a contraceptive method with the knowledge of their husband and had his support for continuing the same. In 43.9% husband was the motivating force of acceptance of family planning whereas in 24.1% the women took the decision herself. On the whole 68% of the couples took the decision by themselves. Health functionaries were mentioned by 17.8% in being instrumental in translating their family planning needs into acceptance. Husbands had accompanied their wives in 39.1% of the acceptors and almost 16% of women had gone alone for obtaining the family planning method. In most of the Districts if husband was helpful in decision making for family planning then he also accompanied here for obtaining the same. There was no concept of using any family planning method for either postponing the first conception after marriage or spacing between the two childbirths. A large majority of women (70.5%) used a family planning method for the first time only after completing their desired family size. This varied from 21.9% (Nalbari, Assam) to 95% (Vellore, Tamil Nadu). Only 43 males, who had undergone vasectomy during last three ears, were available for interview. Of these, vasectomy was performed at camp in 12, at PHC/CHC in 14 cases, hospital 11 and private clinic-6. Thirty-two men were self-motivated and motivation by health worker was not mentioned by anyone. Thirty-seven out of the 43 vasectomy acceptors said they were happy that they had accepted sterilization instead of their wives, only 2 mentioned the opposite and four did not comment on this. Among the 17,082 never users of family planning methods who were interviewed to assess their contraceptive knowledge and awareness, 73.5% mentioned at least one modern method of family planning available in the national programme and 64.3% mentioned the service source where it would be available (Table 3). In most of the districts, spacing methods like IUD, OC were mentioned fewer women as compared to female sterilization. Oral contraceptives were mentioned by more than 60 per cent of women from nine districts including three eastern districts from West Bengal and Orissa, two districts each from Maharashtra and Rajasthan and one district each from U.P. and Gujarat. These were the districts reporting higher acceptance of oral pills as compared to majority of the other districts. The most common source mentioned family planning services was Govt. hospitals as mentioned by 42,8% of the women. Among the primary health care facilities PHC was mentioned by 31.1% followed by subcentre 20.3 and CHC 12.7% The most common reason given for not using any family planning method was "family not complete" (34.6%). Other reasons included "just married" (9.3%), "not acceptable to husband/mother-in-law" (7.1%), "fear of side-effects" (10.1%), "no need, follow natural family planning method" (9.7%). Reasons like lack of knowledge failure to obtain desirable method, health personnel not helpful etc. were mentioned by less than 2% of women (Table 4). About 15 to 40% women from many districts including Jammu, Yamuna Nagar, Haryana; Allahabad and Kanpur in U.P; Trivandrum, Kerala and North Goa reported use of natural family planning method as a reason for not using any modern family planning method in the programme. DISCUSSION This survey having a sample size larger than the National Family Health Survey-2 (NFHS-2) was carried out in 28 districts of 14 states of the country.1 It has provided information about knowledge and use of contraceptive methods in the rural areas of India. This is of practical relevance to programme administrators and policy makers responsible for monitoring existing programmes and formulating new strategies to meet the health and family planning needs of the population and addressing the high-unmet need for contraception. In our series, 45.2% of eligible women were using some method of contraception. This is similar to other studies that report an overall contraceptive prevalence of 37-48%.1-4 We also observed that the use of spacing methods was very limited and a majority of these women had used a permanent method. A matter of concern is that among the ever users of family planning, there was no concept of either delaying the first birth or spacing between two child births, as majority (66%) had adopted a permanent method of contraception for the first time only after completing their desired family size. Similar findings were observed in another study6 and by the NFHS-2.1 Acceptance of sterilization alone will not induce a decline in fertility levels unless it is preceded by a substantial reduction in the achieved family size of couples. About 45% of population increase is contributed by births above two children per family.5 Rajaretnam has demonstrated that even if there is no reduction in the family size of individual couples, delaying childbearing will bring about a decline in fertility and population growth rates.7 Many potential informational barriers exist to contraceptive use. Women must be aware of the methods available, must know where supplies of these methods can be obtained and they must know how to use the method they choose. Lack of this knowledge is strongly associated with unmet need for contraception. Our study concludes that knowledge barriers are relatively insignificant in the rural areas of India, as nearly three-quarters of the non-users were aware of at least one modern method of family planning and at least one source where it could be obtained. Knowledge of spacing methods was expressed by around half the women and a higher acceptance of spacing methods was observed from the districts where women had knowledge of these methods. In our study, social cultural and religious unacceptability of contraception did not emerge as an important obstacle to using a method. Majority of the respondents (non-users) wanted to adopt a contraceptive method only after achieving desired family size. Several studies indicate that in rural areas the desired family size of most couples is still three or more children.7 The women's perception of her husband's/mother-in-laws disapproval is provided far less often as a reason for non use than is the fear of contraceptive side effects on health. It is encouraging to note that most of the women had accessed contraceptive services from the Government health posts and lack of accessibility as a reason for not availing services was mentioned by only 1.1% of women. To enhance the use of spacing methods, there is a need to explore the possibility of utilizing private practitioners and those from the Indian system of medicine. Husbands being the decision-makers in the rural areas, their approval is strongly associated with contraceptive use among women. Almost all women, in our series were using a contraceptive with the knowledge and support of their husbands. However, in a very small proportion the men themselves used a contraceptive. In a study carried out in rural Maharashtra, 57.3% of males had positive view abut their role in family planning while 66.2% stressed the need to improve the acceptance of male methods by providing knowledge and information through different sources.2 An important indicator of the quality of family planning services is the information that women receive when they obtain contraception and the extent to which they receive follow-up services after accepting contraception. Our study reveals that around half the women had received counseling but in only one-fifth, an informed choice was provided. In order to meet the changing needs of women over their lifecycle there is an urgent need to provide them with knowledge about use of spacing methods. A strong commitment is required from field workers and program managers at all levels to promote spacing methods in the rural areas and motivate couples to accept them. In addition, quality services to provide the same should be available. SUMMARY To obtain information form rural women regarding their contraceptive knowledge, practices and utilization of services, a cross-sectional survey of 117,465 eligible women was carried out in the sampled areas of 28 districts from January 1996 to February 1997. From among the current contraceptive users all of IUD, OC and acceptors of a permanent method in the last one-year (14,276) were interviewed in detailed. In addition a systematically selected sample of 17,082 non users were also interviewed. Overall contraceptive prevalence was 45.2% of which 34.2% had used a permanent method. Among the current users, the contraceptive had been availed mainly from either PHC (31.5%) or hospital (42.1%). Around half the women (53.1%) had received counseling and in 20.3% information regarding other methods. Pelvic examination was done in 39.1% Most of the women (>97%) expressed satisfaction with the method, provider and services. Almost all the women (98.8%) were using a contraceptive method with the knowledge of their husband and had his support for continuing the same. There was no concept of using any family planning method for either postponing the first conception after marriage or spacing between the two child births. A large majority of women (70.5%) used a family planning method for the first time only after completing their desired family size. Among the never users, 73.5% mentioned at least one modern method of family planning available in the national programme and 64.3% mentioned the service source where it would be available. Fewer women in most of the districts mentioned spacing methods as compared to female sterilization. The main reason given for not using any family planning method was "family not complete" (34.6%). There is need to promote spacing methods by policy makers and field workers and motivate couples to accept them. PROJECT CO-INVESTIGATORS (IN ALPHABETICAL ORDER) A. Goswami, Medical College, Gauhati; A. N. Shrotri, BJ Medical College, Pune; A. Senthamil Selvi, RSRM Hospital for Women & Children, Chennai; Asha Oumachigui, JIPMER Pondicherry; B. S. Kodkany, JLN Medical College, Belgaum; Durga Gahlot, SP Medical College, Bikaner; Gita Ganguly Mukherjee, RG Kar Medical College, Kolkatta; H. L. Swain, SCB Medical College, Cuttack; K. Mukherjee MLN Medical College, Allahabad; K. C. De, Eden Hospital, Kolkatta; Kalyani Das, KG Medical College, Lucknow; Kurus J. Coyaji, KEM Hospital, Pune; Kusum Zaveri, JJ Group of Hospitals, Mumbai; M. N. Pal, Medical College, Goa; Marry Mahendru, KMC Chennai; Maya N. Hazra, Medical College, Baroda; P. Bhatia, Kasturba Hospital, New Delhi; S. Khajuria, Medical College, Jammu; S. Nagarathinam, Medical College, Madurai; Sarala Gopalan, PGIMER, Chandigarh; Shanti Roy, Medical College, Patna; Shanti Yadav, Safdarjung Hospital, New Delhi; Sujaya Kumari, IOG, Chennai; Tara Mathur, SMS Medical College, Jaipur; Uma Rani, KGH, Chennai; Usha Sharma, LLRM Medical College, Meerut; V. I. Nalini, Sat Medical College, Thiruvanantpuram; V. K. Singh, GSVAM Medical College, Kanpur. REFERENCES
Copyright 2003 - Indian Journal of Medical Sciences. The following images related to this document are available:Photo images[ms03005t1.jpg] [ms03005t3.jpg] [ms03005t4.jpg] [ms03005t2.jpg] |
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