literature review on knowledge attitude and practice of family planning

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Research Article

Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia

Contributed equally to this work with: Tizta Tilahun, Gily Coene, Stanley Luchters, Wondwosen Kassahun, Els Leye, Marleen Temmerman, Olivier Degomme

* E-mail: [email protected]

Affiliation College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia

Affiliation Rhea, Research Center on Gender and Diversity, Brussels University, Bussels, Belgium

Affiliations International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium, Burnet Institute, Monash University, Victoria, Australia

Affiliation International Centre for Reproductive Health, Department of Obstetrics and Gynecology, Ghent University, Ghent, Belgium

• Tizta Tilahun, 
• Gily Coene, 
• Stanley Luchters, 
• Wondwosen Kassahun, 
• Els Leye, 
• Marleen Temmerman, 
• Olivier Degomme

• Published: April 23, 2013
• https://doi.org/10.1371/journal.pone.0061335
• Reader Comments

Understanding why people do not use family planning is critical to address unmet needs and to increase contraceptive use. According to the Ethiopian Demographic and Health Survey 2011, most women and men had knowledge on some family planning methods but only about 29% of married women were using contraceptives. 20% women had an unmet need for family planning. We examined knowledge, attitudes and contraceptive practice as well as factors related to contraceptive use in Jimma zone, Ethiopia.

Data were collected from March to May 2010 among 854 married couples using a multi-stage sampling design. Quantitative data based on semi-structured questionnaires was triangulated with qualitative data collected during focus group discussions. We compared proportions and performed logistic regression analysis.

The concept of family planning was well known in the studied population. Sex-stratified analysis showed pills and injectables were commonly known by both sexes, while long-term contraceptive methods were better known by women, and traditional methods as well as emergency contraception by men. Formal education was the most important factor associated with better knowledge about contraceptive methods (aOR = 2.07, p<0.001), in particular among women (aOR women  = 2.77 vs. aOR men  = 1.49; p<0.001). In general only 4 out of 811 men ever used contraception, while 64% and 43% females ever used and were currently using contraception respectively.

The high knowledge on contraceptives did not match with the high contraceptive practice in the study area. The study demonstrates that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. Thus, projects aiming at increasing contraceptive use should contemplate and establish better counseling about contraceptive side effects and method switch. Furthermore in all family planning activities both wives' and husbands' participation should be considered.

Citation: Tilahun T, Coene G, Luchters S, Kassahun W, Leye E, Temmerman M, et al. (2013) Family Planning Knowledge, Attitude and Practice among Married Couples in Jimma Zone, Ethiopia. PLoS ONE 8(4): e61335. https://doi.org/10.1371/journal.pone.0061335

Editor: Hamid Reza Baradaran, Tehran University of Medical Sciences, Iran (Islamic Republic of)

Received: November 28, 2012; Accepted: March 7, 2013; Published: April 23, 2013

Copyright: © 2013 Tilahun et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: We also thank Belgium Institutional University Cooperation programme with Jimma University, Ethiopia for funding the research. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

The lifetime risk of maternal mortality of women in sub-Saharan Africa is 1 in 39 live births, which is the highest when compared to other world regions. The World Health Organization (WHO) estimated in 2012 that 287,000 maternal deaths occurred in 2010; sub-Sahara Africa (56%) and Southern Asia (29%) accounted for the global burden of maternal deaths [1] . One of the targets of the Ethiopian Ministry of Health, with respect to improving maternal and child health, is to increase the contraceptive prevalence rate (CPR) from 32% to 66% by 2015. In order to achieve this target, the Ministry has given priority to the provision of family planning services in the community [2] .

With 87 million people, Ethiopia is the second most populous nation in sub-Saharan Africa, with a continuing fast growing population of 2.7% per year [3] . The maternal mortality ratio (MMR) is 676 per 100 000 women aged 15 to 49, with an estimated 32% of all maternal deaths attributed to unsafe abortions [4] . A study conducted in Northwest Ethiopia in 2005 indicated that prevalence rates of spontaneous and induced abortions were estimated at 14.3% and 4.8% of all pregnancies respectively [5] .

Despite the recent increase in contraceptive use, sub-Saharan Africa is still characterized by high levels of fertility and a considerable unmet need for contraception [6] . The total fertility rate in Ethiopia is 4.8 births per woman and is considerably higher in the rural then the urban areas. Observed fertility rates among women are 33% higher than the wanted fertility rates. In absolute numbers, this means 0.6 additional children in urban areas and 1.5 in rural areas. This is particularly the case in Oromiya region where the total fertility rate is as high as 5.6 children per woman and 30% of the currently married women have an unmet need for contraception which represents the highest figure of all regions in Ethiopia [4] . In the five years preceding the Ethiopia demographic Health Survey (EDHS) in 2011 it is estimated that, three births of every four (72%) were wanted at that time, 20% were wanted but not at the time of pregnancy, and 9% were unwanted [4] . A better use of family planning could reduce many of these mistimed and unplanned pregnancies, while at the same time it could reduce the number of unsafe abortions as well as the mortality related with child birth [7] .

On the other hand, couples have a right to choose and decide upon the number of children they desire. This means that both partners have the right to be involved in fertility matters and as such husbands play a crucial role in fertility decision-making in most of the world [8] . Clearly, male-involvement in family planning has positively affected contraceptive use and has caused an overall decline in fertility in the developing world. Men's fertility preferences and attitudes towards family planning seem to influence their wives attitudes towards the use of modern contraceptives [9] . Therefore, programs that attempt to promote reproductive health through increasing the use of modern contraceptives need to target men specifically at all levels of the program. Hence, men should be actively involved at the ‘knowledge’ level (the concept of family planning), the ‘supportive’ level (being supportive for other to use contraception) and the ‘acceptor’ level (as contraceptive user). Their decision-making role should be taken into account in order to promote contraceptive use [10] . Similar research indicates that women's feelings about their partners and about involving men in contraceptive and reproductive decisions must always be taken into account [9] . Previous studies indicated that acceptance of children as God's will, attitudes towards preventing pregnancy, knowledge on different method choice and the understanding of the side effects of different methods are among the factors related to contraceptive use [11] , [12] . Moreover, studies on perception of spousal approval and opposition from husbands are positively associated with low contraceptive use [13] .

Given the above factors associated with contraceptive use, the primary objective of this study was to examine the contraceptive prevalence rate among married couples and to study the factors that influence contraceptive use. A secondary objective was to determine knowledge on contraceptives (method-specific; including barrier, hormonal, permanent and dual protection methods), and attitudes towards family planning. Finally, fertility preference among married couples was assessed to see the variation between men and women.

Materials and Methods

This analysis forms part of a baseline assessment for a broader study aimed at determining the effect of a family planning education intervention on the knowledge, attitude and practice of married couples regarding family planning as well as male involvement (will be disseminated separately). The study is conducted in Jimma Zone, one of 14 administrative zones of Oromyia region located in the Southwest of Ethiopia. Its capital, Jimma, is found 352 km to the south west of the national capital, Addis Ababa. Jimma Zone is an area of 15,568.58 Km 2 with 17 woredas (districts) and one special zone. According to the 2007 national census, the total population is 2,486,155, of whom 1,250,527 are men and 1,235,628 women [14] .The rural part counts for 89.5% of the total population size of the zone in which the dominant ethnic group is the Oromo. The study area is thus a typical rural setting.

The study population consisted of couples (women and their husbands) who were legally married, lived for more than six months in the study area and of which the wives were 15–49 years (the reproductive age group) but not pregnant at the time of the survey. Husbands within a polygamous marriage (who had more than one wife) were excluded from the analysis to decrease redundancy of information. A multi-stage sampling design was used with districts ( woredas ) as primary sampling units (PSU), and sub-districts ( kebeles ) as secondary sampling units (SSU). The study covered three woredas i.e. Seka, Manna and Gomma, in which six kebeles were randomly selected: Goyoo qechema, Koffie, Gobiemuleta, Haro, Gembie and Bulbulo. In each selected kebele , a complete census of married couples was prepared to use as a sampling frame. Married couples were then randomly sampled from each locality, based on a computer generated random number list until the required size was achieved.

The sample size was computed using Minitab version 14 statistical software in the context of the broader intervention study. Adding 10 percent for non- responses resulted in a final sample size of 427 couples per group or 854 for the entire sample to be drawn equally from each sub-districts.

This study consisted of two parts, including quantitative and qualitative data collection techniques. Data for the quantitative study were collected using semi-structured questionnaires. Separate questionnaires were administered for male and female respondents but with similar contents including socio-demographic characteristics (age, sex, ethnicity, occupational status, income, age at first marriage), reproductive characteristics (number of children, sex preference of couples), as well as question modules on knowledge, attitudes and practice regarding contraceptive use (types of contraception, use of contraception, user perspective, attitudes of a husband and wife towards contraceptives, husband-wife communication on family planning, ever use of contraceptives, current use of contraceptives and reasons for not using contraceptives).

The questionnaire includes not only types of contraceptive as knowledge part but also how to use, where to get family planning service, side effects of contraception and other points too. The survey instruments were developed from a validated questionnaire and were considered valid and reliable through the favorable comments of experts for obtaining information on couples about knowledge, attitude and contraceptive practice [8] , [9] , [15] , [16] . Pilot testing of 5% of the sample revealed that respondents were able to understand and answer questions. Six male and six female data collectors participated in the study and were supervised by three field coordinators. Data collectors were recruited from the local community. We paired the data collectors by sex: men to husbands and female to wives because of the sensitivity of the issue. Interview conducted in private location, each couple at a time but separately keeping the interviewee privacy. Interview conducted if both spouses willing to participate.

For the qualitative data, focus group discussions, using a semi-structured topic guide were employed. Focus group discussions were done to probe to understand the phenomena of couples contraceptive practices within the society. The semi-structured topic guide covered the socio-cultural factors related with contraception and husband's responsibility towards contraception. Four groups consisted of married women and four groups consisted of married men, making a total of eight focus group discussions. Each focus group discussion consisted of 8 to 12 participants. Participants were selected purposively based on who can give the most and best information about coupes contraceptive practice. The participants were married individuals. The group discussions were moderated by university graduates who speak the local language. Similar to the quantitative part, focus group discussions were done female to female and male to male moderators. For the qualitative data participants were first given number a code and their characteristics registered (age and sex). At each time the participant wanted to give an idea first he/she has to call the number. Notes on points of discussion was taken in addition to tape recording.

Data analysis

The data set for this analysis contained data from 854 husbands and their wives. For the quantitative data analysis, STATA® 10 for Windows® was employed. Analyses were done at the level of the individual independently from the spouses. Simple descriptive analysis was done to explore levels of awareness, knowledge (on different types of contraceptive and knowledge level), attitude and practice among respondents. Bivariate analysis was used to investigate the effect of demographic and socioeconomic variables on fertility preferences and contraceptive practice. Finally, multivariate logistic regression was used to identify predictors of these outcome variables. Statistical significance was considered at p-values less than 0.05.

Qualitative data from focus group discussions were recorded as sound files using tape and subsequently transcribed to text files. Transcripts of the recorded discussions were coded and analysed using thematic areas manually and participants' identifying details were removed. No computer software was used for qualitative data analysis.To check the internal consistency and reliability, data from the quantitative part was used to triangulate with the qualitative results

Ethical considerations

Ethical clearance of the study was obtained from the research and ethics committee of the College of Public Health and Medical Sciences, Jimma University, Southwest Ethiopia and Ghent University's Ethical Committee in Belgium. Written consent was obtained from each man and woman participating in the study after the data collectors explained about the purpose of the study using a predefined information sheet. Written informed consent was taken from spouses on the behalf of those wives for who were in the age less than 18 years. No compensation was rendered as direct incentive to the participants. The ethics committees approved this consent procedure.

Socio Demographic Characteristics

A total of 811 out of 854 sampled couples responded, equating to a response rate of 94.9%. All women were between 15 and 49 years (as per inclusion criteria), with a median age of 30 (IQR = [25;35]). Median age among males was 36 (IQR = [30;45]) (see Table 1 ).

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https://doi.org/10.1371/journal.pone.0061335.t001

Almost two-thirds of the women (n = 532, 66%) had not received education, but 204 (25%) had completed primary education; among men, 184 (23%) had not received education while 437 (54%) had completed primary schooling.

Oromos were the principal ethnic group accounting for 1,417 (87%) individuals; 97 (6%) others were Dawro, 28 (2%) Keffa, 25 (2%) Yem, 23 (1%) Amhara, and 32 (2%) from other ethnic groups. The majority of the respondents, 743 (92%) women and 737 (91%) men, were Muslim; second most prevalent religion was Orthodox Christianity with 55 (7%) women and 53 (7%) men. Education levels were different across these two most prevalent religions: 66 out of 1480 (4%) Muslims had completed secondary education in comparison to 16 of the 108 (15%) Orthodox Christians (χ 2 (1, N = 1588) = 19.98, p<0.001). Similarly, Amhara, Yem and Tigrie, of which approximately 25% are Orthodox Christians, showed higher levels of literacy than the other population groups (χ 2 (1, N = 1622) = 10.46, p = 0.001).

Agriculture was the main occupation of the interviewees with 732 (90%) men and 668 (82%) women; 71 (9%) of the women reported being housewives. The median income of couples was 225 Birr (IQR = [150;370]), which is approximately 9.3 Euro, per month, according to information obtained from the wives. Daily laborers had a median income of 150 Birr per month, government employees 700 Birr.

The median household size was 5 (IQR = [4;6]), with a median of 3 children, and 422 (52%) households comprised of five to seven members. Literate respondents had smaller household sizes than the illiterate (χ 2 (11, N = 811) = 28.23, p = 0.003), as well as less children (χ 2 (10, N = 811) = 30.48, p<0.001). The median age at first marriage for men aged 20–59 was 21 (IQR = [20;25]) and 16 (IQR = [15;18) for women aged 20–49. There were 40 (5%) males and 518 (65%) females who married before age 18. The median duration of the couple's marriage was 11 years (IQR = [6;19]). Among the husbands, 209 (26%) stated having been married already prior to the current union.

One-third of the female respondents (n = 296, 36%) reported having ever lost at least one child; 209 (70.6%) reported ever having lost at least one boy, 181 (61%) at least one girl.

More than 98% of the study participants had access to health facilities providing family planning services in their surrounding (at least health post i.e Primary level health care in Ethiopia (can serve 3,000–5,000 individuals).

Fertility preferences

A majority wanted to have more children: 494 (72%) among the men, 439 (64%) among the women. The median desired number of children before using family planning among both women and men was 4 (IQR = [3;5]). Of the 233 women who had reached or exceeded their desired number of children, 90 (39%) still reported a need for more children; on the other hand, among the men having reached or exceeded that number, 131 out of 252 (52%) wanted more children.

Overall, 413 (44%) respondents of the 933 desiring more children expressed a sex preference for the next child. Among men, 172 (35%) wanted a boy versus 47 (10%) a girl; among women these numbers were respectively 120 (27%) and 74 (17%). Sex preference varied depending on the number of boys and girls already living in the family (see Table 2 ). Respondents with no boys had a distinct desire to have a boy as the next child. This preference disappeared among women once they had at least one boy and among men once they had two boys. A similar preference for a girl is noticed for respondents that did not have girls yet, although the extent of this preference is more limited. On average, both men and women had a preference for a boy if they had at least one girl.

https://doi.org/10.1371/journal.pone.0061335.t002

Knowledge about Family Planning

The concept of family planning was well known to respondents: 760 (94%) women and 795 (98%) men responded ever having heard of it. The median number of methods of contraception that were known among men was 5 (IQR = [2;8]) which was the same among women 5 (IQR = [3;6]); the mean was 5.4 for both sexes (95%CI men  = [5.2;5.7] and 95%CI women  = [5.2;5.5]). As such, there was no statistical difference between the sexes (p = 0.6585). Different levels of knowledge were found across the kebeles : only 3 of the 265 (1%) respondents in Haro knew more than 5 methods of contraception compared to values ranging from 34% to 60% for the other kebeles . No relationship was found between knowledge level and age, religion or ethnic affiliation. Formal education on the other hand, was associated to a higher knowledgeability about contraceptive methods (aOR = 2.07, p<0.001), in particular among women (aOR women  = 2.77 vs. aOR men  = 1.49; p<0.01).

Method-specific knowledge levels varied from 12% for vaginal contraceptives (diaphragm, foam, jelly) to 94% for injectable contraceptives. Differences were found between men and women ( Table 3 ). Only short-term hormonal methods like the contraceptive pill and injectable contraceptives were consistently well known by both sexes. Least known were the permanent methods, traditional methods and emergency contraception. Major differences between women and men were noted for the long-term hormonal methods (χ 2 (1, N = 1622) = 217.96, p<0.001) and emergency contraception (χ 2 (1, N = 1622) = 140.12, p<0.001). A total of 1064 (68%) respondents knew how to use contraceptives, with more women (77%) being knowledgeable about it than men (58%) (χ 2 (1, N = 1622) = 67.42, p<0.001). Similarly, knowledge on contraceptive use decreased with increasing age even when correcting for sex (aOR per additional year of life  = 0.98; p = 0.003).

https://doi.org/10.1371/journal.pone.0061335.t003

Attitudes towards Family Planning

Of the 1622 respondents, 91% (1479) were in favour of family planning; logistic regression showed that factors associated with a more positive attitude towards family planning were: being a man (aOR = 1.67; p = 0.021), young age (aOR per additional year of life  = 0.97; p<0.001) and being literate (aOR = 1.89; p = 0.002). Male respondents were asked specifically whether they would support their wives to use family planning. Of the 811 male respondents, 751 (93%) answered positively and 22 (3%) negatively. This finding was corroborated during the focus group discussions with married men.

“Couples should limit their number of kids for the seek of child's health and for the household economy.” (Male, 18 years)

Contraceptive Practice

We did not consider husbands' number of children at first contraceptive use as only 4 (0.2%) males reported having ever used contraceptives. Condom use was thus very low. Among women, 517 (64%) ever used a method of contraception; 350 (43%) were using contraception at the time of the survey. This difference in contraceptive use between men and women was corroborated by the focus group discussions as these showed that both married women and men mostly considered contraceptive use as a woman's task:

“What will I do in a family planning clinic, contraception is women's business, I will just give my wife the necessary financial support she needs” (Male, 45 years)

Two hundred sixty five (51%) wives had one to two children at their first contraceptive use. The median number of children a woman had when starting contraception was 2 (IQR = [2-2]) which corresponds to 2 children less than what they considered the ideal number of children.

The most commonly used methods when starting contraception were injectable (316 out of 515, 39%) and oral (174 out of 515, 21%) hormonal contraceptives. The prevalence of these hormonal contraception methods was much related to the age of the woman. Injectable methods were most common among younger women (aOR per additional year of life  = 0.94; p<0.001), while oral contraceptives were more frequently used by older women (aOR per additional year of life  = 1.06; p<0.001). Of the 350 women who were using contraceptives at the time of the survey, 283(81%) were using injectables and 33 (9%) oral contraceptives.

Multivariate analysis showed that higher current use of contraception among women was associated with being literate (aOR = 1.58; p = 0.005), the number of children (aOR per additional child  = 1.11; p = 0.027) and being highly supportive of family planning (aOR = 4.01; p<0.001). Household income didn't show an association with current contraceptive use (p = 0.593). The same factors were also determinants for contraceptives having ever used.

Reasons given by males for not using contraception included being recently married 235 (29%) and lack of knowledge of the different types of methods 235 (30%). The reason for not using contraception given by both male and females was the desire to have children (419 (51.8%) men and 203 (44%) women). Among women fear of side effects was reported by 106 (23%) as the reason for not using contraception (see Figure 1 ). Likewise, the qualitative findings also indicate fear of contraceptives' side effects as a barrier to use contraception by women:

https://doi.org/10.1371/journal.pone.0061335.g001

“Women don't use contraceptive because they don't want to get pain by the side effect of pills and injectable” (Female, 25 years)

Additional results from focus group discussions indicate that males are at least partly responsible for women not using contraceptives:

“sometimes husbands oppose wife use of contraceptive because they think she does not want to give birth and instead she has an intention to go for another man” (Female, 33 years)

Among women, 183 (36%) of current contraceptive users reported ever having switched between methods, with 175 (96%) of them giving lack of comfort as one of the reason and 99 (54%) fear of side effects. Likewise the qualitative part supports this result.

“I used one type of contraceptive and it result in burning sensation and excessive menses so I changed to other contraception method” (Female, 20 years)

Despite the recent increase in contraceptive use, Ethiopia, Africa's second most populous country, is known to have a low contraceptive prevalence and high total fertility. The objective of the study presented in this paper was to investigate differences among males and females regarding knowledge on contraceptive methods, fertility preference and contraceptive practice among married men and women in Jimma zone, Ethiopia.

The results of this analysis demonstrate that more than 98% of the couples had access to health facilities that deliver family planning. The median household size of five in the study area (Jimma zone) was comparable to the national household size (4.6 persons), especially that of rural areas (4.9 persons) [4] . Literacy was found to be linked to smaller household sizes, which is in line with previous findings [4] , [16] .

Age at first marriage was lower in our study population compared to national figures. For females aged 20–49 years, the median age at first marriage was 16 years, i.e. one year younger than the national median (17.1 years) and a previously published study from Butajira (16.9 years). Among men aged 20–59, a one year difference with the national median was observed (22 years vs 23.1 years). This also corroborates general trends that men marry at older ages than women [4] , [17] .

Similar to EDHS (2011), this study revealed that more men than women have a desire for more children [4] . This suggests that the low use of contraception among men is partly a well-reasoned decision, and not only a consequence of limited knowledge. In this study the mean ideal number of children was 4.2 and 4.6 among men and women respectively. This is in contrast to the national figures that show a difference in the mean ideal number of children between men and women, i.e. 5.9 and 4.9 respectively [4] .

A study conducted in Tigray, Ethiopia reported that the mean desired number of children among men differed significantly as compared to that of women ( Δ = 1.2; 95%CI: [0.87;1.53]) [10] . The inconsistency with our study could partly be explained by a different formulation of questions since we inquired about the ideal number of children before starting contraception, instead of the actual desired number of children. Furthermore, we identified discrepant results with respect to the desired number of children and the desire to have additional children. Considerable numbers of couples that had reached the desired number of children still desired more. Research should be done exploring the causes of this finding.

With regards to sex preference, respondents with no boys had a distinct desire to have a boy as a next child; the same pattern of wanting a girl was observed among couples that didn't have a girl yet. However, the extent of the preference for a girl was more limited. In addition, the preference was stronger among men, a finding that is supported by the results of a study conducted in Ethiopia in which most men (48%) reported that they would like more sons than daughters [18] . This might be due to cultural norms around son preference or, as suggested by others, the interest for more sons could be based on subsistence reasons, such as economic security and maintaining their status within the traditional family structure [19] . From the focus group discussants, a woman (25 years) described that she wants to have five male and three female; because male stay with me but after marriage female follows her husband. Moreover this study reveals nearly 36% women reported ever had child death of which almost 70% boy child. This could be the other possible expatiation for boy sex preference.

The high level of knowledge on at least one form of contraception among the participants of this study (96%) is in line with previously reported national figures (98.4%). In our study, we observed no significant difference between men and women with regards to knowledge: the average number of methods known in both sexes was 5.4 contraceptive types. In contrast, at national level, the average number of contraceptive methods known by men is higher than women (6.3 and 5.4 respectively) [4] . As such, men included in our study were less knowledgeable about different methods compared to the average Ethiopian man.

In the present study, short-term hormonal contraceptive methods like the pill and injectable contraceptives were consistently well-known by both sexes. Permanent methods, traditional methods and emergency contraception on the other hand were the least known contraceptive methods. Compared to the results from the Ethiopian Demographic Health Survey (2011) women and men are more familiar with long term and standard days methods, but in the case of barrier methods (diaphragm/jelly and male condom) and emergency contraception the reverse is true for the study population [4] . In addition our study identified major differences in knowledge of emergency contraception between the two sexes. The limited knowledge of women on emergency contraception suggests that this type of contraception is not part of the standard information package that is given to women in our study area.

Overall, our respondents had a positive attitude towards family planning (91%), but less than 1% of the males and 64% of the women reported having ever used any type of contraception. Other studies have already described similar findings, i.e high awareness but low utilization of contraceptives, making this situation a serious challenge in developing countries [8] , [20] . The EDHS 2011 reported a current contraceptive prevalence rate of 29% for married women, which is lower than our finding (43%) [4] . A reason for this could be that the majority of our respondents have access to health facilities in the study site. With respect to the method-specific contraception, injectables (39%) and oral hormonal contraceptives (21%) were the main methods used. Compared to EDHS 2011, a noteworthy finding in our study is the low use of implants, suggesting that health facilities in our study area are not able to deliver this service.

Among background characteristics of women, literacy, age, the number of children, and being highly supportive of family planning were found to be important indicators of current contraceptive; this is confirmed by different studies [4] , [20] – [22] . Fear of side effects was identified as the reason for not using contraceptives among married women, a finding that has been described already in other studies conducted in Ethiopia and Bangladesh [23] , [24] .

Our qualitative study findings also assured that fear of side effects is one of the most important reasons of not using contraceptives by women. In addition, this study reported that men's reasons for not using contraception were being recently married and the desire for more children. The latter is also one of the most important reasons of not using contraception among women. In general, in the study area the findings indicate a prevailing belief that contraception is only a women's business.

This study has limitations resulting from the design that was used, in the sense that cross-sectional studies do not allow to establish cause-effect relationships. In addition, an important limitation is the exclusion of couples with pregnant women from this baseline study as per the intervention protocol. This clearly affects the contraceptive prevalence rate and could potentially affect some other indicators too. The group of pregnant couples however represented only 7% of all couples from our sampling frame. This leads us to believe that the effect on the figures is probably relatively small. A final potential limitation is reporting bias. It also suffered from social desirability as it is a community based study. In that context, we decided to exclude one kebele (Gobbie Mulata) from the analyses of the ideal number of children as there was evidence of an erroneous comprehension of the question.

Conclusion and Recommendations

The analysis of this study provides information on married men and women on knowledge, attitudes and contraceptive practice in Jimma zone, Ethiopia. Our results demonstrate that good knowledge among males and females was observed, yet differences on knowledge of specific contraception methods exist. The study reveals that mere physical access (proximity to clinics for family planning) and awareness of contraceptives are not sufficient to ensure that contraceptive needs are met. We also noticed the existence of a sex preference for boys both among men and women. Condom use by men is above the national average but it is low compared to most Sub-Saharan African countries. It is evident from this study that high knowledge on contraception is not matched with the high contraceptive use. Among reasons for not using contraception, want to have a child and side effects of contraceptive were given by men and women respectively. Therefore, family planning interventions should pay particular attention to both wives' and husbands' participation in family planning, while at the same time further educating married women and men on specific methods of contraception and their possible side effects. Moreover, a considerable amount of child death mainly boy child linking with boy sex preference reflects family planning interventions to see the ways beyond only for contraceptive purpose.

Acknowledgments

We would like to forward our gratitude to Jimma University, college of Public Health and Medical Sciences and Ghent University. Our special thanks goes to the supervisors, data collectors and respondents, the zonal health department and health center staffs. All authors read and approved the final manuscript.

Author Contributions

Critically reviewed drafts of the report: TT GC SL WK EL MT OD. Conceived and designed the experiments: TT MT GC SL. Performed the experiments: TT. Analyzed the data: TT OD. Wrote the paper: TT OD.

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• Published: 13 August 2018

Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia

• Ayele Semachew Kasa   ORCID: orcid.org/0000-0003-3320-8329 1 ,
• Mulu Tarekegn 1 &
• Nebyat Embiale 2  

BMC Research Notes volume  11 , Article number:  577 ( 2018 ) Cite this article

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To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017.

The study showed that the overall proper knowledge, attitude and practice of women towards family planning (FP) was 42.3%, 58.8%, and 50.4% respectively. Factors associated with the practice of FP were: residence, marital status, educational status, age, occupation, and knowledge, and attitude, number of children and monthly average household income of participants. In this study, the level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies. Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced. Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Introduction

Family planning (FP) is defined as a way of thinking and living that is adopted voluntary upon the bases of knowledge, attitude, and responsible decisions by individuals and couples [ 1 ]. Family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods [ 2 ].

Family planning deals with reproductive health of the mother, having adequate birth spacing, avoiding undesired pregnancies and abortions, preventing sexually transmitted diseases and improving the quality of life of mother, fetus and family as a whole [ 3 , 4 ].

The Federal Ministry of Health (FMOH) has undertaken many initiatives to reduce maternal mortality. Among these initiatives, the most important is the provision of family planning at all levels of the healthcare system [ 5 , 6 ]. Currently, short-term modern family planning methods are available at all levels of governmental and private health facilities, while long-term method is being provided in health centers, hospitals and private clinics [ 6 ].

The study done in Jimma Zone, Ethiopia showed that good knowledge on contraceptives did not match with the high contraceptive practice [ 7 ]. Different researchers showed that the highest awareness but low utilization of contraceptives making the situation a serious challenge [ 8 , 9 ].

Most of reproductive age women know little or incorrect information about family planning methods. Even when they know some names of contraceptives, they don’t know where to get them or how to use it. These women have negative attitude about family planning, while some have heard false and misleading information [ 10 , 11 ] and the current study aimed in assessing the knowledge, attitude and practice (KAP) of FP among women of reproductive age group in South Achefer District, Northwest Ethiopia.

Methods and materials

Study design and setup.

A community-based cross-sectional study was conducted in South Achefer District, Amhara Region, Northwest Ethiopia from March 01–April 01, 2017. Systematic sampling technique was used to recruit the sampled reproductive age women (15–49 years old). Based on the number of households obtained from the Kebele’s (Smallest administrative division) health post, the sample size (389) was distributed to the households. The sampling interval was determined based on the total number of 4431 households in the kebele. The first household was taken by lottery method and if there were more than one eligible individual in the same household one was selected by lottery method.

The data collection questionnaire was developed after reviewing different relevant literatures. The questionnaire, first developed in English language and then translated to Amharic (local language). Pretest was done on 5% of the total sample size at Ashuda kebele. After the pretest, necessary modifications and correction took place to ensure validity.

Those reproductive age women who answered ≥ 77% from knowledge assessing questions were considered as having good knowledge, those women who scored ≥ 90% from attitude assessing questions were considered as having favorable attitude and those women who scored ≥ 64% from practice assessing questions were considered as having good over all practice towards FP [ 7 ].

Data processing and analysis

The collected data was cleaned, entered and analyzed using SPSS version 21 software. Descriptive statistics were employed to describe socio-demographic, knowledge, attitude and practice variables. Chi squared (χ 2 ) test was used to determine association between variables. Associations were considered statistically significant when P-value was, < 0.05.

Socio-demographic characteristics of participants

The response rate in this study was 97.9%. Among 381 participants included, 185 (49%) were from rural villages. About 47% of the participants were illiterate and 52% were completed primary education. The monthly household income of the majority (42.5%) of the participants was between 1000 and 3000 Ethiopian birr. Regarding the family size of the participant’s, majority (48.3%) of them had ≥ 3 children.

The mean age of participants was 29.7 ± 6.4. Two hundred forty six (64.6%) and 133 (34.9%) were house wife’s and farmers respectively by their occupation. Almost two-third (65.4%) of participants were married, 24.9% were divorced by their marital status (Table  1 ).

Knowledge status of participants

All of participants ever heard about family planning methods. The major sources of information were from health workers (57.5%) and radio (41.5%). Regarding perceived side effects of using family planning, 13.1%, 24.9%, 9.7% and 52.2% of participants were responded heavy bleeding, irregular bleeding, an absence of menstrual cycle and abdominal cramp respectively were mentioned as a side effect. Among those who have children; 24.6% gave their last birth at home and 75.5% gave their last birth at the health institution. Regarding the overall knowledge of study participants, 161 (42.3%) had good knowledge towards family planning and the rest 220 (57.7%) had poor knowledge.

Attitude status of participants

The majority (88.5%) of the respondents ever discussed on family planning issues with their partners and wants to use it in the future. About 24.5% of the participants reported that they believe family planning exposes to infertility. Almost 23 (22.8%) of study participants reported that using family planning contradicts with their religion and culture. Regarding the overall attitude, 224 (58.8%) of the participants had favorable attitude and 157 (41.2%) had unfavorable attitude towards family planning.

Practice on family planning

Three fourth (75.3%) of study participants ever used contraceptive methods. The main types were pills (7.4%) and injectable (77.2%). The most common current reasons for not using were a desire to have a child (53.2%) and preferred method not available (46.8%). Almost half (50.4%) of study participants had good practice and the rest 49.6% had poor practice.

Factors associated with family planning practice

Study participants’ religion was not included in the analysis due to lack of variance, since almost all (99.2%) of participants were Orthodox Christians by their religion.

Women who had good knowledge were more likely to practice FP than those who have low knowledge (χ 2  = 117.995, d.f. = 1, P  < 0.001) and women who had favorable attitude towards FP were more likely to practice FP (χ 2  = 106.696, d.f. = 1, P  < 0.001). It was also seen that residence, age, educational status, occupation, marital status, number of children and monthly income of the were significantly associated with the practice of FP [(χ 2  = 69.723, d.f. = 1, P  < 0.001), (χ 2  = 104.252, d.f. = 2, P  < 0.002), (χ 2  = 119.264, d.f. = 1, P  < 0.001), (χ 2  = 41.519, d.f. = 1, P  < 0.001), (χ 2  = 39.050, d.f. = 1, P  < 0.001), (χ 2  = 144,400, d.f = 3, P  < 0.001) and (χ 2  = 179.366, d.f. = 1, P  < 0.002)] respectively (Table  2 ).

Increasing program coverage and access of family planning will not be enough unless all eligible women have adequate awareness for favorable attitude and correctly and consistently practicing as per their need. Increasing awareness/knowledge and favorable attitude for practicing FP activities at all levels of eligible women are strongly recommended [ 6 ].

The results of the present study showed that 42.3% of study participants had good knowledge, 58.8% had favorable attitude, and 50.4% had good practice towards family planning. This finding was lower than a study conducted in Jimma zone, Southwest Ethiopia [ 7 ], Sudan [ 9 ], Tanzania [ 12 ] and another study done in Rohtak district, India [ 13 ]. The difference may be due to; studies done in Jimma zone, Sudan, Tanzania and Rohtak district involve only those coupled/married women. Married women might have good knowledge and attitude for practicing family planning. But in the current study, all women of reproductive age group regardless of their marital status were studied and this may lower their knowledge and attitude.

The current study showed that, 50.4% of reproductive age women were practicing family planning which was almost in line with a study done in Cambodia [ 14 ] and higher than a study done in rural part of Jordan [ 15 ] and India [ 16 ]. But it was lower than studies conducted in Jimma zone, Ethiopia [ 7 ], Rohtak district, India [ 13 ], urban slum community of Mumbai [ 17 ] and in Sikkim [ 18 ] in which 64%, 62%, 65.6% and 62% of participants respectively used family planning. The difference might be due to that study participants in Jimma zone, Rohtak and Mumbi were relatively residing in large city/town and this may help them to have a better access for family planning compared to the study done in South Achefer District.

In the current study, urban residents were more likely to use family planning methods (71.4%) than their rural counterparts (28.1%). This finding was in line with the findings from Ethiopian Demographic Health Survey (EDHS) [ 2 ]. This might be due to the reason that urban residents are more aware of family planning and hence practicing better.

It has also found that women who completed primary & secondary education were practicing family planning than those who were uneducated (77.1% and 20.6%) respectively. This finding was in line with a study done in Jimma, Ethiopia [ 19 ]. This might be due to the fact that women who were able to read and write would think in which FP activities are useful to be economically, self-sufficient and more likely to acquire greater confidence and personal control in marital relationships including the discussion of family size and contraceptive use.

This study showed that, age of the study participants had an association with practicing FP. Those reproductive age women’s whose age > 30 years were practicing family planning better than those whose age < 18 years. This finding was in line with a study done in India [ 20 ]. This might be due to the reason that, when age increases mothers awareness, attitude and practice towards family planning may increase. In addition, as age increases the chance of practicing sexual intercourse increases and as a result they would be interested to utilize family planning in one or another way.

It has also revealed that women’s average monthly household income has an association with their FP practicing habit. Those study participants whose average monthly income < 1000 ETB were using FP better than whose average monthly income > 3000 ETB. This is might be because those relatively who had better income may need more children and those with low income may not want to have more children beyond their income.

The current study also showed that knowledge and attitude of reproductive age women were related to FP utilization. Those reproductive age women who had good knowledge were utilized FP better than from those who were less knowledgeable. Those participants with favorable attitude were practicing better than those who had unfavorable attitude. This is might be due to the fact that knowledge and attitude for specific activities are the key factors to start behaving and maintaining it continuously.

Conclusion and recommendation

The level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies.

Study participant’s residence, marital status, educational level, occupation, age, knowledge, attitude, their family size and their monthly average income were associated with FP utilization habit of reproductive age women.

Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced.

Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Limitation of the study

As the data were collected using interviewer administered questionnaire, mothers might not felt free and the reported KAP might be overestimated or underestimated.

We do not used qualitative method of data collection to gather study participant’s internal feeling about family planning, so that triangulation was possible. In addition, barriers for utilizing contraception not addressed.

Abbreviations

Ethiopian Demographic Health Survey

Ethiopian birr

Federal Ministry of Health

family planning

knowledge, attitude and practice

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Authors’ contributions

AS: approved the proposal with some revisions, participated in data analysis. MT: wrote the proposal, participated in data collection analyzed the data and drafted the paper. NE: approved the proposal with some revisions, participated in data analysis. All authors read and approved the final manuscript.

Acknowledgements

We are very grateful to all study participants for their commitment in responding to our questionnaires.

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The authors declare that they have no competing interests.

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Ethical clearance was obtained from the Ethical Review Committee of Bahir Dar University, College of Medicine & Health Sciences, and School of Nursing. The objective and purpose of the study were explained to officials at the Woreda and Kebele (smallest governmental administrative division) and a written permission consent was obtained from the study participants. For those study participants whose age is below 18 years consent to participate in the study was obtained from their parent during the data collection time.

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Semachew Kasa, A., Tarekegn, M. & Embiale, N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes 11 , 577 (2018). https://doi.org/10.1186/s13104-018-3689-7

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Predictors of Knowledge, Attitude, and Practice (KAP) Towards Family Planning (FP) Among Pregnant Women in Fiji

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• Mohammed Imtishal 3 ,
• Masoud Mohammadnezhad 4 , 5 ,
• Philip Baker 2 &
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This study aimed to determine the predictors of Knowledge, Attitude and Practice (KAP) towards Family Planning (FP) among pregnant Fijian women.

A cross-sectional study was conducted over two months in 2019 with adult pregnant women attending the Antenatal Clinic (ANC) at Ba Mission Hospital (BMH), Fiji. Data was collected using a self-administrated questionnaire. Statistical analysis included correlation tests and regression analysis in determining predictors of KAP.

240 pregnant women participated in this study with a mean age of 26.02 (± SD = 4.13). The results showed a moderate level of knowledge (mean 14.95, SD ± 3.15), positive attitude (mean 20.56, SD ± 5.68), and good practice (mean 4.97, SD ± 1.73). Linear regression identified that women with more than seven children had a knowledge score of 3.65, lower than null parity (t value = -2.577, p = 0.011). Women aged 20 to 24 had a 6.47 lower attitude score than women aged 18 to 19 (t value = -2.142, p = 0.033). Women in defacto relationships had a 2.12 lower attitude score compared to the married category (t value = -2.128, p = 0.034). Fijian women of Indian descent had a 1.98 lower attitude score than the I Taukei women (t value = -2.639, p = 0.009). Women aged 30–34 had 2.41 lower practice scores than those aged 18–19 (t value = -2.462, p = 0.015).

This study found a medium knowledge of FP among pregnant women. These findings support a recommendation for further research to implement effective strategies.

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Significance

What is already known.

The number of children and spacing interval appears to be influenced by knowledge and contraception usage. The high fertility rate also results from low contraception usage and low knowledge and attitudes toward FP among reproductive-age women.

What does this Study Add?

Fijian women’s knowledge, attitudes and good practice toward family planning differ from women of other ethnicities in the study. The number of children predicts the attitude towards family planning among Fijian women. Women’s age, marital status, and ethnicity predict attitudes toward family planning. Women’s age is a predictor of practice towards family planning among Fijian women.

According to the World Health Organization (WHO), “Family Planning (FP) allows individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births” (Matovu et al., 2017 ; Wanyenze et al., 2013 ). FP is achieved through contraceptive methods and the treatment of involuntary infertility (Elizabeth et al., 2002 ).

The number of children and spacing interval appears to be influenced by knowledge and contraception usage (Wagner et al., 2013 ). FP has a significant impact on reducing maternal and child mortality. The relevance of FP in any strategy for safe motherhood and child survival is clear (Littleton-Gibbs et al., 2004 ; Starbird et al., 2016 ). FP is critical in a woman’s life and is part of their right to choose and control fertility. FP supports the well-being of women and children. Although high fertility rates and rapid population growth affect the economy, it also affects the nation, especially in developing countries, because it has triggered the limitation of resources along with a more significant economic burden (Starbird et al., 2016 ; Apanga et al., 2015 ). High fertility increases health risks for mothers and children, leading to poor quality of life and reducing access to education, food, and employment (Askew et al., 2012 ; Thapa et al., 2018 ).

Maternal Child Health (MCH) is one of the priority areas for the Fiji Ministry of Health and Medical Services (MoHMS). Fijian population growth through a high fertility rate since 2009 appears to have resulted in increased poverty (Naidu et al., 2017 ). In addition, the high fertility rate seems to result from low contraception usage and low levels of FP among reproductive-age women (MoHMS. 2016 ).

Despite significant efforts to increase awareness of FP and contraception availability, assessment of understanding is often lacking (Bearinger et al., 2007 ). A woman’s age, husband’s education, wealth, spousal communication, and favourable attitude toward contraception are all associated with contraceptive usage (Azmat et al., 2015 ; Muhindo et al., 2015 ; Sultan et al., 2002 ). Pacific Island Countries (PICs) appeared as under-researched; however, Cammock et al. identified Fijian contraception usage average of 45% nationally, but as low as 22% of them are sexually active women (Cammock et al., 2018 ). The low level of contraception usage is also associated with the low levels of Knowledge, Attitude and Practice (KAP) of women and their partners (Lincoln et al., 2018 ). The low prevalence of contraception indicates that knowledge about FP is not reflected in behaviour.

Few studies have examined Pacific Islander women’s KAP, usage determinants and perceptions towards FP. As a result, very little is known about what is required to support the adaptation and implementation of evidence-informed public health interventions in Fiji. This study aimed to determine the level of KAP of FP among pregnant women and factors affecting their FP decision in a Fijian community. By understanding the FP decision, this study seeks to address issues like poverty and Malnutrition in Pacific Island Countries and Fiji. In addition, this study’s findings provide an opportunity to review FP policies and improve them to increase family planning knowledge and attitudes and increase contraception usage to improve the FP rate in the country.

Materials and Methods

Study design and setting.

A cross-sectional study was conducted with pregnant women who attended Antenatal Clinic (ANC) in Ba Mission Hospital (BMH), Fiji, from April 15 to June 1 2019. As the only hospital in the Ba Sub-division, BMH receives referrals from two regional health centres. The region has an estimated total population of 57,568, with about 23,000 women of childbearing age.

Study Population and Sample

Eligible were pregnant women of all ethnic and religious backgrounds, 18 years and over, self–identified as Fijian Ba residents, who attended the BMH antenatal clinic at any given trimester during the data collection period. This study excluded all non-pregnant women who attend ANC and pregnant women unable or unwilling to participate. Two hundred and forty women were invited to participate from an estimated 400 eligible women. In alternative order of presentation, we invited mothers to participate on randomly selected days over a month. On average, 30 women participated each day to recruit the target of 240 mothers. Women completed the survey only once.

Data Collection Tool

The self-administered questionnaire was in two parts—the first part comprised patient descriptors such as socio-demographics. The second part measured women’s KAP about family planning, subdivided into three sections. Section One, containing 12 questions, inquired regarding family planning knowledge. For each question, there were three possible responses (yes, no and “I don’t know”). Section Two, containing 15 questions, inquired regarding attitudes. For each question, there were three possible responses (agree, disagree and “don’t have any idea”). Finally, Section Three, containing six questions, inquired regarding practice. For each question, there were two possible responses (yes or no).

For each section, questions were scored between 0 and 2, with Total Points for Section One 24 points, Section Two 30 points, and Section Three 6 points. The correct knowledge answers were quantified as: <15 as “Poor” knowledge (Low level), 15–19 as “Moderate” knowledge (Medium level), and > 20 as “Good” knowledge (High level). For attitude, < 18 was considered as “Negative attitude” (Low level), 18–24 as “Neutral” “Medium level and > 25 “Positive attitude” (High level); and for practice, 0–3 was considered as “Bad” practice and 4 to 6 as “Good” practice. Scores less than 60% were classified as Low, 60 to 79% as Moderate, and 80 to 100% as High (Cleland et al., 2011 ).

To assess face validity, the questionnaire was administered to ten participants who met the study inclusion criteria to determine the extent the questionnaire covered the core concepts. To assess content validity, the questionnaire was provided to content experts (medical and academic staff) who were familiar with the study and worked in family planning. The experts assessed the questionnaire’s content based on the study’s aim and objective. Modifications occurred after assessing their comments.

Study Procedure

Pregnant women attending the ANC were introduced to the study by the researcher in the ANC room. Women meeting the study’s inclusion criteria were provided with an information sheet in the preferred language, either English, Hindi or Fijian. The researcher or the translators answered questions about the study. After reading the information sheet, those interested and eligible were invited to participate. Signed consent was obtained, and the researcher kept completed forms secured. The study’s information sheet remained with the participants. Consenting participants, using a pen, completed the questionnaire in their preferred language (English, Hindi or Fijian). Those unable to complete the questionnaire independently were offered assistance. The participants were assured they did not need to complete all the questions and could withdraw at any time without penalty. Participants were assured that the study was voluntary and without incentive payment.

Participants were asked to complete the questionnaire on one day but could return it at their next visit or within two weeks. The researcher held the names and contact details of those retaining the survey for subsequent submission. Completed surveys were submitted into a secured box available in all study areas. After two weeks, persons who had not returned the survey received a reminder. We deemed unreturned forms as non-responders.

Data Analysis

SPSS Version 22 was used for statistical analysis. Demographic continuous variables such as age were expressed as means and standard deviations. For nominal and ordinal data, we described frequency and percentages. The KAP component’s associations with the independent variables were analysed using ANOVA and Multiple linear regression, and the correlation between the dependent variables was analysed using Spearman and Pearson Correlation. All the tests were set at a 5% level of significance.

Ethical Considerations

The College of Health Research Ethics Committee (CHREC) of Fiji National University (FNU) and the Ministry of Health’s Fiji National Health Research Ethics Review Committee (FNHRERC) approved the study. The study was conducted following relevant guidelines and regulations.

The study comprised 240 female participants aged 18 to 44 (mean = 26.02, SD = 4.13, and median = 26). Many participants were 25 to 29 years of age (44.2%), and very few were 40 to 44 years of age (0.4%). More than one-third of the participants followed Christianity (38.3%), whilst the remainder followed Islam (31.3%), Hinduism (28.3%) and others 2.1%. Regarding ethnicity, the majority were of FID (58.8%). The remaining I Taukei (39.2%) and other ethnic groups (2.1%). About two-thirds of participants identified as unemployed (60.8%). Most women already had one or more children. More than half (57.1%) had 1 to 3 children, while 2.1% had seven or more children. Regarding the participant’s area of residence, more than half (55.4%) lived in rural settings. Most participants (41.7%) completed secondary education, while 27.9% completed only primary education. 30.4% had completed tertiary-level education. Many participants (26.3%) had a low annual income in the $15,000-$20,000 income bracket. Most participants (81.3%) were married, while 18.8% were in a de facto relationship (Table  1 ).

Table  2 shows the distribution of the participant’s level of KAP. About one-third of participants (n = 73, 30.4%) had a high level of knowledge towards FP. In contrast, most women (n = 161, 67.1%) had a medium level of knowledge of FP, and very few women (n = 6, 2.5%) had a low level of knowledge. Most pregnant women (56.7%) had a high level of positive attitude towards FP, while about (35.8%) had a positive attitude towards FP. Fewer women (7.5%) showed a negative attitude towards family planning. Regarding practice, the participants showed a low level of FP practice (20.4%), whereas those with good practice in family planning constituted only (191, 79.6%).

The knowledge score was based on 12 questions, with a maximum possible score of 24. The mean knowledge score was 15.0 (± 3.2), identifying participants with a moderate (medium) level of knowledge towards FP. The attitude score was based on five questions, with a maximum possible score of 30. The mean attitude score was 20.56 (± 5.68), > 20 shows that participants had a positive level of attitudes towards FP. Finally, the practice score was based on six questions, with a maximum possible score of six. The mean practice score was 5.0 (± 1.7), which shows that participants had good practice of FP (Table  3 ).

Table  4 presents the mean and SD of the participants’ level of KAP towards FP, which depended on the various demographic variables, including age, religion, ethnicity, annual income, education level, residence, number of children, employment status and marital status. There was a statistically significant association between knowledge and marital status (p = 0.01), with those in the defacto relationships having higher knowledge levels. Those with many children showed the least low level of knowledge (p = 0.001). There was a significant correlation between attitude and age (p = 0.006). With persons in the youngest age group having a positive attitude towards family planning.

Table  5 identifies the independent variables collectively that could predict only 4.1% of the total knowledge scores (R 2  = 0.109, adjusted R 2  = 0.041). Women with more than seven children had a 3.65 lower knowledge score than those without children (t value = -2.577, p = 0.011).

From Table  6 , all the independent variables could predict only 6.7% of the total attitude scores (R2 = 0.134, adjusted R 2  = 0.067). Women in the age category 20–24 years had a 6.47 lower attitude score than those aged 18–19 (t value = -2.142, p = 0.033). Defacto women had a 2.12 lower attitude score compared to the married category (t value = -2.128, p = 0.034). Fijian women of Indian descent had a 1.98 lower attitude score than the I Taukei women category (t value = -2.639, p = 0.009).

From Table  7 , all the independent variables could predict only 4% of the total knowledge scores (R2 = 0.109, adjusted R2 = 0.040). Women aged 30–34 years had a 2.41 lower practice score compared to those with 18–19 years old (t value = -2.462, p = 0.015).

Table  8 shows the r-value and p-value of the KAP scores of participants for FP. The r-value (-0.082) infers that there was a negative relationship between knowledge and attitude. Likewise, the r value (0.098) shows a weak positive relationship between knowledge and practice. The r value (0.098) denotes a weak positive relationship between attitude and practice. Further, as shown in the table, the relationship between knowledge and attitude (p = 0.2), knowledge and practice (p = 0.170), and attitude and practice (p = 0.129) were not statistically significant.

This study showed the Fijian participants had moderate knowledge, positive attitudes and good practices towards FP. Regarding their knowledge about FP, the mean score of FP knowledge was 14.95 (± 3.15), categorised as moderate. In other words, women are aware of FP concepts, methods and procedures; however, there is an opportunity to improve their knowledge. The completion rate of the questionnaire was 100%.

From this study, it was noted that 57.5% of pregnant women said that they knew about the different types of contraception available, but the level reported here is much lower than a similar study carried out by Ismail et al. ( 2014 ) in Iraqi Kurdistan, identifying almost 97% of women knew about FP. A study conducted in Saudi Arabia had similar findings to the current study 80.6% of the participants knew about FP, and 68.1% correctly defined FP. Many women’s FP knowledge could be increased to improve FP practice (Al-Musa et al., 2019 ). As shown by Saleh et al. ( 2018 ), with of women 95% demonstrating overall general knowledge of FP, high levels of knowledge are achievable.

The analysis shows a significant association between the number of children and women’s knowledge of FP. This association might be valid for the five women having more than seven children, but the observed association could be due to other factors such as religion and ethnicity. Nevertheless, the high precision in the association shows that the number of children is directly associated with the level of knowledge. Conceptually, knowledgeable women may have used FP to control the number of kids. It is widely accepted large family size is directly associated with poverty (Oberta, 2005 ). However, those who have moderate knowledge may undertake ineffective practice. For example, poorer people often have more children to secure caregivers for themselves during their old age (Okanlawon et al., 2010 ). For instance, Mansour et al. found good knowledge of contraceptive methods among Saudi women, 31.7% compared to 68.3% with poor knowledge and the parity among 57.5% was less than 5 with a mean value of 4.4 ± 2.9. Further, the Saudi study identified two primary reasons for parity > 3: being religious (belief children are a gift of God) and having high social prestige through a large family (Mansor et al., 2015 ). This finding is quite pronounced in Abdikadir et al. ( 2018 ) which compared university-educated Somali to women with lesser or no education. In their study of 360 women of reproductive age, university-educated females had a mean desired family size of 9.3 children, compared to women with less or no education, with a mean of 10.5 children. In addition, each group had a mean of 4.5 children. The high fertility rate was attributed to a lack of contraception availability and poor knowledge.

However, our study shows a strong association between the number of children and knowledge, which is opposite to what Lincoln et al. ( 2018 ) which did not find an association of FP knowledge with the number of children. Furthermore, we have found that lower levels of FP knowledge are associated with more children. This lower level can be attributed to half of the participants being from rural areas with higher unemployment. Also, factors like religious and cultural beliefs, husband disapproval, desire for more children and unavailability of contraception and awareness and lack of education on FP appear to be reasons for having more children. The opposite is seen in younger women who might be employed and have a better educational background and fewer children.

The mean score of participants’ attitudes in this study was 20.6 ± 5.7 (out of a maximum possible of 30) identifying those pregnant women with a positive attitude towards FP. Most of the questions were answered favourably, including the ideal number of children, birth spacing and its usefulness, poverty related to FP, the effect of contraception on health, and the impact of some demographic characteristics on FP. The overall agreement with the core elements of family planning was high (86.77%).

Amongst the possible predictors, we initially expected higher age to be associated with positive attitudes toward FP, perhaps reflecting lived experiences. On the contrary, we found that women in the older age group had a lower altitude than those in the younger age group. We speculate that the significant statistical association might be due to the younger generation having a different approach to life, with most of them career-orientated focus. Thus, preferring fewer children who may choose larger families. Similarly, women in the older age group might not be employed or have other contributing factors to attitude may be present such as cultural or religious beliefs. A similar study by Thapa et al. showed that age had a positive correlation with attitude (Thapa et al., 2018 ); similarly, Endrias et al. showed a significant effect of age on attitude (Endrias et al., 2017 ). However, a study by Lincoln et al., ( 2018 ) conducted in Suva, Fiji, showed the opposite of no significant relationship between age and attitude. As shown in several settings, age can impact attitude, but the direction of the association may vary.

Marital status also appears associated with attitude, as women in a de facto relationship had a lower attitude towards family than married women. This finding is similar to Kasa et al. ( 2014 ) who found married women and a more positive attitude to FP than unmarried women. Nyauchi et al. ( 2014 ) also found a similar association. In addition, married women appear to have a more positive attitude toward FP due to the need to limit the number of children (Nyauchi et al., 2014 ). However, a study conducted in Suva, Fiji, failed to observe this association (Lincoln et al., 2018 ).

Ethnicity may be associated with poor FP due to various myths and misconceptions about FP. Some ethnic groups do not allow FP or discourage FP use. Resistance to FP is often associated with religion, cultural beliefs and negative attitudes. In refugee camps in Nigeria, Owolabi et al. (2010) found no association between ethnicity and religious attitudes, which Kamruzaman et al. ( 2015 ) identified. The choice of contraception methods may be cultural (Rasheed et al., 2015 ), as methods vary by religion and ethnicity, which contrasts with Lincoln et al. that showed positive attitudes towards FP varied considerably by ethnicity (Lincoln et al., 2018 ).

FP-related practices among pregnant women in Ba, Fiji, appear to be much better when compared to those reported elsewhere. The older age group had lower practice scores than the younger age group, which may be related to why they were pregnant again at an older age. A possible hypothesis is that older women may be more experienced in practising FP than younger women. It is difficult to interpret the FP practice amongst those 18 to 19 years of age as their current pregnancy may have resulted from failed FP. Adeyemi et al., ( 2008 ) showed that women 40 to 49 years of age were four times more likely to use contraception than single women (p < 0.001) (33). This earlier research contrasts with the findings by Ismail et al. ( 2014 ) suggested that contraception usage decreases after 40 years of age (19). Osmani et al. ( 2015 ) found women preferred not to use FP at an early age as they were newly married and sought to start a family early in the marriage rather than after 40 years of age (34). In contrast, to our findings, Lincoln et al. ( 2018 ) found no relationship between age and practice of FP. Our findings suggest younger women appear to use contraception to avoid early pregnancy to enable completion of education and developing careers.

Limitations

Although, this is the first study conducted in Fiji among pregnant women and assessed their KAP towards FP. This study applied a cross-sectional study and lacks establishment of the temporal relationship between pregnancy and family planning knowledge, attitudes and beliefs. Therefore, causal relationships cannot be determined. The study was a sample from only one regional hospital; the findings may not be generalisable to all pregnant women in Fiji. This study applied a self-administrated questionnaire to collect data and may reflect participants’ views at only one-time point. As shown in earlier research, women might change reporting of their opinions in another setting, such as outside the hospital Antenatal care clinic.

The study identified clear associations of KAP towards family planning with age, marital status and the number of children. Notably, there was a negative relationship between knowledge and attitudes. In addition, the study showed that knowledge towards FP was moderate. In contrast, attitude and practice were high, meaning that women had adequate knowledge of FP but had a positive attitude and good practice towards FP. These findings suggest opportunities for public health to review current policies and practices that could improve the family planning services provided in sub-divisional hospitals.

Data Availability

The authors will consider the application by third parties for the original data of this study consistent with the study’s ethics approval.

Abbreviations

Antenatal Clinic

Ba Mission Hospital

College Health Research Ethics Committee

Family Planning

Fijian of Indian Descent

Fiji National Health Research and Ethics Review Committee

Fiji National University

Knowledge, Attitude, and Practice

Ministry of Health and Medical Services

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Acknowledgements

We acknowledge all the study participants who took part in this study.

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Mohammed Imtishal

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Imtishal, M., Mohammadnezhad, M., Baker, P. et al. Predictors of Knowledge, Attitude, and Practice (KAP) Towards Family Planning (FP) Among Pregnant Women in Fiji. Matern Child Health J 27 , 795–804 (2023). https://doi.org/10.1007/s10995-023-03618-3

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Family planning knowledge, attitude and practice among Rohingya women living in refugee camps in Bangladesh: a cross-sectional study

• Md. Abul Kalam Azad 1 ,
• Muhammad Zakaria   ORCID: orcid.org/0000-0002-6492-7900 1 ,
• Tania Nachrin 2 ,
• Madhab Chandra Das 1 ,
• Feng Cheng 3 , 4 &
• Junfang Xu 5  

Reproductive Health volume  19 , Article number:  105 ( 2022 ) Cite this article

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Considering the high risk of maternal morbidity and mortality, increased risks of unintended pregnancy, and the unmet need for contraceptives prevalent among the Rohingya refugees, this study aims to explore the knowledge, attitude, and practice (KAP) of family planning (FP) and associated factors among Rohingya women living in refugee camps in Bangladesh.

Four hundred Rohingya women were interviewed. Data were collected using a structured and pretested questionnaire, which included study participants’ socio-demographic characteristics, access to FP services, knowledge, attitude, and practice of FP. Linear regression analysis was performed to identify the influencing factors of FP-KAP.

Of the 400 Rohingya refugee women, 60% were unaware that there was no physical harm brought by using a permanent method of birth control. Half of the women lack proper knowledge regarding whether a girl was eligible for marriage before the age of 18. More than two-thirds of the women thought family planning methods should not be used without the husband’s permission. Moreover, 40% were ashamed and afraid to discuss family planning matters with their husbands. Of the study participants, 58% had the opinion that a couple should continue bearing children until a son is born. Linear regression analyses found that study participants’ who have a profession, have less children, whose primary source of FP knowledge was through a physician/nurse, have had FP interventions in the camp, and talk with a health care provider on FP were found to have better FP-KAP.

The study showed that Rohingya refugee women are a marginalized population in terms of family planning and their comprehensive FP-KAP capability was low. Contraceptives among the Rohingyas were unpopular, mainly due to a lack of educational qualifications and family planning awareness. In addition, family planning initiatives among Rohingya refugees were limited by a conservative culture and religious beliefs. Therefore, strengthening FP interventions and increasing the accessibility to essential health services and education are indispensable to improving improve maternal health among Rohingya refugees.

Plain Language Summary

Considering the high risk of maternal morbidity and mortality, increased risks of unintended pregnancy, and the unmet need for contraceptives prevalent among the Rohingya refugees, this study aims to explore the knowledge, attitude and practice (KAP) of family planning (FP) and associated factors among Rohingya women living in the refugee camps in Cox’s Bazar, Bangladesh. Four hundred Rohingya women participated in the study. We found that Rohingya refugee women were a marginalized population in family planning and their comprehensive FP-KAP status was low. Contraceptive uptake among the Rohingya women was low due to a lack of education and family planning awareness. In addition, family planning initiatives among Rohingya refugees were limited by various traditional cultural and religious beliefs. Therefore, strengthening FP interventions and increasing accessibility to essential health services and education are indispensable to improving maternal health among refugees.

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Over the last few decades, the number of stateless people who are usually identified as refugees has grown exponentially around the world. The most recent focus is Myanmar’s Rohingya diaspora, who have left their homes since 25 August, 2017 [ 1 , 2 , 3 ]. This influx of more than 700,000 Rohingya into Bangladesh has produced the fastest-growing refugee crisis in the world [ 1 , 2 , 4 , 5 , 6 ]. Bangladesh’s total number of unregistered refugees was about 220,000 before the recent influx [ 2 , 7 ]. However, as of 31 March 2021, approximately 884,000 Rohingya refugees who are Forcibly Displaced Myanmar Nationals (FDMN) resided in 34 camps in Ukhiya and Teknaf Upazilas (sub-districts) of Cox’s Bazar District of Bangladesh [ 8 ], which have grown to become the largest and most densely populated camps in the world [ 9 ]. Among the refugees, women and children make up the majority [ 6 , 10 , 11 , 12 ], which accounts for more than 50% [ 1 , 13 , 14 , 15 ].

The Government of Bangladesh and development partners, including the United Nations High Commissioner for Refugees (UNHCR), United Nations Children's Fund (UNICEF), United Nations Population Fund (UNFPA) and the World Health Organization (WHO) are working together to provide humanitarian relief to the Rohingya people [ 4 ]. The Rohingya, while living in Myanmar, were deprived of nationality and fundamental rights to education and health care. These restrictions have substantially affected their knowledge of contraception and family planning [ 16 , 17 ], indicating that adverse health outcomes related to maternal health may be extremely high [ 18 ]. Evidence also suggests that worldwide, forcibly displaced women and adolescent girls are experiencing intensified sexual and reproductive health (SRH) concerns, including a high risk of maternal morbidity and mortality, increased risks of unintended pregnancy, and an unmet need for contraceptives [ 1 , 14 , 19 ]. For example, 179 mothers die from preventable causes related to pregnancy and childbirth for every 100,000 live births in the camps [ 20 ]—nearly two-and-a-half times the global maternal mortality goal [ 21 ]. Save the Children estimated that 76,000 babies were born in the Rohingya camps in Bangladesh over the past 3 years [ 22 ]. Correspondingly, more than 60 babies were born every day in the refugee camps of Bangladesh [ 23 ].

In order to address reproductive and maternal health issues of Rohingya women and adolescent girls, humanitarian actors collaborated with the Ministry of Health and Family Welfare (MOHFW), providing basic health services including family planning (FP) programs, intrauterine devices (IUD) and implants, as well as other short-acting modern methods of FP (condoms, oral contraceptive pills, injectables) [ 11 , 14 , 15 , 16 , 24 , 25 ] to increase community awareness [ 1 , 14 ]. Moreover, at the community level, health workers are implementing different interventions including FP counseling sessions and community meetings with the intended population at reproductive age [ 1 , 4 , 16 ].

According to estimations from recent studies, the Rohingya women’s contraceptive prevalence rate (CPR) was higher than reported in 2018. A survey conducted by the International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) [ 3 ] exposed that contraceptive use amongst Rohingya refugees rose by 2.1 percentage points from 33.7% in 2018 to 35.8% in 2019. Increasing awareness of modern contraceptive methods among Rohingya refugees may contribute to these positive outcomes. However, challenges also exist due to cultural values, traditional misconceptions, and dogmatic beliefs towards contraceptive use among the majority of the Rohingya people [ 1 , 4 , 6 , 14 , 16 , 17 , 26 , 27 , 28 , 29 ]. The hindrances may include: the religion of Islam not permitting use of contraceptives [ 1 , 4 , 16 ], husbands’ disapproval of contraceptive use [ 1 , 14 , 16 , 29 ], actively trying to fall pregnant [ 28 , 29 ], the belief that lessening the number of children is a sin [ 1 , 4 , 29 ], the belief that a child is a gift of Allah (God) [ 1 , 4 , 16 , 29 ], considering children as economic assets [ 4 ], considering that a large family would enable better chances of survival in refugee camps [ 4 , 30 ], the belief that use of contraceptives can lead to adverse health outcomes including infertility [ 16 ], and the negative role of husbands and mothers-in-law as the two most influential decision-makers regarding contraceptive use [ 4 ]. In addition, despite various organizations’ providing FP services, Rohingya women and girls do not have adequate and equal access to these services [ 16 ]. This highlights the significance of increasing contraceptive use among Rohingya women and improving their maternal health. Under this background, we aim to analyze FP in terms of knowledge, attitude and practice and other associated factors among the Rohingya women living in Cox’s Bazar refugee camps, Bangladesh. It is hoped that this study could provide evidence for developing interventions in a coordinated and effective manner to improve maternal and child health for Rohingya women in refugee camps.

Study design and setting

This study used a quantitative research approach designed with a camp-based cross-sectional survey. It was conducted at Rohingya refugee Camp-4 (located at Lombashiya, Modhurchora in Kutupalong Mega area) in Cox’s Bazar, a district under the Chittagong Division, geographically the largest of the eight administrative divisions of Bangladesh. This camp was selected as the study area as it is one of the largest camps in Bangladesh.

Participants

The population of the study consists of married Rohingya refugee women of reproductive age (18–49 years old) who had been living with their husbands at the camp and had delivered at least one child at least 1 year before the survey was conducted. A total of 32,389 Rohingya people were living in Camp-4 during the study period while the number of women was 16,968, and 7683 of them were women of reproductive age [ 31 ]. The sample size was determined using the single population proportion formula considering the following assumption: p = 50% (it was hypothesized that the percentage frequency of having better FP-KAP in the population was 50% for the estimated proportion of Rohingya women), significance level 5% (α = 0.05), Z \(\frac{\mathrm{\alpha }}{2}\) = 1.96, margin of error 5% (d = 0.05) and assuming 10% non-response rate. The required sample size was 422, which is the number of individuals the research team invited to participate in the survey. Finally, a total of 400 refugee women (94.79% response rate) participated in the study. Study participants were selected following convenient sampling, due to the humanitarian context and inadequate funds. A previous study [ 32 ] also faced this methodological challenge due to the structure of the camps. In the camp, the houses were built sporadically on hills with no identification numbers. Furthermore, there was no complete list of Rohingya persons living in a particular block or camp. Registered Rohingya people were also hesitant to provide their registration numbers, making it difficult to establish a sampling frame. Due to time constraints, we were unable to compile a list of households to construct a sampling frame for simple random sampling. As a result, the study team chose convenience sampling.

Reliability and validity of the instrument

In order to ensure the relevance of the questionnaire items with the study aims, the content validity of the questionnaire was reviewed by three experts working in the same field. Each expert reviewed the questionnaire separately and various changes were made to the questionnaire based on their recommendations. The internal consistency was also measured to check the reliability. Cronbach’s Alpha (α) values of the scale of FP knowledge, attitude, and practice suggested very good internal consistency reliability for the scales of this study. The alpha (α) value was good among knowledge-related 10 items (α = 0.84) and attitude-related 10 items (α = 0.89) and strong among practice-related 10 items (α = 0.95).

Study variables

There were three dependent (outcome) variables in our study which included knowledge of FP, attitude towards FP, and practice regarding FP. The independent (potential predictor) variables included the respondents’ region of residence in Myanmar, age, educational status, occupation, amount of land owned in Myanmar, and number of children. We included the respondents’ educational and residential status and amount of land owned in Myanmar under the socio-demographic variables as we hypothesized that these past statuses might be an important indicator of health behavior in the current settings. Media use–related variables were respondents’ listening to radio and internet use, while access to NGO programs and health facilities included respondents’ prime source of FP knowledge, person(s) who make respondents’ SRH-related decisions, availability of NGO FP activities in camp, respondents’ participation in FP programs, visiting of clinic/health facilities, talking with a health care provider. To gain further context, we also collected information on different FP methods heard and used by the Rohingya women and the main reasons for not using a contraceptive.

Data collection

Data collection began on October 14 and was completed on December 26, 2019. Data were collected using a pretested, structured, and facilitator-administered questionnaire. The questions used in the questionnaire were prepared based on a review of related literature. The questionnaire was developed in Bengali (Bangla) language applicable to the context in Bangladesh. It was not translated into the Rakhine/Arakanese language of the Rohingya people since it lacks an appropriate written form the majority of the Rohingya people in the camp are illiterate. The survey was guided and conducted by ten female data collectors who had graduate degrees and work experience in the Rohingya camp and were quite familiar with the study setting. The data collectors were fluent in the Rakhine/Arakanese language, which helped them explain the questions to the interviewees and understand the responses. Ten Rohingya women, who were known as the community leaders in the survey area, assisted with the data collection process in the camp. They helped build rapport and gain the trust of the participants. Thus, it is believed that the participants felt comfortable speaking openly and sharing issues in their personal life. The Rohingya women trust these community leaders, so therefore they agreed to cooperate and participate in the study [ 32 ]. All the recruited Rohingya women had experience working with their community. The interviews took place at different blocks of the camp. Before the survey, a pilot study was conducted among 40 Rohingya women to test the understandability of the survey and to ensure its comprehensiveness and consistency in providing the information needed for the study.

Despite the limitations encountered due to camp’s layout, privacy and confidentiality were ensured during the data collection process. The community leaders obtained permission from the respondents beforehand to ensure that the respondent would be free and comfortable to talk. Before starting the questionnaire interview, the purpose and confidentiality of the study were clearly explained to the respondents. Interviews were conducted in a quiet room of the house of the respective refugee women situated in a particular block of the camp where only the data collector and a community member were present. An appropriate level of privacy was able to be met whilst collecting the data as the male members of families generally undertake daily work during the day and children go to the learning centers, child-friendly spaces or madrasas (religious center to study Quran). Moreover, prior to the interview the respondents asked the other family members to go to another room so that they could talk with data collectors comfortably.

Measurements

KAP items having 10 items for each section were designed with a five-point Likert scale. For the FP knowledge section, the score of each positive statement ranged from 1 to 5 for ‘definitely false’, ‘probably false’, ‘do not know’, ‘probably true’ and ‘definitely true’. For the FP attitude section, the score of each positive statement ranged from 1 to 5 for ‘strongly disagree’, ‘disagree’, ‘neutral’, ‘agree’, and ‘strongly agree’. For the FP practice section, the score of each positive statement ranged from 1 to 5 for ‘never’, ‘rarely’, ‘sometimes’, ‘often’, and ‘always’. The score was reversed for negative statements. The total score of FP knowledge, attitude, and practice was the sum of the score for questions under each section respectively. In order to understand the level of FP knowledge and attitude, we categorized both variables’ scores into two levels using the mean as the cut-off value. However, five scales of each section were recoded into three categories because of the low frequency at the endpoint of the scale for the percentage distribution of respondents’ responses regarding KAP.

Statistical analysis

Descriptive statistics were used to analyze the respondents’ FP-related KAP. A linear regression analysis was performed to estimate the proportion of variance in FP knowledge, attitude, and practice based on socio-demographic, NGO, and health facility-related factors. The linear regression models included the variables with p < 0.05 in bivariate analyses (independent-samples t-test and Pearson correlations). Multicollinearity was also checked. The ANOVA values for overall FP knowledge ( F  = 64.84, p  < 0.001), attitude ( F  = 59.56, p  < 0.001), and practice ( F  = 170.36, p  < 0.001) report that the regression model was a good predictor of the main outcome variables. R 2 of each step was changed considerably, and F changes were also statistically significant ( p  < 0.001). These analyses were performed with a 95% confidence interval using SPSS 24.0. Variables with p  < 0.05 were considered statistically significant.

Socio-demographic characteristics of Rohingya women

Table 1 showed that of the 400 respondents, 210 (52.4%) were residents of Buthidong sub-district of Myanmar before taking shelter in Bangladesh. The mean age was 25.53 (± 6.34) years. More than half (51.8%) of them had no formal education and more than three-quarters (78%) were housewives. On average, the study participants had 4 (3.98 ± 2.60) children. Regarding media use, 233 (58.2%) listened to the radio and 103 (25.8%) used the internet. In addition, 181 (45.3%) women reported that NGO workers and health workers were their primary sources of FP-related information.

Different contraceptive methods heard and used by Rohingya women

Table 2 presents data on contraceptive methods that respondents had heard of and currently used. Of the Rohingya refugee women, 195 (48.7%) heard about condoms, however, only 8 (2%) of their husbands used them during the survey period. Moreover, 336 (84%) were aware of the oral contraceptive pill (OCP) and 115 (28.8%) were using it. In addition, only 42 (10.5%) heard about intra-uterine devise (IUD), 9 (2.3%) were aware of Norplant as the contraceptive, but no one had used either of the two methods. Furthermore, 356 (89%) knew about the injection Depot-Provera and 162 (40.5%) had used it during the survey.

Reasons for not using FP by Rohingya women

Figure  1 displays the distribution of the causes for not adopting contraceptive measures among the respondents (N = 102) who were given the option. More than half of them, 53 (51.96%), acknowledged that they were not using the family planning method due to their husbands’ disapproval; 47 (46.08%) were not using it as they wanted to get pregnant; 45 (44.12%) felt that using the FP method was considered as a sin; 29 (28.43%) thought that irregular sexual intercourse was a way to avoid pregnancy; 23 (22.55%) did not know how to use a contraceptive; 22 (22.57%) were worried about probable side effects; 17 (16.67%) did not want to use any; 11 (10.78%) believed that more children might bring financial solvency to the family; and 7 (6.86%) respondents felt that contraceptive usage would reduce the pleasure of sexual intercourse.

Reasons for not using contraceptive by the Rohingya women (N = 102)

Rohingya women’s access to FP programs and services

Figure  2 illustrates the respondents’ access to health services and participation in different FP-related programs. Of the 400 Rohingya refugee women, 62.8% reported participating in a FP related meeting or event organized by GoB/INGOs/NGOs, and almost three-quarters (74.5%) received FP-related interventions of government and NGOs in the camp. Furthermore, about 80% of the study participants visited a health center or facility due to FP and 68.3% talked with a health worker about FP and SRH issues.

Rohingya women’s access to FP and RH services

Rohingya women’s FP knowledge

Percentages with mean scores of Rohingya women’s FP knowledge-related items are reported in Table 3 . Of the 400 respondents, 180 (45%) were aware of the appropriate age of marriage for a girl. Only 162 (40.5%) respondents answered correctly whether taking a permanent contraceptive has any physical harm. Regarding whether contraceptive use had a negative effect on the husband-wife sexual relationship, 45.5% of respondents had appropriate information. Moreover, 63% responded correctly regarding the consequences of unintended or unplanned pregnancy. In addition, two-thirds of the participants (66.5%) answered correctly that there might be a risk for a woman if she has two births in a period of less than 2 years. In addition, Fig.  3 depicts that 223 (56%) respondents had good knowledge regarding FP.

Distribution of the study participants’ level of FP knowledge (left) and FP attitude (right)

Rohingya women’s FP attitude

Table 4 shows that only 159 (39.8%) Rohingya refugee women agreed that having two children is enough for a couple. Besides, 120 (30%) thought that using FP might be regarded as a sin, and slightly less than one-quarter (23.3%) believed that discussing FP with their husband might lead to sin. In addition, 272 (68%) believed that one should not use FP if her husband objects. Of the study participants, 57% supported the idea to bear children until a male child is born and 40% of them would express more happiness if a male child is born. More than half (52%) of the respondents agreed that having more sons would ensure a more secure life for parents in elderly age. Moreover, 216 (54%) respondents had a positive attitude towards FP.

Rohingya women’s FP practice

Table 5 showed that 43% of the respondents reported that they always felt ashamed to discuss FP and 45% were usually afraid of FP discussions with their husbands. In addition, about one-quarter felt shy while discussing FP with relatives and neighbors. About three-quarters of Rohingya refugee women regularly used contraceptives during the survey period. Furthermore, 60% of the respondents regularly obtained new contraceptives after running out of them and 62 percent continued FP use despite experiencing side effects.

Influencing factors associated with FP-related KAP

Table 6 demonstrates that Racidong in Myanmar as the region of residence (β = 0.09, t = 2.84, p = 0.005), having a profession (β = 0.10, t = 2.73, p = 0.007), having less children (β = − 0.28, t = − 7.28, p < 0.001), having a physician/nurse as the source of FP knowledge (β = 0.21, t = 6.45, p < 0.001), having GoB/INGOs/NGOs’ FP interventions at the camp (β = 0.15, t = 3.62, p < 0.001), visiting a clinic/health facility (β = 0.22, t = 4.96, p < 0.001), and talking with any health care provider (β = 0.24, t = 5.54, p < 0.001) were significantly associated with Rohingya women’s better knowledge on FP and accounted for 66% of the variation in this regard.

Furthermore, the amount of land owned in Myanmar (β = 0.11, t = 3.02, p = 0.003), having less children (β = − 0.17, t = − 3.83, p < 0.001), having a physician/nurse as the source of FP knowledge (β = 0.18, t = 4.88, p < 0.001), having GoB/INGOs/NGOs’ FP interventions in the camp (β = 0.25, t = 5.45, p < 0.001), participating in a FP awareness program (β = 0.12, t = 2.82, p = 0.005), visiting a clinic/health facility (β = 0.19, t = 3.78, p < 0.001), and talking with a health care provider (β = 0.16, t = 3.19, p = 0.002) contributed significantly to the regression model (F = 59.56, df = 4/387, p < 0.001) and appeared as predictors of Rohingya women’s more positive attitude towards FP and accounted for 56% of the variation of the outcome variable.

It was also found that, having resided in Racidong in Myanmar before coming Bangladesh (β = 0.07, t = 2.57, p = 0.010), having a profession (β = 0.07, t = 2.27, p = 0.024), having less children (β = − 0.15, t = − 4.54, p < 0.001), having a physician/nurse as the source of FP knowledge (β = 0.13, t = 4.66, p < 0.001), having GoB/INGOs/NGOs’ FP interventions in the camp (β = 0.10, t = 2.81, p = 0.005), participating in a FP awareness program (β = 0.07, t = 2.33, p = 0.020), visiting a clinic/health facility (β = 0.46, t = 12.31, p < 0.001), and talking with a health care provider (β = 0.24, t = 6.32, p < 0.001) were the most important factors influencing a more regular, healthy practice of FP and accounted for 74% variations of good FP practice.

This study assessed Rohingya refugee women’s knowledge, attitude, and practice towards FP along with the overall status of FP in the camps. Our study found that despite their familiarity with the traditional contraceptives like injections, oral pills, and condoms, most of the respondents are not familiar with the modern contraceptive methods such as IUDs and Norplant. According to local media reports, Rohingya refugee women would take oral pills given by health stations in the camps and would throw them away upon returning home. Later, when they were given the 3-month injection method they accepted it. Although contraceptive methods have been introduced among the Rohingyas who took shelter in Bangladesh since the 1990s, recently FP programs increased after a massive influx of Rohingyas into the country. Indeed, NGOs do not disseminate the information of different modern birth control methods among the Rohingya women as the women are reluctant to use them [ 3 , 26 , 33 ].

Consistent with other studies [ 34 , 35 ], our findings also demonstrate that there is a dearth of accurate and sufficient knowledge of FP among the Rohingya women living in the refugee camp of Cox’s Bazar even though they have some ideas about FP and using contraceptives. Even for women who report to be willing to pursue FP approaches, discontinuation of use may be motivated by a general feeling of uncertainty and fear, particularly about health-related side effects [ 4 ]. Away from the positive knowledge gained through education, this group is influenced by traditional religious practices [ 33 ].

Half of the respondents lack proper knowledge of whether a girl is eligible for marriage before the age of 18. Among the Rohingyas, girls are likely to get married at an early age. A previous study [ 4 ] noted a clear preference for girls but not boys for child marriage. There are some reasons behind early marriage of girls in Rohingya society [ 1 , 4 ]. Firstly, this tendency is more prevalent in families with more daughters because parents feel that more than one daughter still living with the parents is a burden, and older parents want all their daughters to get married while they are still alive. Secondly, members of the community also say different types of harsh words and pass nasty comments if more than one young girl lives with them in the household, so, the parents want to marry their daughters off as early as possible. Thirdly, as is prescribed by their faith, girls are deemed suitable for marriage until they hit puberty. Parents believe that keeping young girls unmarried at home for a long time is a sin. Fourthly, the financial insolvency of Rohingya people leads them to send their daughters to the in-laws’ house so that they do not have to bear their living costs for too long a period. Ainul et al. [ 4 ] identified some important shifts in the trends and behaviors of marriage among Rohingya refugee after displacement. Unlike Myanmar, the camps in Cox’s bazar have no age limit for marriage, consequently, Rohingya girls and boys tie the knot as early as the age of 14/15 years.

The present study found that Rohingya women have also shown interest in having more children. Our finding is supported by a previous study [ 16 ]. Lagging in their education, they still see childbirth as an achievement [ 36 ]. Half of the respondents think having more children will give them more protection and support in their old age. They believe that children are a God-given blessing and they will receive more rewards or benefits if they have more children. Getting food cards is also a factor in the camps since it is allocated to every child [ 37 ]. By showing that card, parents get various benefits, including food, medicine, and clothes. They know that they will get more food cards or help if they have more children [ 38 ]. Many of the children's food items they get with food cards are sold outside the camp for money. During the study it was also found that at the Teknaf bus station food items provided by the UN were being sold openly among the host community and tourists. Therefore, a cohort of the Rohingya families does not use contraceptives, although they are urged by the government to practice this FP method. Another reason the Rohingya population has more children may be explained by their thinking of the Myanmar government’s oppression to eradicate them ethnically [ 39 , 40 ]. Having more children can also be an attempt to sustain their existence as a nation. This assumption is also supported by media reports [ 40 ].

Our study findings also showed that more than two-thirds of the Rohingya women thought family planning methods should not be used without their husband’s approval. In Rohingya society, patriarchy prevails and women mostly obey their husbands as they regard it as a sin to do anything without their husband’s permission. Therefore, the use of CPR is low due to the husbands’ reluctance for their wives to use contraceptives [ 41 ]. In addition, according to our findings, 58% of respondents said that they should continue childbearing until the birth of a son. Besides, 40% of the respondents said that having a son is a matter of pride, whereas one-fifth attributed having daughters as a burden. Parents also have a similar feeling as arranging the marriage of a daughter costs a lot, and daughters would not be responsible for taking care of their parents in the future. On the contrary, a male child is highly desired by the Rohingya couples, as the think that boys can earn money and will be responsible for taking care of their parents later in life.

Our data also found that more than 40% were ashamed of and afraid of discussing FP with their husbands, considering it a sin. In Rohingya society, FP or birth control are perceived as a high-level taboo. Rohingya women are typically conservative due to their religious and social values. There is no positive viewpoint regarding FP or birth control in Rohingya society, and religiously it is considered an immoral behavior [ 29 ]. Those who have not used FP yet and are still reluctant to use it might be regarded as being extremely against FP. This type of people is called the hard-core resister group by Rogers [ 42 ]. A typical couple in this category would be very religious and the husband an older religious leader. A strategic communication program would need to be implemented in order to make them more open to FP methods. If nothing is done to deal with the KAP of this radical group, then it is likely that they will contribute to significant population growth in the refugee camps.

Comparing Rohingya women from the surveyed areas, the knowledge and behavior of the women from Rachidong area are better than those of the women from Maungdaw and Buthidong area as the transportation system in Rachidong is better and Rachidong people have more opportunities of commuting to the city for study and work.

According to the results, Rohingya women involved in various professions had a better KAP of FP. They usually work with various NGOs serving as the teacher for providing education and psychosocial support, community mobilizers for nutritional activities, cleaners, or day laborers. NGOs offer different training and awareness sessions for them, so their attitudes and behaviors towards FP are more positive. They are also interested in learning new things and have a better chance to communicate with the Bangladeshi staff more closely.

Women with fewer children were found to have better FP-KAP in our study. This cohort is more conscious and progressive than others as they engage and remain focused actively in various awareness programs. Consequently, they become the primary and early receivers of FP services. Family members, particularly husbands and mothers-in-law, play a key role in making decisions about a married girl’s childbearing and contraceptive options in Rohingya society [ 4 ]. Nevertheless, Rohingya women who can make their own decisions about their health have better FP-KAP. Generally, these women are more aware and self-reliant. They also have a better attitude and perspective since their husbands and families allow them to express their views independently.

We observed that the Rohingya women who received a consultation from doctors and nurses had better FP-KAP. In this case, the women’s interest in FP plays a significant role in listening carefully to the information provided by health care providers and applying it in real life. Health care providers have been able to talk to them, change their attitudes and make them regard FP in a more positive way. According to the Department of Family Planning, besides raising awareness of birth control attitudes among the Rohingya men and women, doctors and nurses working in clinics and health facilities also provide various suggestions and medicines for pregnancy, maternity, child health, and general health services. Such efforts are more significant than those of NGO health workers. Many Rohingya couples now do not want to have 10–12 children; instead, they want to limit the number of children to 4–5 [ 36 ]. Most of these programs and services have created a positive outlook on FP that makes women and girls more aware and engaged on the topic than before [ 33 ].

The Rohingya women who had visited a clinic and talked to a doctor were more likely to have better FP-KAP. Doctors and nurses play a supporting role in understanding FP. Visiting a clinic, they can observe the posters and communication materials and can be informed about different aspects of FP and maternal health issues.

The study has some limitations. Firstly, the data from the participants may have been influenced by social desirability, which could affect the validity of the outcome. Secondly, this analysis could provide a more precise understanding and a more in-depth insight if qualitative data were collected. Thirdly, the data was collected from only one camp due to inadequate research funds.

The study showed that the comprehensive FP-KAP capability of Rohingya refugee women was low. Contraceptives among the Rohingyas were unpopular, mainly due to a lack of general education and awareness of family planning. In addition, family planning initiatives among Rohingya refugees were limited by various traditional cultural and religious beliefs. Participation in the FP program, visiting a health facility, and talking with a health care provider were reported as the most significant predictors for a better FP-KAP. Therefore, designing appropriate campaigns and developing effective communication materials is important to improve this vulnerable community’s maternal health status. Accordingly, politicians, program managers, and implementers should educate and equip Rohingya women on essential FP, SRH, and maternal health-related topics through a sustainable and continuous training program. Moreover, the program should involve religious leaders in planning and implementations phases, and provide them with appropriate training so that they can play a supportive role as community leaders.

Availability of data and materials

All of the primary data has been included in the results. Additional materials with details may be obtained from the corresponding author if required.

Abbreviations

Analysis of variance

Family planning

Government of Bangladesh

International Centre for Diarrhoeal Disease Research, Bangladesh

International non-governmental organizations

Inter Sector Coordination Group

Intrauterine device

Knowledge, attitude and practice

Non-governmental organizations

Oral contraceptive pill

Standard deviation

Statistical Package for Social Sciences

Sexual and Reproductive Health

United Nations Children’s Fund

United Nations High Commissioner for Refugees

United Nations Population Fund

World Health Organization

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Acknowledgements

We thank all the participants for their support during data collection.

This work was partially funded by Zhejiang Soft Science Program (No.2021C35015), the Research and Publication Office of the University of Chittagong, Bangladesh (No. 3752/GOBE/PORI/PROKA/DOPTOR/CU/2019), China Medical Board (No. 202033) and Research Fund, Vanke School of Public Health, Tsinghua University (No. 2021ZZ004).

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Md. Abul Kalam Azad, Muhammad Zakaria & Madhab Chandra Das

Department of Communication, University of Louisiana, Lafayette, 70504, USA

Tania Nachrin

Vanke School of Public Health, Tsinghua University, Beijing, 100084, China

Institute for Healthy China, Tsinghua University, Beijing, 100084, China

Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou, 310058, China

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AKA, MZ, TN, and JX were involved in the study design and conceptualization; AKA and TN supervised the data collection; MZ, MCD, and JX performed the data extraction and analysis; AKA and MZ drafted the manuscript; MCD, TN, JX, and FC reviewed and edited the manuscript; AKA was involved in project administration; FC supervised the study. AKA and MZ contributed equally to the study and shared first authorship. All authors read and approved the final manuscript.

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Correspondence to Feng Cheng or Junfang Xu .

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The study was reviewed and approved by the Research and Publication Office of the University of Chittagong. The study was conducted in accordance with the Declaration of Helsinki, and ethical approval for the study was provided by the Ethical Review Board of the University of Chittagong (No. CU SOC-21-0003). An informed consent form by via signature or thumb-stamp was obtained from each participant.

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Abul Kalam Azad, M., Zakaria, M., Nachrin, T. et al. Family planning knowledge, attitude and practice among Rohingya women living in refugee camps in Bangladesh: a cross-sectional study. Reprod Health 19 , 105 (2022). https://doi.org/10.1186/s12978-022-01410-0

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Knowledge, attitude, and practices of family planning methods among married women from a rural area of Jaipur, Rajasthan: An observational study

Yadav r. singh.

1 Department of Community Medicine, SMS Medical College, Jaipur, Rajasthan, India

2 Department of Community Medicine and Family Medicine, AIIMS Jodhpur, Rajasthan, India

Japneet Sidhu

Somya grover, komal sakrawal.

This study was planned with the objective to assess the knowledge, attitude, and practices of family planning methods among married women and to find out the factors associated with not using the family planning method.

Materials and Methods:

This community-based cross-sectional observational study was conducted in 300 married women residing in a rural area of Jaipur, Rajasthan. Written informed consent was obtained, and data were collected using a pre-tested semi-structured questionnaire. Knowledge, attitude, and practices were summarised in proportion, and their association was measured using Chi-square test.

The mean age of the participants was 26.7 years. Most of them (88.8% women) had knowledge of at least one contraception method. Almost two-thirds had positive attitude towards contraceptive use. The most used method was oral contraceptive pills, among 17.7% of participants. Knowledge was significantly associated with educational level and caste of the participants ( P value <0.05), and practice was not significantly associated with any socio-demographic factors ( P value >0.05).

Conclusion:

Knowledge, attitude, and practices related to modern family planning methods are still not high in rural areas. The media can play a major role in increasing awareness about family planning methods. The involvement of community and family, especially spouse, should be facilitated to maximize the understanding of family planning methods.

Introduction

In 1952, India became the first nation in the world to introduce a national programme for family planning because of its fast-growing population.[ 1 ] The focus gradually shifted from clinical to reproductive child health, and the National Population Policy (NPP) of 2000 introduced a comprehensive and goal-free strategy that assisted in lowering fertility. As the programme has grown over the years, it has infiltrated every nook and cranny of the nation, including primary health centres and sub-centres in rural areas as well as urban family welfare centres and post-partum centres in urban areas. The crude birth rate (CBR), total fertility rate (TFR), and growth rate have rapidly decreased as a result of technological advancements, better health care quality, and coverage.[ 2 ]

The Indian government has made significant efforts, but there is still a persistent need for contraception. More than one in seven of all unwanted pregnancies that occur each year around the world take place in India.[ 3 ] Studies from India show that unplanned pregnancy is linked to decreased use of maternal health services and worse results for both newborn and mother health.[ 4 - 6 ] In India, according to National Family Health Survey-5 (NFHS-5, 2019–21), the birth rate for women in the 15–19 age range was 43 per 1000 women, which has reduced from 51 per 1000 in NFHS-4 (2015–16).[ 7 ]

According to the NFHS-5 report for the year 2019–21, the current use of any family planning method by married women in India aged 15–49 years was 66.7%, while the current use of any family planning in Rajasthan was found to be 72.3% with an increase of 12.6% from the reported data of 59.7% in NFHS-4. The birth interval is less than 24 months in 27% of non-first-order births (NFHS-4). Female sterilisation accounts for 37.9% of family planning (FP) technique adoption in NFHS-5.[ 7 , 8 ]

With diverse variability and urban–rural divide in Rajasthan, the unmet need of contraception varies from 4.2% to 11.2% in different regions of Rajasthan, so it needs to be studied and addressed through appropriate policy and intervention.[ 9 ] Hence, this study was conducted with the objective of assessing the knowledge, attitude, and practices regarding family planning methods among married women residing in Nayla village, Jaipur, and to find out the factors associated with not using the family planning method among married women.

Materials and Methods

This study was a community-based, cross-sectional, analytical type of observational study conducted in a rural area under Field Practice Area of Rural Health Training Centre (RHTC), attached to tertiary care facility, Jaipur. The study was conducted for a period of 12 months from December 2021 to November 2022 after approval of the research protocol from Institutional Research Review Board and Institutional Ethics Committee with reference number 1316/MC/EC/2021 dated 03/12/2021. Additional 3 months was taken for data analysis and report writing.

Aseri G et al .[ 10 ] reported the prevalence of knowledge of at least one contraception method as 80.4% among rural women. The sample size was calculated using the formula n = z 2 pq/d 2 , and taking the value of z (standard normal deviate) as 1.96 at 95% confidence interval (α =0.05), P (prevalence) as 80.4%, q (100-p) as 19.6%, and d (allowable absolute error) as 5%, a sample size of 243 was obtained. It was further rounded off to 300 as the final sample size to accommodate for attrition. All married women residing in village Nayla for more than 1 year duration in the reproductive age group (15–49 years) and who gave written informed consent to participate in the study were included in the study. Women who were non-cooperative and pregnant and did not give consent were excluded from the study.

To select the study participants for this study, first, the houses were selected using systematic random sampling technique. The total population of the study area was 5084 at the time of data collection. The number of houses in a study area was found to be 1259 in a survey conducted by ASHA. To achieve the required sample size, every fourth house was then visited after identifying the first house which was selected in the direction pointed out by spinning bottle at the centre of the study area. From each selected house, one eligible married woman was selected by simple random technique through the lottery method. In case no eligible married woman was found in the family, the next house was surveyed and so on. A total of 22 houses were there with no eligible married women. Thus, from selected 300 houses, 300 eligible married women were selected to include in this study.

Data were collected using a pre-tested semi-structured schedule; this schedule consisted of Section A , containing the socio-demographic profile of married women including age, age at marriage, religion, educational qualification, occupation, family income, and number of family members, and Section B , comprising a schedule regarding knowledge, attitude, and practices of married women about family planning methods. Questions were asked by the investigator, and response was filled by the investigator himself. Questions had ‘Yes/No’ as options; a maximum of one mark was given for ‘Yes’ as the correct response and zero mark for don’t know or a wrong response.

Data collected were entered in Microsoft Excel sheets by the investigator himself on the same day so as to minimise data entry bias if any. Continuous data were summarised in the form of mean and standard deviation. Discrete data were summarised in the form of proportion. Chi-square test was used to find out the association of knowledge and practice with socio-demographic profile. The level of significance was kept at 95% for all statistical analyses, that is, P value <0.05.

Table 1 depicts the socio-demographic profile of the participants. The mean age of the participants was 26.7 years. Most of them belonged to 18–25 years. Almost three-fourths of the participants were married between 16 and 20 years of age. One tenth of participants were illiterate. Most of the participants were homemakers.

Socio-demographic profile of the participants

*Modified BG Prasad July 2021 was used for socio-economic status

Table 2 depicts the proportion of participants with knowledge of contraceptives. Most of them had knowledge of condoms (246, 82%), followed by sterilization (242, 80.7%), oral contraceptive pills (OCPs) (238, 79.3%), breastfeeding as contraceptive (213, 71%), intra-uterine contraceptive devices (IUCDs) (206, 68.7%), safe period method (142, 47.3%), non-scalpel vasectomy (NSV) (137, 45.7%), and injection depot medroxyprogesterone acetate (DMPA) (128, 42.7%), and the least had knowledge of post-partum intra-uterine contraceptive devices (118, (39.3%).

Distribution of knowledge regarding contraception

In the current study, about two-thirds of participants (203/300) had positive attitudes towards the use of contraceptives. Most participants, 86.3% (259/300), had a positive attitude towards control of family size. Similarly, 83.7% (251/300) participants had a positive attitude towards the discussion of planning pregnancy. A significant proportion of women (60.3%, 181/300) had a negative attitude about the use of NSV in their partners.

Out of 300 participants, 32 (10.7%) were breastfeeding. Out of all eligible women, around two-third of them (62.3%, 167/268) were practicing any method of contraception; the most used method was OCPs in 53 (17.7%), followed by condoms in 32 (10.7%), DMPA in 31 (10.3%), IUCD in 30 (10%), and safe period method (rhythm method) in 21 (7%) women.

Table 3 shows that association of knowledge of contraceptives with age group of participants, age of marriage, religion, occupation, and socio-economic status was statistically insignificant ( P value >0.05) and was significant with educational level and caste of the participants ( P value <0.05). Women with higher education have higher knowledge of contraceptives, and women of general caste had higher knowledge of contraceptives compared to women of other backward class (OBC), scheduled tribe (ST), and scheduled caste (SC). Table 4 shows that association of practices of contraception with any of the socio-demographic variables was statistically insignificant ( P value >0.05).

Association of knowledge about contraceptive methods with socio-demographic variable

*Chi-square test was used for analysis

Association of practice of contraception with socio-demographic variable

This study was designed to understand the knowledge and practices of women regarding family planning methods in the rural area of Jaipur. In this study, about two-third participants were married by the age of 20 years and almost half of the participants belonged to the age of 18–25 years, which was an important finding and emphasizes that success of the family planning programme lies in focussing on this age group of participants.

In the present study, 88.3% women had knowledge about any family planning methods. Among them, maximum women had knowledge about condom (82%), followed by sterilization (80.7%), OCPs (79.3%), breastfeeding (71.0%), IUCD (68.7%), safe period method (47.3%), NSV (45.7%), Inj. DMPA (42.7%), and post-partum intra-uterine contraceptive devices (PPIUCDs) (39.3%).

This result contrasted with the study done by Daya PA et al .[ 11 ] (2018), which concluded that 56.0% women had knowledge about IUCD, 38.0% knew about permanent sterilization (38%), 21.0% knew about pills, and only 14.0% knew about condoms. Srivastav A et al .[ 12 ] (2014), in his study, reported that 71.22% women knew about contraception. In a study by Devaru JS et al .[ 13 ] (2020), the knowledge of contraception was 88.7% among women; Gupta V et al .[ 14 ] (2016) reported that all participating women knew about any contraception method with maximum knowledge of OCPs (97.7%), sterilization (95.6%), condom (92.4%), male sterilization (89.6%), and IUD 284 (89.3%). A study by Shumayla S et al .[ 15 ] (2017) found that 87% women had knowledge of contraception, which was like the present study. Knowledge of contraceptive was higher in women with higher education compared to illiterates; this indicates that education plays a significant role and education provides individuals with accurate information about contraception, including different methods, their effectiveness, and potential risks and benefits. With proper education, people can make informed decisions about their reproductive health. They learn about the importance of family planning, the consequences of unplanned pregnancies, and the various options available to them. Knowledge empowers individuals to take control of their sexual and reproductive lives, make responsible choices, and protect themselves from unwanted pregnancies and sexually transmitted infections.

In the present study, it was observed that 67.7% of women had favourable attitude towards contraceptive use. It may be because either they are willing to use birth control but not have sufficient knowledge to decide which planning methods are available and best for them or it may be the result of investigator-induced bias. Most women were in favour of controlling family size, and 83.7% were in favour of discussing their partner about a planned pregnancy. On the contrary, only 39.7% of women had favourable attitude towards the effect of NSV on sexual performance. As attitude has a significant and robust impact on practicing health behaviours, the majority of women believed that NSV will have poor effects on sexual performance. Srivastav A et al .[ 12 ] (2014) reported that 71.22% participants had favourable attitude towards contraceptive methods. In yet another study by Nisha C et al .[ 16 ] (2018), maximum participants had favourable attitude about post-partum sterilization (94.8%), followed by IUCD (13.2%), periodic abstinence (3.2%), condoms (2.8%), and OCP (2.0%). Quereishi MJ et al .[ 17 ] (2017) reported that 62% of respondents showed favourable attitude towards family planning methods; in a study by Gupta V et al .[ 14 ] (2016), 83.1% participants had favourable attitude.

Most (82.7%) of the women were discussing about the family planning method with their husband, and 26.6% women were using OCPs as the family planning method. Out of all women using contraceptive methods, 91.0% of them were satisfied with the current contraceptive method. It was observed that 90.9% women faced no problem while using the current contraceptive method, but there were a few women who faced some minor problems like bleeding (3.0%), hormonal imbalance (4.5%), and pain (1.5%). Around half (45.5%) of study participants did not use any contraceptive method. The major reasons stated for not using any contraceptive were that first, they wanted to have a child, and second, non-availability of contraceptives (36.6%), followed by rejection of conceptive use by their families (12.9%), and about 5.0% women believed that contraceptive use was against their religion. It indicates that besides having a national programme, there is non-availability of contraception for almost one-third of married women, which is a significant proportion, and 12.9% women stated opposition of families; it signifies the fact that along with married women, we have to counsel husbands and family members along with married women.

In a study of Daya PA et al .[ 11 ] (2018), it was observed that the major reasons preventing the women from using contraceptive methods were having desire to have a child (60.5%), followed by lack of knowledge among women (42.4%). In a study by Srivastav A et al .[ 12 ] (2014), 48.3% women were not practicing any contraceptive method and the rest were using contraceptives; the majority of them used sterilization (62.9%), barrier (51.2%), OCPs (45.4%), and IUDS (36.6%), and no one was using injectable contraception methods; in a study by Gahlot A et al .[ 18 ] (2017), it was revealed that condom was the most common contraceptive method in 27.2% participants, followed by IUCD in 22.8%, OCP in 21.0%, sterilization in 13.5%, and DMPA in 9.8%, but 36% participants were not using any type of contraceptive method. The most common (90.4%) practicing contraceptive method in a study by Nisha C et al .[ 16 ] (2018) was post-partum sterilization, followed by IUCD (4.4%), periodic abstinence (2.6%), condoms (1.8%), and others (0.8%). In a study by Quereishi MJ et al .[ 17 ] (2017), 53% of respondents were using any one of family planning methods.

Strengths and limitations

This study was conducted with a well-designed schedule by taking a proper sample size with proper sampling techniques and using pre-designed proformas which were validated, but there are a few limitations of the study; for example, this study was done only among married women in rural areas. Therefore, the findings of the study cannot be generalized to the whole population. Practice was evaluated as verbal responses as the women were shy to talk about family planning. Further objectives like the effect of the health education programme are not taken up.

The impact of knowledge on health behaviours has been validated in many public health areas based on the idea that the public can make “informed decisions” about health behaviours by utilising their knowledge of pertinent health issues. To increase family planning options and close the knowledge–practice gap in Rajasthan’s rural areas, government and non-government organisations should organise health education and awareness campaigns in addition to information, education, and communication (IEC) and behaviour change communication (BCC). From the time a person reaches puberty, both formal and informal education regarding family planning methods must be provided. The media can significantly contribute to raising public knowledge of family planning options. To ensure that the community, family, and spouse are involved, family planning methods should be explained as thoroughly as possible. The service provider must guarantee that family planning options are always available. Therefore, they must be inspired to do their work for the community. Health care professionals, notably front-line health workers, must play a vital role in educating the public.

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Conflicts of interest.

There are no conflicts of interest.