Knowledge, Attitude and Practice of Contraception in Rural Kashmir

Abstract

Background

Human fertility is determined by many factors such as customs, morals and habits of social groups with regard to marital obligation of life. Acceptance of family planning methods varies within and between societies and there are many factors which are responsible for such variation at community, family and individual level. Socioeconomic environment, culture and education are few of them that play a vital role. Jammu and Kashmir state in general and Kashmir valley in particular is a Muslim-dominated population with traditionally a conservative society. Apart from family customs and influence of the elders, religious background has always been behind the passive resistance, or at the best indifference towards contraception. This study makes an attempt to assess the knowledge, attitude and practice of contraception in rural Kashmir.

Objective

To assess the knowledge, attitude and practice of contraception in rural Kashmir.

Study Design

Community-based Cross-Sectional study.

Study period

December 2006 to May 2008.

Participants

1900 currently married women in the age group of 15–49 years of age.

Setting

Rural households.

Methods

1900 currently married women, aged 15–49 years, selected by multi-stage random sampling technique from three districts of Kashmir valley who were interviewed at home using a pretested oral questionnaire. The assessment of various socioeconomic and other variables made as per the available standard procedures and scales.

Analysis

Percentage, Chi square test and Bivariate analysis.

Results

Knowledge of the contraceptive methods was fairly good especially for terminal methods i.e. female sterilization (97.7 %). Main source of information on contraception was obtained from mass media (60.4 %). Contraceptive practice was significantly related to number of living children, literacy, socioeconomic status and type of family.

Conclusion

What is needed is to promote and stress contraceptive methods and their advantages using mass media approach and to explore more and more participation of private sector.

Introduction

Human fertility is determined by many factors such as customs, morals and habits of social groups with regard to marital obligation of life. Acceptance of family planning methods varies within and between societies and there are many factors which are responsible for such variation at community, family and individual level. Socioeconomic environment, culture and education are few of them that play a vital role [1]. Jammu and Kashmir state in general and Kashmir valley in particular is a Muslim-dominated population with traditionally a conservative society. Apart from family customs and influence of the elders, religious background has always been behind the passive resistance, or at the best indifference towards contraception. Acceptance of contraception by a couple is governed by various socio-cultural factors, such as religion and education of husband and wife. Mass media also plays an important role in promotion and acceptability of contraception [1, 2]. Son preference, women’s age, literacy, number of living children and number of living sons also influence contraceptive use [2]. Our country is the second most populous in the world having a rapidly growing population. Despite constant efforts by the government, unmet needs still remain. The reasons for these unmet needs have to be analyzed to help the government in formulation of appropriate policies and modified approaches. The present paper is an effort to assess knowledge, attitude and practice of contraception in Kashmir (See Tables 1, 2, 3, 4 and 5).

Table 1.

Knowledge about various contraceptive methods in the studied population

Contraceptive	No.	Percent
Female sterilization	1,856	97.7
Male sterilization	1,840	96.8
Oral contraceptives	1,739	91.5
Injectibles	1,229	64.7
Diaphragms and spercimide	1,61	8.5
Periodic abstinence	621	32.7
Withdrawal methods	824	43.4
Condoms	1,527	80.4
IUCDs	1,490	78.4

Table 2.

Source of information about contraceptives in studied population

Source	No.	Percent
Friend	432	36.3
Family member	369	31.0
Mass media	719	60.4
Husband	452	38.0
Health personnel	566	47.6

Table 3.

Main source of family planning supplies

Current method of contraception	Government hospital		Private physician		Pharmacy		Private hospital
	n	%	n	%	n	%	n	%
Female sterilization	573	88	33	5.1	38	5.8	7	1.1
Male sterlization	18	75	3	12.5	3	12.5	0	0
IUCD	34	63	8	14.8	12	22.2	0	0
Pill	13	27.7	6	12.8	28	59.6	0	0
Injectibles, diaphragms and spermicides	0	0	4	40	6	60	0	0
Condom	32	49.2	2	3.1	31	47.7	0	0
Total	670	78.7	56	6.6	118	13.9	7	0.8

Table 4.

Reasons for not using any contraceptive method

Reason	n	%
Want more children	198	27.9
Not acceptable to husband	15	2.1
Harmful for health	48	6.8
Failure to obtain desirable method	26	3.7
Breast feeding	35	4.9
Currently pregnant	90	12.7
Newly married	71	10.0
Religious reason	120	16.9
Fear of side effects	61	8.6
Indifferent attitude of health personnel	34	4.8

Table 5.

Contraception approval by society

	No.	Percent
Yes	1769	93.1
No	131	6.9

Aims and Objectives

To assess the knowledge, attitude and practice of contraception in Kashmir.

Materials and Methods

The present study was carried out in three districts of the Kashmir valley. Kashmir division was divided into six districts administratively at the time of this study. Three districts were selected by random sampling. Two blocks were selected from each district, making use of random tables, making a total of six blocks. List of villages was procured from each of the above-mentioned blocks and 2 villages were selected from each block using systematic random sampling procedure, making a total of 12 villages. List of households from the selected villages were procured and all the households were surveyed. The currently married women in 15–49 age group were included in the study. Data were collected in a standard pre-tested proformas.

Observations

Female sterilization was the most widely known method of contraception (97.7 %), followed by male sterilization (96.8 %). Knowledge of modern spacing methods was less widespread.

Mass media was the most common source of information about contraceptive methods (60 %) followed by information from health personnel (47.6 %) (See Tables 6, 7, 8, 9, 10 and 11).

Table 6.

Contraceptive advice given to other women

	No.	Percent
Friends	301	24.2
Neighbours	287	23.1
Relatives	267	21.4
All	390	31.3
Total	1,245	100.0

Table 7.

Aptitude of adoption of contraception in current users

	No.	Percent
Self-motivated willingly	767	84.4
By suggestion from others	142	15.6

Table 8.

Contraceptive use in relation to number of existing children

Contraceptive method		None		One		Two		Three		>=Four		Overall
		n	%	n	%	n	%	n	%	n	%	n	%
Permanent methods	Female sterilization	0	0	0	0	183	20.1	270	29.7	198	21.8	651	71.6
	Male sterlization	0	0	0	0	4	0.4	5	0.6	15	1.7	24	2.6
Temporary methods	IUCD	0	0	3	0.3	12	1.3	24	2.6	15	1.7	54	5.9
	Pill	4	0.4	7	0.8	17	1.9	15	1.7	4	0.4	47	5.2
	Injectibles, diaphragms and spermicides	0	0	1	0.1	7	0.8	2	0.2	0	0	10	1.1
	Natural methods	0	0	3	0.3	27	3	22	2.4	6	0.7	58	6.4
	Condom	6	0.7	10	1.1	24	2.6	12	1.3	13	1.4	65	7.2
Total		10	1.2	24	2.6	274	30.1	350	38.5	251	27.6	909	100

Table 9.

Contraceptive use in relation to woman’s literacy

Current method of contraception		Illiterate		Primary		Secondary		Higher		Overall
		n	%	n	%	n	%	n	%	n	%
Permanent methods	Female sterilization	297	32.7	172	18.9	145	16	37	4.1	651	71.6
	Male sterlization	10	1.1	7	0.8	4	0.4	3	0.3	24	2.6
Temporary methods	IUCD	14	1.5	12	1.3	16	1.8	12	1.3	54	5.9
	Pill	8	0.9	14	1.5	19	2.1	6	0.7	47	5.2
	Injectibles, diaphragms and spermicides	1	0.1	1	0.1	4	0.4	4	0.4	10	1.1
	Natural methods	12	1.3	11	1.2	20	2.2	15	1.7	58	6.4
	Condom	14	1.5	9	1	20	2.2	22	2.4	65	7.2
Total		356	39.2	226	24.9	228	25.1	99	10.9	909	100

Table 10.

Contraceptive use in relation to socioeconomic status

Current method of contraception		Class I		Class II		Class III		Class IV		Class V		Overall
		n	%	n	%	n	%	n	%	n	%	n	%
Permanent methods	Female sterilization	7	0.8	55	6.1	179	19.7	258	28.4	152	16.7	651	71.6
	Male sterlization	1	0.1	4	0.4	6	0.7	7	0.8	6	0.7	24	2.6
Temporary methods	IUCD	1	0.1	22	2.4	17	1.9	8	0.9	6	0.7	54	5.9
	Pill	1	0.1	17	1.9	11	1.2	11	1.2	7	0.8	47	5.2
	Injectibles, diaphragms and spermicides	4	0.4	2	0.2	2	0.2	1	0.1	1	0.1	10	1.1
	Natural methods	2	0.2	8	0.9	20	2.2	19	2.1	9	1	58	6.4
	Condom	4	0.4	23	2.5	20	2.2	9	1	9	1	65	7.2
Total		20	2.1	131	14.4	255	28.1	313	34.5	190	21	909	100

Table 11.

Depiction of the relation of contraceptive methods and type of family

Current method of contraception		Joint		Nuclear		Overall
		n	%	n	%	n	%
Permanent methods	Female sterilization	336	37	315	34.6	651	71.6
	Male sterlization	17	1.8	7	0.8	24	2.6
Temporary methods	IUCD	14	1.5	40	4.4	54	5.9
	Pill	10	1.1	37	4.1	47	5.2
	Injectibles, diaphragms and spermicides	3	0.3	7	0.8	10	1.1
	Natural methods	17	1.9	41	4.5	58	6.4
	Condom	18	2	47	5.2	65	7.2
Total		415	45.6	494	54.4	909	100

Majority of permanent contraceptive adopters sought contraceptive services from government hospitals (female sterilization 88 % and male sterilization 75 %). Private medical sector was the main source for oral pills (about 70 %) and injectables (100 %).

The major reason for not using contraception was need of more child (27.9 %). The next common reason observed in 17 % was because of religious reasons.

Overall about 84.4 % (767) of the studied women currently using contraceptives were using it by their will.

A significant statistical relationship was observed between the current method of contraception and number of living children (p < 0.05). With increase in number of living children there was a shift from temporary to permanent methods.

There was a significant shift (p < 0.05) from permanent method to temporary ones with higher levels of education. The decline in adopting female sterilization from 32.7 % in illiterate women was noticed to just 4.1 % among women with higher education and similar trend was observed in adopting permanent sterilization in males. There was an increasing trend in the use of most of the temporary methods with higher levels of education.

Among temporary methods, modern spacing methods were more common in higher socioeconomic groups viz. class III (5.5 %), class II (7 %) and class I (1 %). Natural methods were more common in class III (2.2 %) and class IV (2.1 %). Female sterilization was the more common method adopted by class III, IV and V (19.7, 28.4 and 16.7 %, respectively) as compared to class I and class II (0.8 and 6.1 %, respectively), and again similar trend for male sterilization was observed and the difference was statistically significant (p < 0.05).

Couples living in joint families preferred permanent methods of contraception (37 % female sterilization and 1.8 % male sterilization) to temporary methods. All of the temporary methods were used mostly by the couples living in nuclear families (4.4 % IUCD’s, 4.1 % oral pills and 5.2 % condoms).

Discussion

Knowledge of the contraceptive methods was fairly good especially for terminal methods i.e. female sterilization (97.7 %) and almost negligible information about modern spacing methods. Main source of information on contraception was obtained from mass media (60.4 %) i.e. Television and radio and health personnel (47.6 %). These results were similar to observations made in NFHS-II [3], III [4] surveys. 3/4th of contraceptive users sought contraceptives from government hospitals. Private medical sector was the source of supply for contraceptives in the remaining current users. This shows that a large section of population depends still on private sector for obtaining contraceptives in our population.

The attitude of the studied population was unfavourable as despite good knowledge of contraceptive methods about 1/4th were not using any method because of desire for more children and 17 % had religious reasons for not using contraception. Comparable results were observed by Kansal et al. in 2006 [5]. Although 93.1 % of the studied women responded that contraception is approved by their society, yet only 65.5 % (2/3rd) conveyed the contraceptive advice to others namely friends, neighbor and relatives. Whosoever got motivated for contraceptive use was primarily by self motivation (willingly). Similar results were observed by Singh et al. in 2006 [6]. Although maximum women in the studied population were not affected by contraceptive usage, only 13.5 % reported that contraception was affecting their marital life in many ways like sexual displeasure and fear of pregnancy.

Contraceptive prevalence not only varies in relation to number of living children but also shows definite shift from one type of method to another type as the number of children increase. Similar trends were observed in study by Balaiah et al. [7].

The education in general and female literacy in particular not only improves awareness but also helps in acceptance of new contraceptive techniques for spacing of children. Educated women also desire fewer children than their less educated counterparts. These trends more or less are consistent with all India NFHS-III data [4] and Saha et al. [8]. Thus an overall improvement in female literacy is likely to be the major tool in improving adoption and acceptance of family planning methods and techniques. Income is at best proxy indicator of community and improved SES of the families promote acceptance of family planning methods. Both overall national data and J&K NFHS-III [4] data also confirm these findings. Thus improving overall socioeconomic status in a community does help and motivate adoption of small family norm and hence should remain an important strategy in population control.

There was a high temporary method adoption in nuclear families compared to joint families. These trends were consistent with study by Singh et al. in 2006 [6] and strategically it may, therefore, be important to choose separate motivational/counselling approaches for acceptance of family planning in different family setups.

Conclusion

What is needed is to promote and stress contraceptive methods and their advantages using mass media approach and to explore more and more participation of private sector. A strong commitment is required from field health workers and programme managers at all levels to promote spacing methods in rural areas and extensive and continuous effort needs to be made in sensitizing the society especially those who influence the decision making, like the religious leaders, teachers and village headman.