Women's experience regarding the role of health centers in empowering them for family planning.

BACKGROUND: Nowadays, the concept of family planning has been detached from the population control and it is expressed as an essential element in women's reproductive rights, empowering them and promoting their status in society. Family planning services have an important role in fertility decisions using contraception methods in women. This study was carried out to explore the experience of women from the role of health centers in empowering them for family planning.
MATERIALS AND METHODS: This qualitative study was performed on 37 married women who were volunteer and eligible for contraception as well as 8 staffs and directors of family planning services. They were selected useing purposeful sampling method in Isfahan, Iran. Data were collected by recording discussions of focused group in 7 sessions and 5 individual interviews. Conventional content analysis was used for coding and classification of data.
FINDINGS: Participants descriptions about the role of health centers in empowering the family planning was classified into 4 main categories including: encouraging male's participation in family planning, providing comprehensive reproductive health services, expanding free services for family planning and appropriate technology for public awareness.
CONCLUSIONS: Accessibility to health centers and offering free services for family planning are not sufficient for empowering women in terms of their fertility desires. The health centers should offer comprehensive reproductive health services and provide family planning services with a new approach for helping women and men to consciously and freely make a responsible decision in order to have more control over their fertility.

INTRODUCTION

The rapid population growth is expressed in the world as the greatest obstacle in the social, economical and cultural development of nations. While, family planning is considered as a vital basis in sustainable developing of communities as it helps couples to decide voluntary, based on their knowledge and insight, about their childbearing ccording to their economical, physical and mental possibilities and make a balance between sustainable development and population growth. In the years 1960-1970, the concept of family planning was largely included population policies for controlling fertility, decreasing population growth and confining the birth. But in 1994, the concept of reproductive health and family planning were the main interests of policy makers and planners of world development in the ICPD (International Conference on Population and Development) in Cairo (1994) and since then, the concept of family planning was separated from population controlling concept and it was expressed as an essential element in reproductive rights, empowerment of women and improving women’s position in society.[1] The statement of this conference emphasizes especially on ensuring from the ability of couples in family planning, especially women’s empowerment as a prerequisite for promotion of reproductive health and family planning and this empowering must be done in a manner in which the power of decision-making, selection and childbearing is given to them in order they can execute their role and responsibility in family planning and achieving their demands in the field of fertility.[2] While, studies show that there is a clear gap between the fertility demands of women and their contraceptive behavior and also they show that 15-25 percent of women have no contraceptive behavior regardless the desire to end childbearing or delay in the next pregnancy.[3] A great amount of this gap is resulted from the inability of women in controlling the fertility and the related decisions about childbearing, as in many parts of the world; women do not have the sufficient power to make decisions freely about sex issues and contraception.

Also, women’s contraceptive choices and fertility intended is seriously affected by various socio-cultural barriers and health services quality that have been caused to their inability in accessing to their fertility plans.[4] So the role of these elements must be recognized in empowering the women for achieving their fertility demands. Especially, the accessing manner of women to the health service centers and properties of these services which affects the use of contraceptive methods and empowering the women in fertility controlling, namely, offering the family planning services, must be designed in such a way that they can gain necessarily skills for decision making and then they can reach to their fertility demands by using these services.[5] The Clinics that offer family planning services have an important role in achieving women to their fertility decisions and using of contraception methods. Women fertility behavior and their empowerment would be affective if some criteria (like selection of contraception way by clients, sufficient informing about the contraceptive methods and proper interaction between the staff and clients) are taken into serious concern in the health centers.[6] Furthermore, evaluation of studies in the field of family planning services in different regions of Iran indicate a gap between the fertility demands of women and performance of the health service centers. In a qualitative study, entitled women’s perception of the quality of family planning services in Tabriz, Iran, by Mohammad-Alizadeh et al.,[7] they showed that the family planning services with the present quality could not be able to make a proper response to the women’s needs and demands; the participants emphasized on choice right, independent decision making and respectful behavior while receiving family planning services and they asked for more involvement of their husbands in family planning and better access to treatment of complications raised from different contraceptive methods. They expected that their sexual health must be especially regarded by the health system.[7] In a descriptive study by Simbar et al.,[8] for examining the quality of family planning services from the viewpoint of Tehran’s referrers, they tried to recognize the structure, process and outcomes of family planning services. Their obtained results showed that despite adequate facilities and having educated personnel, the necessary counseling and trainings with good quality are not provided and the awareness of the clients about contraceptive methods is inadequate.[8]

In an examination of women’s perceptions from family planning services in Kerman, Iran, by Nakhaee and Mirahmadizadeh, it was found that the family planning service centers have an important role in success of women in reproductive decisions and also some factors like lack of privative environment, inadequate information about contraceptive methods and lack of access to all targeted contraceptive methods by women in these centers have been caused to dissatisfaction of women from the family planning services and defeating them in achieving reproductive decisions.[9] Then, promoting the quality of family planning services is expressed as a priority to help women to have more control over their fertility and empower them in achieving their reproductive demands; so, the specialty of providing family planning services must be regarded according to social and cultural circumstances and particularly, the services that lead to empowering the fertility decisions of women and also their success in family planning must be regarded from their viewpoint.[10]

International conference on population and development in Cairo also stated on the assurance from women’s ability in their fertility regulation as the basis of population and development programs of countries and it expresses that the women’s ability and freedom must be increased in fertility decisions by considering the great definition of women’s empowering and also their access to opportunities, control over resources and choices must be provided so that they can reach to their fertility demands.[11] Then, recognizing the role and feature of family planning services which leads the women to their reproductive demands and independent decision making in family planning is very essential.[12] This study, with a qualitative approach, was carried for exploring the women’s experience from the role of health clinics in empowering them for family planning.

MATERIALS AND METHODS

This study was carried with a qualitative approach and naturalism paradigm for exploring and discovering the experience of women from the role of health clinics in their fertility decisions and family planning.[13] Coding and grouping raw text data process was performed for discovering the categories by using conventional content analysis.[14] Participants included thirty seven married women who were eligible for contraception and 8 family planning services providers that participated in the study for 7 sessions in 5–6 person focused group discussions and 5 individual interviews.

Firstly, sampling was done by a purposeful method and then it continued with maximum variation. The women were identified using family records kept in health centers. They were called by phone, the objectives of the study were explained and then they were invited to participate in it. The discussions and interviews were arranged at health centers and their workplaces according to their preferences. Data collection continued until no new themes emerged from the data.

Data analysis: The data were simultaneously processed using conventional content analysis method. The researcher listened to focus group discussions and individual interviews were recorded and transcribed them word by word. The transcripts were read line by line, the important sentences and phrases underlined and the main ideas derived labeled as codes. Overlapping codes were assimilated and primary categorization of data was performed. Data reduction continued in all analysis units until main categories emerged.

Data trustworthiness: Credibility was enhanced through member checking, validation of emerging codes and categories in subsequent discussions and debriefings with two supervisors. Using member checking, peer checking and maximum variation of sampling attested to the credibility. To establish inter-transcripts reliability, three qualitative researchers carried out a second review. Approximately 60% of the transcript, codes and categories were rechecked and there was 90% agreement among them.

Ethical considerations: The study was approved by the University Ethics Committee. Written informed consent was obtained from study participants and the option was given to withdraw from the study at any time.

FINDINGS

37 married women who were eligible for contraceptive methods, 3 managers and 5 personnel of the providers of family planning services participated in this study. Most of them were 30–40 years old and their education status was high school or diploma. They had two children and were housewives.

4 main categories were extracted along 6 sub-categories by analyzing the description of participants. Firstly, the main categories would be introduced by using the description of participants and then, sub-categories will be presented in details by relying on their narratives.

1. The main first category is” encouraging male’s participation in family planning”

The majority of participants stated that cooperation and participation of men would increase their ability in fertility decisions, use of contraceptive methods and planning for childbearing. Providing proper conditions for couple consulting by health centers in the presence of informed and capable personnel and offering the family planning services at the workplace of men was expressed by women as the factors for strengthening the participation of men.

1-I: Couple consulting in health centers

Most of the participants expressed that men usually do not have any conscious attention to issues of family planning and the advisor of the couples can provide an opportunity for them to talk together about their fertility demands in the presence of an experienced staff and reach to a targeted consensus. Couple consulting caused men to acquire a proper knowledge about the fertility program and in fertility decisions feel more commitment and cooperation for themselves. 24 year old housewife said: “I cannot talk with my husband about family planning issues but if we are consulted in health centers, we can achieve an agreement”.

Besides, most of the participants mentioned that the responsibility for family planning is considered as a female task by men and expressed this issue as a serious barrier in their empowerment. They mentioned that absence of men in family planning centers caused men to not be able to make informed decisions on family planning issues and do not regard the participation and execution of family planning as their responsibilities. A 38 year old housewife said:

“Men make the final decision about childbearing in our community but they don’t undertake the contraceptive responsibility”.

The participants emphasized on the necessity of setting and staff facilities in health clinics for providing family planning advice to new couples that are going to marry and expressed the continuation of such services as a factor to value women ideas in the field of family planning issues and increasing woman decision making power and their control over the fertility programs. A 26 year old housewife said: “If my husband and I frequently had come to health center from the early stages of our marriage and took advice and information about fertility issues, my husband would pay more attention to my ideas and decisions.”

1-2: Calling up the men for participating in family planning services

Most of the participants expressed that men do not have time for receiving family planning services because of their job involvements, so, a situation must be provided for addressing men in family planning services by health centers and these services must be offered to men in their workhouse if possible. Offering family planning in morning shift by women personnel, lack of men personnel and physical environment for service offering to men makes the family planning to be considered as a responsibility for women and most of family planning responsibilities are taken by women. So, existence of family planning health centers in different hours of day with men personnel is advised. A middle manager of family planning services said:

“Providing family planning services in the morning by female staff in health centers can induce more responsibility for contraception in women. Men are often busy with their job and even if they want to participate in these programs they are not allowed, so they don’t have any opportunity for participation.”

2. The main second category is “providing comprehensive reproductive health services”

Some of the participants referred to the more attention of health centers to the other reproductive health needs of women and they stated that nowadays, the couples and community are adopted the less-child approach and the health system must provide the other needs of the couples like their sexual health by expanding its services for men and women. Also they stated that family planning services must consider the fertility issues of other age groups especially teenagers and youths before their marriage.

2-I: Providing sexual health services

Most of the participants introduced the health centers as a safe and reliable environment for counseling about their sexual health needs and also emphasized on sexual training but they also expressed that the physical environment of these centers and insufficient ability of the personnel cause failure in acquiring appropriate information about sexual problems and prevention from sexually transmitted disease. The participants expect that their other reproductive health needs are considered along offering the family planning services. A 32 year old housewife said:

“When I go to the health center and ask some questions about sexual issues, there is no one to response and they only offer contraceptive methods”.

2-2: Planning services for teenagers and youths

The participants considered insufficient school training programs and also parents’ knowledge deficit for adolescence training in reproductive issues. They expected health centers to seriously help the promotion of reproductive health in puberty period by offering these services through trained personnel. Also, the participants stated that the marriage age has been increased and so, there is more need for offering reproductive health services for this age group. A 41 year old housewife said:

“I have two teenage girls that have so many questions about fertility issues but they feel ashamed to talk with me and also I don’t have proper information about that. Health centers must give services to them.”

3. The main third category is “expanding free services in family planning”

Most of the participants mentioned the expanding of the present free services of health clinics for achieving of women to family planning decisions in order to both free charge treating the side effects of contraceptive methods and increasing the number of free contraceptive methods in health centers.

3-I: Free treatment of complications arose from contraceptive methods

Participants stated, although the services related to contraceptive methods are free but the health centers do not have sufficient personnel for complete treatment of the complications of contraceptive methods and women must undertake the charges of their frequently refereeing to physicians for treatment and most of them were housewife and did not have the financial ability for paying the charges of treatment. They expected health centers to empower women in reaching to their family planning decisions by expanding free services and using of expert personnel for treating complications of contraceptive ways. A 42 year employed woman said:

“Health centers provide free contraceptive methods but they cannot treat the complications of it and frequently they refereed us to physicians that charge more.”

3-2: Diversity of contraceptive methods

Participants stated that increasing the number of free contraceptive methods in health centers is considered as an important factor in the success of women in selection of an effective contraceptive method and reaching to fertility desires. They mentioned on the limitation of the present contraceptive methods in the health clinics and they stated that there are various contraceptive methods with less complication that are presented in the private clinics and women are not able to undertake their expenses. A 30 year old housewife said:

“In the health center, there are a few limited contraceptive methods that are not suitable for me and I can’t undertake the expenses of my desired methods in the private clinics.”

4. The main forth category is “appropriate technology for public awareness”

Most of the participants considered the awareness of their fertility right and contraceptive methods as an important factor in planning their fertility programs. Furthermore, they expressed that increasing of society’s awareness cause acquaintances and relatives that are effective on the fertility decision of couples behave more consciously. They expected from the health clinics to design training software proportional with the social-cultural values for different age groups. A 32 years old housewife said:

“In the firstly stages of my marriage I was looking for information about contraceptive methods but I couldn’t find any proper book or CD in the health centers.”

Some of the other participants expressed that the school and TV programs have a serious role in forming the social status of decision making and empowerment of women in the reproductive issues. Health centers must use properly from the capabilities of these organizations through an effective coordination in order to offer appropriate information to the targeted groups. A 34 years old housewife said:

“When a girl learns the decision making and self--confidence skills at the school then she would be able to take proper decisions about her family planning in future.”

DISCUSSION

This study was carried in order to explain the experience of women from the role of health centers in empowering them for family planning. Categories appeared such as, encouraging men’s participation in family planning, providing comprehensive reproductive health services, expanding free services for family planning and appropriate technology for informing the society that show the properties of family planning services that can cause the increase of women’s decision making power in family planning issues and help them in selecting and reaching to their fertility desires.

In this study, easily physical access to the existing free family planning services could not cause sufficient empowering of women in order for them to reach their fertility desire and choices because the participants will have the feeling of empowerment in family planning when responsibility is taken by couples with a mutual consent and men consciously support their wife along the period of using contraceptive methods. Indeed, family planning services must be offered in such a way in which there will be an informed consent among the couples about childbearing plan and encouraging men’s participation in family planning services. Beijing conference held in 1995 emphasized on the importance of men’s participation in taking the responsibility of contraception for improving reproductive health.[15] Obtained results of the study by Rostamian et al.[16] similarly referred to the men’s support and cooperation in family planning. Men’s awareness from the proper usage of contraceptive methods, awareness of the possible complications of the contraceptive methods, awareness of the complications of unwanted pregnancies and ultimately joint decisions about childbearing, all were proofs of men’s participation in family planning.[16] In a study by Mutambirwa et al. also the participants believed that a cooperative decision must be made in all the issues related with family planning and fertility in order for the couples to have a sense of control over fertility program.[17]

Also, results showed that consulting in a proper environment and in the presence of husband at the health center is considered as an important factor for cooperative decision making and increasing men’s responsibility in its execution. The participated women in a study by Mohammad-Alizadeh et al. expressed that the couples are not proficient and comfortable enough to talk about family planning and their presence in health center for counseling can cause more understanding and agreement in family planning decisions.[7] Obtained results of Da Silva et al., showed similar results that a proper situation must be provided for couple consulting in order an opportunity is provided for awareness from the needs and demands of clients and then, family planning services are planned according to the couples family planning needs.[15] The findings of Ehsanpour et al., showed that attitude is an important factor in using contraception methods and behaviors related to family planning; therefore, for reviewing the attitude of the couples, family planning counseling should be done carefully.[18]

On the other hand, addressing men for participating in family planning services is considered as another effective factor on the strengthening of the men’s participation. Since offering of family planning services by women personnel in the morning shift was the main reason for neglecting the men’s participation, so it must be tried to expand these services to the places where men are present. In a study by Rostamian et al.,[16] showed that health system itself caused decreasing of men’s participation despite the global commitment to promote gender equality because most of effective contraceptive methods are designed for women and on the other hand, the family planning services are addressed to women in their reproductive age and so, a clear separation of men is occurred from the family planning services. Even the service provider personnel are trained for providing services to women while for achieving to men’s participation in family planning both side must be addressed.[16] Obtained results from the other countries show that there is no appropriate fertility health services for men and this issue generated a complex situation in the women’s controlling over their fertility because women must try to both preserve their decision making power and draw their husbands attention.[19] The Cairo conference has a strong emphasis on the participation of men in reproductive health care system so that the healthy system of each region should offer these services to men by a good marketing because training and counseling about contraception issues increases men’s support of women’s reproductive decisions.[20]

Another category derived from the participants description analysis was offering comprehensive reproductive health services in the health centers, like the sexual health and adolescence education, which was considered as an important factor in forming the fertility programs, prevention of sexually transmitted diseases and unwanted teenagers pregnancy and they expected that sexual and reproductive services be planned and provided to the youths before their marriage along with the family planning services and adolescence education. The participants of the study by Mohammad-Alizadeh et al., refereed to the lack of reproductive health services and they believed that sexual consulting is more important than family planning consulting and the personnel of the health centers do not have the sufficient ability for these kinds of services.[7] Also, Simbar et al., confirmed the insufficient knowledge and skills of health centers in providing the sexual consulting to the clients; also, the obtained results of the other countries studies showed a similar status.[82122] Gwatkin also believed that providing the family planning services and polices must be planned with a comprehensive view and lead to the providing reproductive health services in order to empowering more of women and more control over the fertility.[1] Also, Creel et al. showed that the proper services must be offered according to the situation and needs of each clients because the women are different in their fertility demands and needs and independent decision making power.[4]

Expanding the free family planning services was one of the main categories of participants’ description analysis. They requested for free services in treating of the complications arose from contraceptive ways and increasing the contraceptive methods in health centers. From their view, expanding of these services can cause the empowering of women in achieving their family planning demands while limitation of the free services in treating the complications of contraceptive methods caused that the women undertake all of the treatment costs and lead them to using of low-cost but ineffective methods such as condoms and withdrawal that prevents them from achieving to their fertility demands and decisions. Also Qureshi and Shaikh found that lack of financial independence in women caused that they can never protect their health from facing with complications aroused from contraceptive methods and they turn to using ineffective but with less complications methods, such as withdrawal method.[23] Obtained results of a study by Abbasi Shavazi and Khademzadeh confirmed that the client beginning to use withdrawal method after experiencing the complications of modern contraceptive methods and the cost of their treatment.[24] So, side effects of contraceptive methods and the expenses for their treatment is considered as a main reason for non--using of contraceptive methods by women.[25]

The participants believed that a proper informing in society can increase general awareness about family planning and also can help to strengthen of women’s decision making power in fertility issues. They expected from the health centers to use proper technologies for training and use the abilities of schools and media effectively for training the different society’s groups. Casterline et al., in a similar finding, showed that the sufficient knowledge of women about contraceptive methods and their ability for independent decision making are considered as two main factors in achieving fertility demands and decreasing the unmet needs.[3] The participants of a study by Mohammad-Alizadeh et al., also believed that training the family planning for women in the health centers is not sufficient for their empowerment rather, this informing must be executed in all over the society in order to include all the effective ones on the fertility decisions. Also, they preferred printed or electronically software to take to their homes.[7]

This study was carried on women of Isfahan city and it should be noted that we did not aim to generalize findings to the other societies but this results are generalizable to the similar societies. According to this study, it was suggested that quantitative research should be designed in a greater population for considering the role of health centers on the ability of women in family planning.

CONCLUSION

Examination of the main extracted categories of this study shows that the present approach of healthy system in providing the family planning services requires a revise in a direction that can support from the women’s overall fertility demands and strengthen their independent decision making power in this field. Then, the management of family planning services must be in such a way that can help women in achieving their fertility demands by offering family planning services to couples, comprehensive reproductive health services and complete treatment of the complications of contraceptive methods. Also, it should strengthen the awareness of the society about the concepts of family planning and fertility right by designing proper software and more intersectional cooperation particularly with schools and media in order to help forming the women’s empowerment basis.