Exploring the contraceptive behaviour on spacing methods among the married women of reproductive age group in a rural area of Purba Bardhaman district, West Bengal - a qualitative study.

Introduction: One of the goals of the National Population Policy 2000 was to stabilize the population at a level consistent with the requirement of national economy. Spacing methods are reversible methods of contraception. Vision FP2020 will build on policy of increasing focus on spacing services through voluntary adoption of family planning. With this background, the study was conducted to explore the spacing contraception behaviour among married women of reproductive age group.
Methods: A descriptive cross-sectional study was conducted from July to August 2018 at a rural block of West Bengal. Four subcentres from a list of total 38 subcentres in the Bhatar block were selected by Simple random sampling (SRS). A list of currently married women of reproductive age group fulfilling the inclusion criteria was prepared and 10 women of each SC were chosen randomly. In-depth interviews were conducted among selected women and a focused group discussion was conducted involving the auxiliary nurse midwife (ANMs) to elicit reasons and barriers for contraceptive use from service providers' perspective.
Results: The reasons for their current contraceptive choice were change in behaviour and, according to gender of the first baby, poor information, education, communication (IEC), personal preference, motivation by family members and health workers, religion and caste factors, fear and side effect for other methods, easy availability etc.
Conclusion: The findings reinforce the need for targeted spacing contraception promotion that includes delivery of localized contraceptive services, increase of knowledge on safety and utility of spacing methods among eligible clients, their family members and local health workers. Copyright:

Introduction

India is the second most populous country of the world and houses of almost 17.3% of the world’s protected couples and 20% of world’s eligible couples with unmet need.[1] Contraception is the intentional prevention of conception through the use of various devices, sexual practices, chemicals, drugs or surgical procedures. Spacing methods are reversible methods of contraception to be used by couples who wish to delay childbirth. Spacing methods are very important to successfully regulate the birth interval. Short birth intervals may adversely affect a mother’s health and her children’s chances of survival. The Government of India emphasizes for newly married couples to ensure spacing of 2 years after marriage and couples with one child to have spacing of 3 years after the birth of first child.[234567] Vision Family Planning 2020 will build on the current policy of increasing focus on spacing services based on the felt need of the community and ensuring couples have children by choice, not by chance.[891011121314151617181920212223242526]

With this background, the current study was conducted in a rural community of West Bengal, that is, Bhatar block of Purba Bardhaman district, in order to explore the spacing contraception behaviour of eligible mothers to facilitate identification of issues and challenges involved in FP programme implementation regarding spacing methods at grass-root level.

Materials and Methods

Study type, design, settings and study period

This is a descriptive study. The study was conducted in selected villages and subcentres of Bhatar block of Pubra Bardhaman district, WB, from July to August 2018.

Study population

Currently married women of reproductive age group registered in Eligible couple register (ECR) of subcentres were considered as study population. Each subcentre was study unit. Clients who are using different spacing methods were the best judge for finding out advantages and disadvantages of specific methods. This leads to the selection of this group among the married women of reproductive age group from their perspective as well as from the service providers’ perspective.

Objectives

The objectives of this study are to ascertain the reasons and the barriers for different contraceptive behaviour.

For eliciting reasons and barriers from service providers’ perspective, ANMs working in subcentres were considers as study population.

Inclusion criteria

A. For married women of reproductive age group:

• Women who were eligible for adoption of spacing methods and who had not adopted any permanent method till date.

• Registered married women (i.e. in ECR).

B. For ANMs:

• ANMs working in her allotted subcentre for at least last 6 months.

Sample size and sampling technique

Contraceptive use is a personal matter and people may hesitate to divulge the reasons for their choice. To explore the reasons, hence, qualitative study design was an appropriate choice. In-depth interviews were done for eliciting the reasons and barriers of contraceptive choice which might otherwise be missed. Due to resource constraint, it has been decided to incorporate 4 subcentres – 2 GP subcentres and 2 non-GP subcentres from a list of total 38 subcentres present in Bhatar block. Thus, total four subcentres were selected from the whole block as shown in [Figure 1].

Figure 1

Flow diagram showing sampling of selected Sub-centers

From the subcentres, a list of currently married women of reproductive age group fulfilling the inclusion criteria was prepared. From this list, 10 mothers of each subcentre were chosen randomly. This had been done to ensure that the expected sample size should remain around 30.

A focused group discussion (FGD) was conducted involving the ANMs of selected subcentres to elicit reasons and barriers for contraceptive use from service providers’ perspective. Total eight ANMs working in four selected SCs were selected for the FGD.

Study tools and techniques

In-depth interviews were conducted among selected eligible mothers using an in-depth interview guide. Informed consent was sought for participation and recording of the interview. They were ensured about the confidentiality and anonymity regarding the whole process and the findings of the study. A careful approach was adopted not to give away too much detail that would bias participants’ responses. Clear, simple and open-ended questions were asked and the participants were given adequate time to fully express their views.

Structure of focus group discussion involving ANMs:

Recruitment: Eight selected ANMs were recruited for the proposed FGD.

Physical arrangements.

Preparation of the FGD guide: A written list of the topics that need to be discussed in the group consisting of a series of open-ended questions was used for session conduction.

Conduct of the session: The moderator was vigilant about covering all the material in the focus group guide. A recorder recorded the complete proceedings of the FGD, the date, time, place, name and characteristics of the participants; the general group dynamics, that is, level of participation, interest etc., including the opinion of participants, their emotional reactions, language, vocabulary etc., Dr. Md. Samszumman, MD, drew a sociogram of the whole discussion and interaction. Audio-recording of FGD was also ensured. The session was lasted for around an hour and a half.

Facilitating group discussion: The session was opened with a general comment and the moderator then waited for a response.

Covering the material in the guide: Moderator was responsible for asking all of the questions in the focus group guide. Checking off the questions was done time to time and timely return to questions was skipped in the natural progression of the discussion. If any inaccurate information was stated during the FGD, a note to correct the misinformation was done but only after the FGD was over. Afterwards, however, the moderator provided the correct factual information.

Ethical approval was duly obtained from the Institutional Ethics Committee of Burdwan Medical College and approval and permission were also taken from the Head of the Institution, BMCH and local health authorities.

Data analysis

At first, the entire audiotape (both of the IDIs and FGD) was transcripted. The verbal and non-verbal cues were incorporated in the transcript to facilitate the capturing of the entire essence of the interviews and discussions. Then, the important and salient phrases that match the research question were identified from the transcript. Related phrases were assembled and subsequently were given specific codes. Codes were interpreted into various themes. Themes were undergone thematic analysis to understand the opinion, beliefs and behaviour of the study participants on the issues of spacing contraception. A narrative expression of salient quotes that surfaced during conversation was presented.

Results

Reasons

Overall reasons for their current contraceptive choice

The main reasons to choose any kind of spacing methods by eligible women of reproductive age group are the motivation and IEC given by local health workers, as shown in the statements below:

‘When the girls get married in young age … we tell them to use at least one spacing methods’ (F65)

And sometime it is due to change in behaviour and according to gender of the first baby

‘[…] change in their behaviour according to gender of first baby … male or female.’ (F71)

Reasons for individual spacing methods of choice

Reasons for oral pill as a choice of spacing method

Minimum knowledge regarding other methods:

‘Everything is with medicine […]’ (I1)

As it can be used for longer duration of time:

‘once in every night … I am taking it for long time. At least since last 5 year’ (I17)

Motivation by doctor:

‘One lady doctor prescribed pills for me that suited me […]’ (I40)

Easy availability of OP from subcentre and from health worker.

Afraid of Intra uterine contraceptive device (IUCD):

‘i was feared after seeing Copper T. So I have started to take medicine […]’ (I60)

As OP can be kept by the client personally and secretly:

“[…] it is my own thing. I can keep it myself … secretly’ (I61)

Religion factor:

‘Muslim community … OP is most popular […]’ (F14)

Reasons for IUCD as a choice of spacing method

Personal preference for IUCD:

‘I feel Copper T is better’ (I5)

Less or no side effect or problem and convenient feeling with the current IUCD use:

‘Because I never face any problem with Copper T’ (I21)

Motivation by health worker for IUCD use:

‘didi advised you to take Copper T’ (I22)

Motivation by family members:

‘…I asked my mother-in-law. She advised me that don’t take any further babies now […]’ (I53)

Motivation and initiation of IUCD in hospital:

‘ After the delivery of this baby from hospital they have given me copper T […]’ (I71)

Can be taken just after delivery:

‘[…] now PPIUCD have started. They are taking it just after delivery of the baby’ (F26)

Reasons for choosing nirodh/condom as a choice of spacing method

Minimum or no time gap between discontinuation of nirodh and pregnancy:

‘[…] discontinuation of condom brings pregnancy at once, it is liked’ (I11)

Comfortable feeling with the current practice:

‘[…]I’m comfortable and fine with the method’ (I28)

Side effect of OP:

‘I changed to condoms for side effects of oral pills’ (I26)

Condom stop spreading disease:

‘Condom won’t spread diseases’ (I27)

Safety for both partner:

‘Condom is safe for both of us’ (I30)

Sufficient free supply of condom:

‘free supply of nirodh is sufficient’ (I45)

Breast feeding mothers:

‘ breastfeeding is essential for her baby … then we tell them to use CC according to need […]’(F68)

Reasons for choosing injectable contraceptive

Very few or no side effect of injectable contraceptives:

‘No side effects or bad effects of the injections ever felt by me.’ (I36)

Barriers

Overall barriers for available spacing methods

Some barriers for using available spacing methods were found both from the FGD and in-depth interview. Those are like the following:

Prefer permanent method, that is, ligation

Using natural method or personal alertness

‘we follow the natural rules’ (F74)

Want pregnancy or male baby or motivation by family members to take early pregnancy and not to use any spacing methods till the first pregnancy to come

‘those who have a girl as first baby … the want a male baby … so they do not use any spacing methods’ (F72)

Husbands or Male partner states outside home or occasionally visit home

‘There is specially a problem for those women whose husband states outside their home … they don’t use anything’ (F75)

Waiting for newer method like Antara or Chhaya to be launched.

‘they using nothing, just waiting to launch the newer programmes […]’ (F80)

Barriers for individual spacing methods of choice

Barriers for IUCD use

Side effects:

Feeling of burning sensation in abdomen and during micturition after IUCD insertion

Massive abdominal pain

Feeling of weakness or unable to lift heavy objects

Longer duration of menstrual bleeding

Partners opposition or disliking:

‘My husband won’t like Copper-T. He said you take whatever you prefer but don’t use Copper-T.’ (I11)

Lack of IEC, fear of side effects, health apprehension and rumours:

‘Someone saying that copper T will cause cancer’ (I49)

Fear and panic of IUCD and the procedure of IUCD insertion:

‘I have gone for copper T insertion, but fly away from my bed […]’ (I66)

Accruing negative message from hospital:

‘I heard in hospital that someone got copper T. She had experienced severe bleeding […]’ (I69)

Impracticable and difficult to reach target setting for health worker by higher health authority

‘We are getting particular target for IUCD insertion from higher authority, but it is very impracticable task for us […]’ (F13)

Thread missing and patients harassments

‘[…] there is 1 to 2 thread missing happened in most of the sub-centres…and for this thread missing. The patient was so much harassed.’ (F17)

Poor quality of IUCD

‘The quality of IUCD should increase’ (F20)

Misbehaviour of staff nurses in hospitals.

Barriers for OP use

Side effect like vertigo or dizziness or white discharge

‘I felt vertigo, dizziness, so stopped taking it’ (I4)

Forgetfulness to take OP regularly or occasionally

‘I forget to take the tablet regularly’ (I7)

Apprehension for problem regarding future pregnancy

Fear of getting obese and newly married women don’t like OP

Barriers for nirodh/condom

Male partner not using it properly or regularly

Caste-wise barrier

‘no one take CC as it is a ST prevalent area […]’ (F24)

Misuse of CC from box situated outside and bachelor and adolescent are using it mostly.

‘it is said that keep it in box outside … those are misused mostly in my area’ (F45).

Barriers for newer injectable contraceptive (Antara)

Unavailability

‘We have already 10 to 12 mothers ready … just waiting to launch the programme’ (F80)

Long duration required to return fertility after stopping injectable contraceptive

‘[…] and after stopping it, 7 to 10 months may be taken to return fertility … and they have to use any other method during […]’ (F81)

Stoppage menstrual bleeding for entire duration of use or its use will stop menstruation

‘Your period will be postponed for 3 years … I think … it will be difficult to motivate them’ (F82).

Barriers for Chhaya method

Missed pills or client will forget to take the pills regularly

‘It is given to mothers hand. Invariably it will be missed.’ (F84).

Discussion

It would have been better if the study was conducted among the women who were not using any sort of spacing methods which could be because of their various problems. But this study was done among the concerned population because of the difficulties in identification of the mothers who were not using any contraceptive methods. Among the reasons the study was conducted among the present study population were to identify the obstacles or barriers in spite of which they had adopted the present contraceptive methods to enlighten them further so that their use of the current contraceptive method is scientifically enhanced.

From the current study, we could found different issues relating to reasons and barriers for using of spacing methods. But it was strongly found from this study that IEC of the clients and motivation by health worker is lagging behind. So for future planning, if we could reduce the fear due to lack of IEC, may be a relatively better result can be seen. Some issues relating to religion or caste were also found. It needed to be clarified by community participation and by the help of local community leaders. It may be tried to increase its quality control from the manufactures’ point.

The current study can enrich the primary care physician with respect to knowledge regarding the barrier of contraception and further can apply this knowledge during the counselling and prescribing the contraceptive methods. They can suggest the facility where the relevant services will the available and also can suggest to the service providers to do proper counselling and IEC.

Key findings

This study demonstrates that eligible women are using spacing methods mainly due to motivation by health workers. In spite of experiencing different problems, many are using any of the spacing methods and few are avoiding or changing to other available methods. Different barriers or reasons behind individual’s choice for spacing methods have been also found out. until the birth of two children and at-least one male child, they did not like to use any contraceptive. These findings reinforce the need for targeted spacing contraception promotion in rural India.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.