Prevalence, awareness and determinants of contraceptive use in Qatari women

Publication date: 2011

طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما لولأا ددعلا 11 Prevalence, awareness and determinants of contraceptive use in Qatari women A.A. Arbab,1 A. Bener 2,3 and M. Abdulmalik 4 ABSTRACT We determined the knowledge of, attitude to and practice of contraception and the associated sociodemographic factors among a representative sample 1130 Qatari married women aged 18–49 years. Data were collected by questionnaire. The mean age of the women was 32.5 (SD 7.6) years. The vast majority (94.6%) knew about contraception but of these 1070, only 694 (64.9%) were in favour of contraception. Knowledge of contraception increased with increasing level of education (P < 0.001), but decreased the lower the household income (P = 0.002). Only 511 (47.8%) women were currently using contraceptives, which was significantly associated with age, husband’s age, years of marriage, education level, income level and attitude to family planning. The most commonly known and used contraceptives were intrauterine device and pills. Friends were the most common source of knowledge about family planning method (80.0%). 1Department of Mother Child Health, 4Women Hospital and Hamad Medical Corporation, Doha, Qatar. 2Department of Medical Statistics & Epidemiology, Hamad General Hospital and Hamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar (Correspondence to A. Bener: abener@hmc.org.qa; abb2007@qatar-med.cornell.edu). 3Department of Evidence for Population Health Unit, School of Epidemiology and Health Sciences, University of Manchester, Manchester, United Kingdom. Received: 14/05/09; accepted: 27/08/09 اهمادختسا تاددمحو ،ابه يعولا ةجردو تاّيرَطَقلا ءاسنلا ىدل لملحا عناوم مادختسا راشتنا لدعم كلالما دبع ميرم ،يرنيب يرابلا دبع ،بابرأ ركب وبأ لمأ ّمضت ة ِّربَعُم ةنيع في ،ةيفارغوميد ةيعماتجا لماوع نم اهقفاري امو ،لملحا عنمب ةقلعتلما تاسرمالماو فقاولماو فراعلما نوثحابلا َسَرَد :ةـصلالخا رمعلا نأ اودجوو ،نايبتسا للاخ نم تايطعلما نوثحابلا عجم دقو .ًاماع 49و 18 ينب نهرماعأ حوارـتت نممو ،تاجوزتلما تايرطقلا ءاسنلا نم 1130 ّنك تيلالا ددع نأ لاإ .ةديج لملحا عنم لوح )%94.6( نهمظعم فراعم تناكو ،)7.6 هرادقم يرايعم فارحناب( ًاماع 32.2 غلبي ءاسنلل يطسولا ميلعتلا ىوتسم دايدزاب دادزت لملحا عنم لوح فراعلما نأ ظحولو .)%46.9 يأ( 694 زواجتي الم ،1070 ـلا ةوسنلا ءلاؤه ينب نم لملحا عنم َندّيؤي تقو في لملحا عناوم نمدختسي َّنُك تيلالا ةوسنلا ددع زواجتي لمو .)P <0.001( ةسرلأا لخد ضافخنا عم صقانتت انهأ ينح في .)P <0.001( ،لخدلا ىوتسمو ،ميلعتلا ىوتسمو ،جاوزلا تاونسو ،جوزلا رمعبو ،رمعلاب ًايئاصحإ هب ُّدَتْعُي ًاطُبارت كلذ طباتريو ،)%47.8( ةديس 511 ةساردلا .صارقلأاو بلاوللا يه اهمادختسا ثيح نمو اهنع فراعلما عويش ثيح نم لملحا عنم لئاسو رثكأ تناكو .ةسرلأا ميظنت نم ذختلما فقولماو .)%80( ةسرلأا ميظنت قرط لوح ًاعويش تامولعلما رداصم رثكأ ءاقدصلأا ناكو Prévalence et déterminants de l’utilisation de la contraception et connaissances en la matière chez les femmes qataries RéSumé Dans un échantillon représentatif de 1 130 femmes qataries mariées, âgées de 18 à 49 ans, nous avons évalué les connaissances, l’attitude et les pratiques en matière de contraception ainsi que les facteurs sociodémographiques associés. Les données ont été recueillies au moyen d’un questionnaire. L’âge moyen des femmes était de 32,5 ans (E.T. 7,6). La grande majorité (94,6 %) avait des connaissances en contraception mais sur 1 070 femmes, seulement 694 (64,9 %) y étaient favorables. Les connaissances en matière de contraception augmentaient parallèlement au niveau d’instruction (P < 0,001), et diminuaient parallèlement au niveau de revenus du ménage (P = 0,002). Seules 511 femmes (47,8 %) utilisaient alors une méthode contraceptive. Ce pourcentage était étroitement associé à l’âge, l’âge du conjoint, au nombre d’années de mariage, au niveau d’instruction, au niveau de revenus et à l’attitude vis-à-vis de la planification familiale. Les méthodes contraceptives les plus connues et les plus fréquemment utilisées étaient les dispositifs intra-utérins et les pilules. Les amies représentaient la source de connaissances la plus utilisée au sujet des méthodes de planification familiale (80,0 %). EMHJ  •  Vol. 17  No. 1  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 12 Introduction Family  planning  assists  “families  in  achieving  the  number  of  children  desired with  appropriate  spacing  and  timing,  ensuring optimal  growth  and  development of each  family member”  [1,2].  Failure  to  plan  a  pregnancy  can  adversely  affect  the health of  the  mother,  the child and  the  families as a  whole. Family planning can also protect  women  from  high-risk  pregnancies,  unsafe abortion,  reproductive  tract  in- fection (RTI) and sexually  transmitted  infections (STIs) including HIV/AIDS  [3]. The  International Conference on  Population and Development (ICPD)  defined voluntary family planning serv- ices  as  a  fundamental human  right  as  well as a couple’s right [4,5]. Gaps in reproductive health/family  planning and sexual health care account  for nearly one-fifth of  the worldwide  burden of  illness and premature death,  and one-third of  the  illness and death  among  women  of  reproductive  age  [5,6].  Large  number  of  pregnancies  and short birth interval cause the health  risk  to  rise [7,8]. The total  fertility  rate  (15–49) years  in Qatar  for  the  last 2  years was 2.3, but it was 3.4 in 2001 [9].  By reducing the number of pregnancies  that women have  in  their  lifetime,  the  risk of maternal mortality and morbidity  is reduced considerably [10]. Education can bring about appro- priate behavioural changes and improve  participation  in  the use of  family plan- ning [3]. Free choice and promotion of  a wide range of effective contraceptives,  including  responsible counselling, will  improve  the  quality  of  reproductive  health/family planning  services  [11].  This will avoid unplanned pregnancies,  reduce complications, injury and of ma- ternal mortality could fall by one-fourth  [3]. The United Nation Family Planning  Association (UNFPA) have stated that  1  in 3 deaths  related  to pregnancy or  childbirth could be avoided if all women  had access  to voluntary contraceptive  services,  that  is,  some 175 000 women  each year could be saved [12]. Johns Hopkins  School  of  Public  Health studied the relationship between  fertility and contraceptive use of  some  100 countries  surveyed  in  the 1990s.  Results showed that in countries where  contraceptive prevalence  is  high,  the  total  fertility  rate (TFR)  is  low; where  contraceptive prevalence  is  low, TFR  is high [13]. The latest TFRs posted by  WHO  in  the Core Health  Indicators  database  show  that  there was  a  large  decrease in the TFRs of the countries of  the Gulf Cooperation from the 1990s to  2005 [14,15]. Family planning services are sensitive  to cultural conditions and background.  While  these  services  are  available  in  Qatar, there is little information on their  uptake and  the use of  family planning  methods by Qatari women. The aim of  this  study  therefore was  to determine  the knowledge of and attitudes towards  contraceptives  ,  and  the determinants  of  contraceptive  use  among  Qatari  women. Such information will be useful  to maternal  and  child  health  policy- makers  for  future planning and organi- zation of family planning services. Methods Study design This was a prospective cross-sectional  study based  in  the primary health care  (PHC) clinics of Qatar. The survey was  conducted only among Qatari married  women aged 18–49 years old who had  not reached menopause. Sampling size and sampling procedure In order to secure a representative sam- ple of  the  study population,  the  sam- pling was  stratified with proportional  allocation  according  to  stratum  size.  Stratification was based on geographical  location. The  sample  size was  deter- mined with the a priori knowledge that  the  prevalence  of  family  planning  in  Qatar is similar to that previous reports  [16] (43%) about the married Qatari fe- male population, and allowing an error  of 2.5% and 95% confidence limits. Thus  the  sample  size needed  to achieve  the  objectives of our study was estimated to  be 1300 subjects. A  multistage  stratified  cluster  sampling design was developed; Qa- tar was divided  administratively  into  21 primary health  centres  (PHCs)  in  terms of number of  inhabitants. Then  the 11 PHCs visited mostly by Qatari  women  (8 urban  and 3  semi-urban)  were selected; the remaining 10 PHCs  were excluded from our survey. The 11  selected PHCs represented geographi- cally, east, west, north, south and central  locations of the country and hence were  representative of the Qatari population.  The women were selected by simple ran- dom sampling among married Qatari  women aged 18–49 years registered and  attending the PHCs for various medical  conditions. Qualified nurses and health  educators were trained to interview the  women and complete a questionnaire.  The interviewers explained the purpose  of the study to the possible participants  and assured  the confidentiality of  the  data;  those willing  to participate gave  verbal informed consent. The  study  was  carried  out  from  April 2008  to October 2008 after get- ting approval  from the Medical Ethics  committee of the Hamad Medical Cor- poration. Data  collection was  carried  out  according  to a  schedule  for PHC  centres in the 7-month period.  Questionnaire and interview The  instruments used  for data collec- tion was designed  in English and  later  translated  to Arabic by  a professional  translator and reviewed for consistency  by  the  investigators. The questionnaire  included sociodemographic character- istics of the participant and her husband,  followed  by  items  related  to  socio- economic  status,  pregnancy  history,  knowledge of  contraception,  attitude  towards contraception and current use  طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما لولأا ددعلا 13 of  contraception. The  questionnaire  also included some items to determine  the causes for use and reasons for avoid- ing contraception. Breastfeeding, withdrawal, safe peri- od and isolation were defined as natural  family planning methods.  Intrauterine  device (IUD) (the loop) is classified as  medical methods. Vaginal cream/sup- plement, pills, injectable contraceptives,  tubal ligation, condoms and emergency  contraceptive were defined as modern  methods of family planning. The questionnaire was pre-tested  for validity and reliability.  It was  tested  to check if it was easy for the interview- ers  to understand  the  instructions and  flow of questions. Prior  to pre-testing  in the field, the interviewers underwent  training and were provided with instruc- tions about the survey. Data analysis The Student t-test was used to ascertain  the significance of differences between  mean values of 2 continuous variables  and  the Mann–Whitney  test was used  for  nonparametric  distribution. Chi- squared  analysis  was  performed  to  test  for  differences  in  proportions of  categorical variables between 2 or more  groups.  Spearman’s  correlation  coef- ficient was used to evaluate the strength  of concordance between variables. P < 0.05 was considered as the cut-off value  for statistical significance. Results A  total  of  1300 Qatari women were  approached and 1130 consented to par- ticipate  in  this  study, giving a  response  rate  of  86.9%. Of  these,  170 women  were excluded, either due to incomplete  questionnaires or  they excused  them- selves before completing  the question- naire due to lack of time. The mean age of  the participating  women was 32.5  [standard deviation  (SD)  7.6]  years.  Table  1  shows  the  sociodemographic  and  basel ine  characteristics of  the  study  sample by  knowledge, attitude and practice of fam- ily planning. The majority of the women  (1070, 94.6%)  reported  that  they had  heard about contraceptives  and men- tioned one or more. Women under 25  years of  age were more  likely  to  lack  knowledge of  family  planning 28.3%  compared  to  14.7%  in  the  same  age  group who knew (P = 0.036). Knowl- edge of family planning was also associ- ated with educational  level; knowledge  increased with increasing level of educa- tion (P < 0.001). Moreover in the lowest  income group, 40% of  the women did  not  know about  contraception  com- pared with 19.8% who did (P = 0.002). Of the 1070 women who knew about  contraceptives, 376 (35.1%) expressed  an unfavourable attitude towards them  (Table 1). More women over 40 years  were  not  in  favour  of  contraception  compared to those who viewed favour- ably in the same age group: 25.8% versus  17.3% respectively (P = 0.003). The hus- band’s age also played a significant and  similar  role  in  the participant’s attitude  (P = 0.005). Longer duration of mar- riage was also associated with a negative  attitude  towards  family planning (P < 0.019). Education was also associated  with  attitude  to  contraception: more  illiterate  (12.0%) and primary-school  educated  (21.5%)  women  were  not  in  favour of  contraception compared  to  women  with  secondary  school  (5.6%) or  college  (14.8%) education  (P < 0.001). Women with a history of  abortion were more likely to be against  contraception than those with no such  history (P < 0.001). Only 511 women out of  the 1070  women who knew about  family plan- ning methods were currently using any  family planning method (Table 1). The  practice of family planning was strongly  associated with women  aged  30–39  years and husband’s age group between  30–39 years (P = 0.001 and P = 0.017  respectively). The practice was more  common among women who had been  married  for 5–14 years – 44.8% using  contraception compared  to 38.3% not  using (P < 0.001). Table 2 gives  the  factors  related  to  attitude  towards and practice of  family  planning methods. Having a history of  abortion was lower among women who  were  in  favour of  contraception com- pared with women who were not in fa- vour (33.9% versus 44.7% respectively)  (P < 0.001). Significantly more women  in  favour of  and using  contraception  had husbands also  in  favour of contra- ception and discussed their choice with  their husbands (P < 0.001). Over 80%  of the women who were in favour of and  using a contraceptive method  thought  they needed more  information on  the  methods. Modern methods of family planning  (67.7%) were more  commonly prac- tised  among  those who currently use  family planning method (Table 3). The  use of traditional or natural method was  35.4%. IUDs (32.9%) and pills (30.1%)  were the most common specific meth- ods  identified while condoms (7.8%),  breastfeeding  (4.5%),  withdrawal  (4.5%)  and  injectable  contraceptives  (2.7%) were  the  least common  in cur- rent practice with  the studied women.  Most of  the women who currently use  contraceptives  (71.0%)  mentioned  child  spacing  as  the  most  common  reason  for using  them, while very  few  (17.6%)  women  did  not  want  have  more children. In addition, 10.8% of the  women used contraception on a physi- cian’s  advice while only 0.6% women  use  contraception  for  economic  rea- sons. Only 15.9% of  the women who  currently used contraceptives  reported  experiencing one or more  side effects  from  the method. The most common  complications identified by the women  were bleeding (4.1%), severe headache  (3.1%),  abdominal  pain  (2.3%)  and  vaginal discharge (2.0%). Figure 1  shows knowledge of  the  type of family planning method among  women who had heard of  family plan- ning method. Women mostly  knew  about pills (90.0%) and IUDs (89.1%).  EMHJ  •  Vol. 17  No. 1  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 14 Ta bl e 1 So ci od em og ra ph ic a nd b as el in e ch ar ac te ri st ic s of th e st ud y sa m pl e by k no w le dg e, a tt itu de a nd p ra ct ic e of fa m ily p la nn in g (F P) Va ri ab le K no w a bo ut FP D on ’t kn ow ab ou t F P P- va lu e In fa vo ur o f FP N ot in fa vo ur of F P P -v al ue Pr ac ti se F P D on ’t pr ac ti se F P P -v al ue N o. (% ) N o. (% ) N o. (% ) N o. (% ) N o. (% ) N o. (% ) (n = 10 70 ) (n = 6 0 ) (n = 6 94 ) (n = 3 76 ) (n = 5 11 ) (n = 5 59 ) A ge (y ea rs ) < 25 15 7 (1 4. 7) 17 (2 8. 3) 10 2 (1 4. 7) 55 (1 4. 6) 51 (1 0 .0 ) 10 6 (1 9. 0 ) 25 –2 9 27 3 (2 5. 5) 13 (2 1.7 ) 0 .0 36 19 5 (2 8. 1) 78 (2 0 .7 ) 0 .0 0 3 13 8 (2 7.0 ) 13 5 (2 4. 2) 0 .0 0 1 30 –3 9 42 3 (3 9. 5) 18 (3 0 .0 ) 27 7 (3 9. 9) 14 6 (3 8. 8) 21 6 (4 2. 3) 20 7 (3 7.0 ) 40 –4 9 21 7 (2 0 .3 ) 12 (2 0 .0 ) 12 0 (1 7.3 ) 97 (2 5. 8) 10 6 (2 0 .7 ) 11 1 ( 19 .9 ) H us ba nd ’s ag e (y ea rs ) 25 –2 9 20 9 (1 9. 5) 17 (2 8. 3) 14 0 (2 0 .1) 69 (1 8. 4) 82 (1 6. 0 ) 12 7 (2 2. 8) 30 –3 9 45 2 (4 2. 2) 19 (3 1.7 ) 0 .0 75 31 5 (4 5. 4) 13 7 (3 6. 4) 0 .0 0 5 23 4 (4 5. 8) 21 8 (3 9. 0 ) 0 .0 17 40 –4 9 40 9 (3 8. 2) 24 (4 0 .0 ) 23 9 (3 4. 4) 17 0 (4 5. 2) 19 5 (3 8. 2) 21 4 (3 8. 3) Ye ar s m ar ri ed < 5 27 0 (2 5. 2) 21 (3 5. 0 ) 18 5 (2 6. 7) 85 (2 2. 6) 10 1 ( 19 .8 ) 16 9 (3 0 .2 ) 5– 14 44 3 (4 1.4 ) 17 (2 8. 3) 0 .0 97 29 8 (4 2. 9) 14 5 (3 8. 6) 0 .0 19 22 9 (4 4. 8) 21 4 (3 8. 3) < 0 .0 0 1 ≥ 15 35 7 (3 3. 4) 22 (3 6. 7) 21 1 ( 30 .4 ) 14 6 (3 8. 8) 18 1 ( 35 .4 ) 17 6 (3 1.5 ) Ed uc at io na l l ev el Ill ite ra te 84 (7 .9 ) 18 (3 0 .0 ) 39 (5 .6 )† 45 (1 2. 0 ) 24 (4 .7 ) 60 (1 0 .7 ) Pr im ar y 18 4 (1 7.2 ) 14 (2 3. 3) < 0 .0 0 1 10 3 (1 4. 8) 81 (2 1.5 ) < 0 .0 0 1 86 (1 6. 8) 98 (1 7.5 ) 0 .0 0 2 Se co nd ar y 35 1 ( 32 .8 ) 16 (2 6. 7) 23 9 (3 4. 4) 11 2 (2 9. 8) 17 2 (3 3. 7) 17 9 (3 2. 0 ) C ol le ge /u ni ve rs ity 45 1 ( 42 .1) 12 (2 0 .0 ) 31 3 (4 5. 1) 13 8 (3 6. 7) 22 9 (4 4. 8) 22 2 (3 9. 7) Em pl oy m en t s ta tu s W or ki ng 47 2 (4 4. 1) 20 (3 3. 3) 31 7 (4 5. 7) 31 7 (4 5. 7) 0 .16 1 24 1 ( 47 .2 ) 23 1 ( 41 .3 ) 0 .0 55 N ot w or ki ng 59 8 (5 5. 9) 40 (6 6. 7) 0 .10 1 37 7 (5 4. 3) 15 5 (4 1.2 ) 27 0 (5 2. 8) 32 8 (5 8. 7) A ve ra ge m on th ly in co m e (Q R ) a < 12 0 0 0 19 2 (1 9. 8) 20 (4 0 .0 ) 11 3 (1 7.8 ) 79 (2 3. 4) 76 (1 6. 4) 11 6 (2 2. 8) 12 0 0 0 –2 4 99 9 47 6 (4 9. 0 ) 20 (4 0 .0 ) 0 .0 0 2 31 3 (4 9. 3) 16 3 (4 8. 4) 0 .0 76 23 0 (4 9. 6) 24 6 (4 8. 4) 0 .0 25 ≥ 25 0 0 0 30 4 (3 1.3 ) 10 (2 0 .0 ) 20 9 (3 2. 9) 95 (2 8. 2) 15 8 (3 4. 1) 14 6 (2 8. 7) In te rv al b et w ee n la st 2 d el iv er ie s ( ye ar s) a < 1 68 (8 .0 ) 2 (4 .8 ) 46 (8 .0 ) 22 (8 .0 ) 46 (1 0 .0 ) 22 (5 .6 ) 1– < 2 28 7 (3 3. 7) 18 (4 2. 9) 0 .4 17 20 5 (3 5. 7) 82 (2 9. 7) 0 .2 13 14 8 (3 2. 2) 13 9 (3 5. 5) 0 .0 55 ≥ 2 49 6 (5 8. 3) 22 (5 2. 4) 32 4 (5 6. 3) 17 2 (6 2. 3) 26 6 (5 7.8 ) 23 0 (5 8. 8) H is to ry o f a bo rt io n Ye s 40 3 (3 7.7 ) 17 (2 8. 3) 0 .14 6 23 5 (3 3. 9) 16 8 (4 4. 7) < 0 .0 0 1 18 2 (3 5. 6) 22 1 ( 39 .5 ) N o 66 7( 62 .3 ) 43 (7 1.7 ) 45 9 (6 6. 1) 20 8 (5 5. 3) 32 9 (6 4. 4) 33 8 (6 0 .5 ) 0 .18 6 a V al id p er ce nt ag e sh ow n. Q R = Q at ar i r iy al s طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما لولأا ددعلا 15 Only 25% knew about  injectable con- traceptives,  17.1%  about withdrawal,  15.9% about condoms and 11.3% about  the safe period. Friends  were  the most  common  source  of  knowledge  about  family  planning methods among  the women  (80.0%), followed by physicians (35.8%)  and  relatives (34.8%). Health workers  (12.6%),  teachers (2.7%) and husband  (0.9%)  were  uncommon  sources  of  knowledge about family planning. On  the  other  hand, women who  were  not  currently  using  any  family  planning method either wanted to have  more  children  (34.5%)  or  believed  that  contraceptives  have major  side- effects (14.7%). Some women did not  use contraceptive methods because of  their husband’s objection (7.0%) or for  medical  reasons  (6.4%). Few women  who did not use contraceptives consid- ered it to be against their religious beliefs  (3.0%) (Figure 2). Discussion Our  study  shows  that  the vast major- ity of women (1070, 94.6%) had heard  about  family  planning methods  and  knew one or more method; intrauterine  device and pills  (30.1%) were  the  two  methods most commonly known and  Table 2 Factors related to attitude and practise of family planning (FP) Variable In favour of FP Not in favour of FP P-value Practise FP Do not practise FP P-value No. (%) No. (%) No. (%) No. (%) (n = 694) (n = 376) (n = 511) (n = 559) History of abortion 235 (33.9) 168 (44.7) < 0.001 182 (35.6) 221 (39.5) 0.186 Have a child who died 21 (3.0) 15 (4.0) 0.404 19 (3.8) 17 (3.3) 0.667 Husband in favour of FP 598 (86.2) 141 (37.5) < 0.001 453 (88.6) 286 (51.2) < 0.001 Think it is right for married couple to decide how many children to have according to their economic situation 457 (65.9) 178 (47.3) < 0.001 342 (66.9) 293 (52.4) < 0.001 Discuss the choice of contraceptive method with husband 631 (90.9) 196 (52.1) < 0.001 479 (93.7) 348 (62.3) < 0.001 Think there is a need for more information on contraceptive methods 575 (82.9) 218 (58.0) < 0.001 412 (80.6) 381 (68.2) < 0.001 Table 3 Type of family planning (FP) method used, reasons for use, complications faced among women who practise FP (n = 511) Variable % FP method a Injectable 2.7 Withdrawal 3.7 Breastfeeding 4.5 Condom 7.8 Tubal ligation 10.4 Pills 30.1 Intrauterine device (loop) 32.9 At least one natural method 35.4 At least one modern method 67.7 Reasons for using current FP method a Economic 0.6 Physician’s advice 10.8 Do not want to have children 17.6 For child spacing 71.0 History of side-effects Reduced breast milk 0.2 Back pain 0.2 Irregular period/absence of period 0.2 High blood pressure 0.2 Anxiety 0.4 Intrauterine device rejection 0.4 Nervous/heart palpitation 1.0 Got pregnant 1.2 Nausea and vomiting 1.4 Obesity 2.0 Vaginal discharge 2.0 Abdominal pain 2.3 Severe headache 3.1 Bleeding 4.1 Any side-effect 15.9 aMultiple answers were accepted thus percentages do not add up to 100. EMHJ  •  Vol. 17  No. 1  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 16 used. The knowledge of family planning  was  associated with  education  level,  increasing with  increasing  level of edu- cation. This is consistent with a previous  reported studies  in the Middle-East re- gion among Arabs [6,15–19]. Women  with  secondary education (32.8%) or  those with  college/university  educa- tion (42.1%) were more likely to know  about  family planning compared with  women with  lower educational  levels.  Furthermore,  fewer women with  lower  monthly household income knew about  contraceptives  than  those with higher  income.  As  regards use of  family planning,  illiterate women were the least likely to  practise  any  family planning method  and women with university or college  education constituted  the majority of  the sample that were currently using any  family planning method. Family plan- ning was more common among women  with higher household income which is  in agreement with  studies  reported  in  Jordan  [6], Oman  [15]  and Turkey  [17]. The  number  of  clients  with  no  children was  very  low. Considering  the  importance of  contraception be- fore a first pregnancy, the reasons why  this  group does not make use of  the  public  family planning  services needs  to be determined. More emphasis on  this  area may be needed during pre- marital  counselling. While premarital  Figure 1 Knowledge of type of family planning method among women who had heard of family planning: multiple answers were accepted thus percentage do not add to 100% (n = 1070) Figure 2 Reasons for not using any family planning method among participants who currently do no use any family planning method: multiple answers were accepted thus percentage do not add to 100% (n = 559) طسوتلما قشرل ةيحصلا ةلجلماشرع عباسلا دلجلما لولأا ددعلا 17 References Fisher AA et al. 1. Handbook for family planning operations re- search design, 2nd ed. New York, Population Council, 1991. Leke RJI. 2. Family planning in Africa south of the Sahara. Geneva Foundation for medical Education and Research (www.gfmer. ch/Books/Reproductive_health/Family_planning_Africa. html, accessed 18 October 2010). moronkola OA, Ojediran mm, Amosu A. Reproductive health 3. knowledge, beliefs and determinants of contraceptives use among women attending family planning clinics in Ibadan, Nigeria. African Health Sciences, 2006, 6:155–159. Fertility and Contraceptive use. uNICEF Statistics (4. http://un- stats.un.org/unsd/demographic/products/Worldswomen/ Gender%20statistics%20sources.htm, accessed 11 November 2010). uNFPA State of World Population 2004: Reproductive Health 5. and Family Planning (www.unfpa.org/swp/2004/english/ ch6/index.htm, accessed 18 October 2010). Sueyoshi S, Al-Khozahe HO, Ohtsuka R. Effects of reproduc-6. tion norms on contraception practice among muslim women in Amman, Jordan. European Journal of Contraception & Repro- ductive Health Care, 2006, 2006, 11:138–145. Obuekwe IF, marchie CL. Family planning: a possible inter-7. vention in maternal mortality. The regional Institute; 25th Congress of the medical Women’s Association (www.regional. org.au/au/mwia/papers/full/33_flossy1.htm, accessed 18 October 2010). Population Resource Center website. Executive summary: ma-8. ternal mortality and morbidity (http://www.prcdc.org/files/ maternal_mortality.pdf, accessed 11 November 2010). Annual Heatlh Report for the year 2009, Department of Epi-9. demiology & medical Statistics, Hamad medical Corporatiojn, July 2010. Ronsmans C, Campbell O. Short birth intervals don’t kill 10. women: evidence from matlab, Bangladesh. Studies in Family Planning, 1998, 29:282–290. Atighetchi D. The position of Islamic tradition on contracep-11. tion. Medicine and Law, 1994, 13(7–8):717–725. Dharmalingam A, morgan SP. Pervasive muslim-Hindu fertility 12. differences in India. Demography, 2004, 41:529–545. Family planning for the future13. . Baltimore, Johns Hopkins School of Public Health, 1999 (Population Reports, Volume XXVII, Number 2) (Series J, Number 49) (www.infoforhealth.org/pr/ j49/j49chap11.shtml, accessed 18 October 2010). WHO Statistical Information System (WHOSIS). Core health 14. indicators (www.who.int/whosis/database/core/core_se- lect.cfm, accessed 18 October 2010). Al Riyami A, Afifi m, mabry Rm. Women’s autonomy, educa-15. tion and employment in Oman and their influence on contra- ceptive use. Reproductive Health Matters, 2004, 12:144–154. Al-Jaber K, Farid Sm. 16. Qatar Family Health Survey, 1998. Doha, Qatar ministry of Health. Cindoglu D, Sirkeci I, Sirkeci RF. Determinants of choosing 17. withdrawal over modern contraceptive methods in Turkey. counselling is not mandatory in Qatar  it  is  shortly be  introduced. Premarital  counselling  is  one  of  the  important  measures which can help  reduce  the  incidence of genetic diseases and can  contribute  to a healthier and happier  married life.  It  has  been  shown  that  the  rate  of  discontinuation  is  higher  among  women who have not been adequately  counselled  about  side-effects.  Similar  observations have been  reported  from  other developing countries such as Pa- kistan [18]  in  Islamic Republic of  Iran  [19] in Botswana and Tanzania [20]. In  a  study among Pakistani  rural women  [16],  a positive  attitude  towards con- traception was  found among (76%) of  the women, while 41% stated their hus- bands’ had a positive attitude  towards  contraception; this is consistent with in  our study although higher. Fertility transition in Arab countries  occurred when the use of modern con- traceptives was  sanctioned by  Islam.  Several  legal opinions  in  Islamic  juris- prudence  on  contraception  indicate  that  Islam approves contraception use  including  the non-permanent modern  methods [6,21–24]. Previous reported  studies have also explained  the contra- ception practices among Arab women  in  the context of  Islam.  In brief, Arab  women tended to avoid the use of con- traception unless they had decided they  had had a sufficient number of children,  particularly at  a certain age,  and  to  let  God  decide  on  the  ideal  number  of  children. In addition, men play a signifi- cant  role  in determining childbearing  [22]. These sociocultural norms explain  women’s  inconsistent behaviours  (i.e.  not  wanting  more  children  but  not  practising contraception) and the low ef- fectiveness of contraception (e.g.  short  duration and/or high discontinuation  rate of contraception use) [23,24].  The women who were  in  favour of  family  planning methods were  likely  also to be currently using contraception.  Moreover most of the women in favour  of  contraception believed  that  it was  right  for married couples  to decide on  how many children  to have according  to their economic situation and almost  half of those not in favour also held this  believe; this is consistent with previous  reported studies [21–24]. Conclusions Our results show that  the knowledge  of contraception was high among the  women  interviewed (95%) although  only  a  small majority had a positive  attitude  to  it (61%) and only minor- ity  (albeit  a  large  minority)  used  contraception.  Our  research  sug- gests  that  educational  programmes  are  important  to  teach how  family,  individual,  cultural  and  relationship  environments  influence  decision- making about contraceptive use and  child spacing. EMHJ  •  Vol. 17  No. 1  •  2011 Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale 18 European Journal of Contraception & Reproductive Health Care, 2008, 13:412–421. mustafa R, Afreen u, Hashmi HA. Contraceptive knowledge, 18. attitude and practice among rural women. Journal of the Col- lege of Physicians and Surgeons--Pakistan, 2008, 18:542–545. Simbar m et al. Quality assessment of family planning services 19. in urban health centers of Shahid Beheshti medical Science university, 2004. International Journal of Health Care Qual- ity Assurance Incorporating Leadership in Health Services, 2006, 19:430–442. miller K et al., eds. Indicators20. of readiness and quality: basic findings. Clinic-based family planning and reproductive health services in Africa: Findings from situation analysis studies. New York, Population Council, 1998:31–85. musallam BF. Why Islam permitted birth control. 21. Arab Studies Quarterly, 1981, 3:181–197. Petro-Nustas W. men’s knowledge of and attitudes toward 22. birth spacing and contraceptive use in Jordan. International Family Planning Perspectives, 1999, 25:181–185. Sueyoshi S, Ohtsuka R. Effects of polygyny and consanguinity 23. on high fertility in the rural Arab population in South Jordan. Journal of Biosocial Science, 2003, 35:513–526. Sueyoshi S, Ohtsuka R. Ineffective contraceptive use and its 24. causes in a natural fertility population in southern Jordan. Hu- man Biology, 2004, 76:711–722. Selected practice recommendations for contraceptive use Selected practice recommendations for contraceptive use (second edition) is one of two evidence-based cornerstones of the  World Health Organization’s new initiative to develop and implement evidence-based guidelines for family planning. The  first cornerstone, the Medical eligibility criteria for contraceptive use, 4th edition is about to be published, and offers guidance  on the safety of use of different methods. Selected practice recommendations for contraceptive use provides guidance for how  to use contraceptive methods safely and effectively once they are deemed to be medically appropriate. The document  provides selected practice recommendations based on the best available evidence and is intended to be used by policy- makers, programme managers, and the scientific community. It aims to provide guidance to national family planning/ reproductive health programmes in the preparation of guidelines for service delivery of contraceptives. Further information about this and other WHO publication is available at: http://www.who.int/publications/en/

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