Study of unmet need for family planning in Dar Assalam, Sudan 2001

Publication date: 2005

594 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 Study of unmet need for family planning in Dar Assalam, Sudan 2001 T. Umbeli,1 A. Mukhtar2 and M.A. Abusalab1 1Department of Obstetrics and Gynaecology; 2Department of Community Medicine, Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan (Correspondence to T. Umbeli: umbelli1@hotmail,com). ABSTRACT In this descriptive study, the main objective was to determine the magnitude of unmet need for family planning among women of child-bearing age (15–49 years) in Dar Assalam. Using a detailed question- naire, we studied 530 ever-married women selected randomly through a multistage sampling technique. Current use of contraception was 21.3%. Using the Westoff model, unmet need was 30.7%. Contraceptive pills were the most commonly used method, 92%. Knowledge on contraception was 61.3% for a single method and 23.4% ≥ 2 methods. Knowledge was obtained mainly from relatives, 48.6%. Étude des besoins non satisfaits en matière de planification familiale à Dar Assalam (Soudan), 2001 RÉSUMÉ Dans cette étude descriptive, l’objectif principal était d’examiner l’ampleur des besoins non satis- faits en matière de planification familiale chez les femmes en âge de procréer (15-49 ans) à Dar Assalam. À l’aide d’un questionnaire détaillé, nous avons étudié 530 femmes ayant déjà été mariées, choisies au hasard par technique d’échantillonnage à plusieurs degrés. L’utilisation de la contraception au moment de l’étude était de 21,3 %. Mesurés au moyen du modèle de Westoff, les besoins non satisfaits étaient de 30,7 %. La pilule contraceptive était la méthode la plus couramment utilisée (92 %). Les connaissances sur la contraception étaient de 61,3 % pour une seule méthode et de 23,4 % pour deux méthodes ou plus. Les connaissances étaient obtenues principalement auprès de parents (48,6 %). 08 Study of unmet need.pmd 2/1/2006, 1:02 PM594 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 595 Introduction Family planning is an important strategy in promoting maternal and child health. It im- proves health through adequate spacing of birth and avoiding pregnancy at high-risk maternal ages and high parities. Family planning services became publicly available in the 1960s. In Sudan, services were initi- ated in 1965 and in 1985 were integrated into the primary health care system. Yet, utilization rates, 9% current use and 24% ever use, are among the lowest in the world [1]. These low rates may be the result of poor acceptance, inadequate knowledge or inaccessibility of the services in a commu- nity that is large and of such diverse cultur- al backgrounds [2]. The low levels of utilization may reflect an unmet need for family planning in the Sudanese population, which necessitates scientific documenta- tion. We aimed to assess the magnitude of unmet need for family planning and knowl- edge of contraception in Dar Assalam. Un- met need means “the percentage of fecund married women who are not using an ap- propriate method of contraception even though they do not want to get pregnant” [3]. Methods Khartoum state was chosen for this study. It is divided into 3 regions: Khartoum, Khartoum North and Omdurman. Omdur- man was randomly selected for the study. In the second stage, Ombada was random- ly selected from the 3 provinces in Omdur- man. Ombada is subdivided into 3 localities, Alamir, Abugaa and Dar Assalam, which was randomly selected for this stage. Dar Assalam is a new peri-urban area in Omdurman with a total population of 234 000, mainly the result of migrant flow from war and natural disasters. We carried out a descriptive cross- sectional study on 530 ever-married wom- en of childbearing age (15–49 years), se- lected randomly through a multistage sampling technique (8 women were ex- cluded from the original 538 selected be- cause their questionnaires were incom- plete). Official clearance for the study was ob- tained from both federal and Khartoum state ministries of health. The health centre is the main health ser- vice provider in the area, providing services for 45.8% of the population. Medical assis- tants provide 78.1% of services and the health visitor provides the other 21.9%. Supplies are received from the maternal and child health and family planning servic- es and the Sudan Family Planning Associa- tion. Only a few of the medical assistants in the study area had undergone a training programme on family planning. We select- ed 2 health centres in Dar Assalam, 1 pri- mary health care unit and 1 operated by a nongovernmental organization. Data were collected on 10 working days (08.00 to 14.00), 1 day per week over a 10-week period in 2001. Each woman was interviewed using a detailed, standard- ized, precoded questionnaire after informed consent was obtained. Information collect- ed included demographic data, use and knowledge of contraception, family size and birth spacing. Data were analysed using SPSS. Unmet need was calculated using the Westoff model, developed by Charles Westoff, which is widely used as the standard to measure unmet need [3]. In this formula- tion, the unmet need group included: all fe- cund women who were married or living in union, sexually active, not using any meth- od of contraception and not wanting to get pregnant or wanting to postpone their next birth for at least 2 years; all pregnant mar- ried women whose pregnancies were un- 08 Study of unmet need.pmd 2/1/2006, 1:02 PM595 596 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 wanted or mistimed because they were not using contraception; and amenorrhoeic women or pregnant women whose current pregnancy or recent birth was unintended and they did not want to have any more children. In accordance with the Westoff model, those in our study sample not using contra- ception were classified into 2 groups: preg- nant or amenorrhoeic and non-pregnant or non-amenorrhoeic. The pregnant or amenorrhoeic women were classified by whether: • their pregnancy was intentional (de- sired): these women did not have unmet need; • their pregnancy was unintentional (ear- lier than desired; some may have experi- enced contraceptive failure, all were in need of a method of spacing births): they had unmet need (women using contraception at the time of the study were excluded); • their pregnancy was not wanted at all at the time: they had unmet need for family planning; they needed a method to pre- vent further births. Non-pregnant or non-amenorrhoeic women were classified as fecund or infe- cund. The infecund were not at risk of pregnancy and were not in need of family planning. They included women who had no births for at least 5 years although they were not using contraception. They also included those who had secondary amen- orrhoea for at least 6 months and were not pregnant. Widows and separated women were also included in this group. The fecund were classified by whether: • they wanted pregnancy soon: these women did not have unmet need; • they wanted no more pregnancies: they had unmet need; • they wanted pregnancy later: they also had unmet need. Results The study sample was a relatively mixed group of women from different tribes and from different parts of Sudan. Of the 530 participants, 493 were currently married, 16 were widowed and 21 were separated/ divorced. Literacy was 46.2% for the women in the study group (64.5% for their husbands). Concerning knowledge of modern methods of contraception, 61.3% knew ≥ 1 method and 23.4% knew ≥ 2 methods. Only 50 (9.4%) had never heard of contraception. Their knowledge was mostly obtained from relatives, 48.6%. Level of knowledge obtained from medical personnel was low: 23.7% from health vis- itors, 10.1% from midwives and 3.1% from doctors (Table 1). Ever-use of contraception was 33.0%, current use was 21.3% and 59.1% of the study sample stated they would like to use family planning. Contraceptive pills were the commonest method in use in the study area, 92.0%. In spite of their availability, condoms and local foaming tablets were not used. The intra-uterine contraceptive device was not available in the health ser- vice area. Just over half the participants, 59.1%, said they desired a big family of > 5 chil- Table 1 Distribution of women in the study sample who knew about family planning according to source of knowledge Source of knowledge No. (n = 325) % Relatives 158 48.6 Health visitor 77 23.7 Mass media 35 10.8 Midwife 33 10.1 School 12 3.7 Doctor 10 3.1 08 Study of unmet need.pmd 2/1/2006, 1:02 PM596 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 597 dren, 38.1% wanted 4–5 children and only 2.8% said they would like a small family of ≤ 3. There was a significant association between family planning use and desired number of children (χ2 = 26.17; P < 0.001) (Table 2). There was also a significant as- sociation between family planning use and education status (χ2 = 22.96; P < 0.001) (Table 3). About 39% of the women in our sample did not know whether the health centre provided family planning or not (perceived availability). Village midwives provided family planning services to 8.5% of the population. Using the Westoff model, unmet need was estimated at 30.7% (Figure 1). Discussion In this mixed sample, knowledge on family planning, 61.3%, was consistent with that reported in the 1989/1990 demographic and health survey, 71.4% [2]. It is, howev- er, higher than that found by the Sudan Family Planning Association, 1978–80, 50.8% [4] and the safe motherhood survey of 1999, 54% [5]. These differences may be due to regional variation or efforts exert- ed by the Sudan Family Planning Associa- tion and mother and child health/family planning programmes during the past 20 years. Knowledge gained from relatives may be deficient regarding information about methods, their use, complications and rela- tion to future pregnancy. The low level of knowledge gained from medical personnel may reflect lack of proper training of med- ical service providers in the study area. In- effectiveness of the mass media in delivering knowledge (10.8%) may be re- lated to illiteracy, unavailability of mass media or lack of simple family planning messages on family planning use and birth spacing. Contraceptive pills were the common- est method in use in the study area. This may be because of their availability, afford- ability, repute and the perception by users that they produce only minor complica- tions. However, the non-use or unavailabil- ity of other methods would affect the choice. The current use rate (21.3%) is higher than that found in the 1990 demo- graphic and health survey, 9%, [2] and the safe motherhood survey of 1999, 5.4%, [5] for the whole country. In comparison, it has been reported that 50% of married women in Brazil, China, Colombia and Cos- ta Rica were using a modern method of contraception [6]. Table 2 Relationship between desired number of children and family planning use among married women of reproductive age 15–49 years in Dar Assalam, 2001 Desired number No. non-users No. users Total of children (n = 417) (n = 113) (n = 530) ≤ 3 8 7 15 4–5 140 62 202 > 5 269 44 313 χ2 = 26.17; P < 0.001. 08 Study of unmet need.pmd 2/1/2006, 1:02 PM597 598 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 Unmet need of 30.7% is consistent with that reported in the 1990 demographic and health survey, 28.9% [2]. In most surveyed countries, unmet need for family planning ranges between 20% and 30% of married women of reproductive age [7]. It is 11% in Thailand, 36% in Kenya and 37% in Rwanda [8]. In our study, unmet need was mainly for spacing of birth rather than lim- itation. Those who wanted no more chil- dren were more easily convinced or satisfied to use family planning than those who wanted to have children at some time in the future. Those who wanted children were influenced by the number and sex of their surviving children. Our findings may help in calculating the potential demand for contraception, by adding current use to to- tal unmet need. It is not easy to discuss why women with unmet need do not use contraception. Reasons may change or may not be well Table 3 Relationship between female education and family planning use married in women of reproductive age 15–49 years in Dar Assalam, 2001 Education level No. non-users No. users Total (n = 417) (n = 113) (n = 530) Illiterate 246 39 285 Elementary school 144 58 202 Secondary school 27 16 43 χ2 = 22.96; P < 0.001. Figure 1 A schematic representation of family planning use in a sample of ever-married women in Dar Assalam, 2001 (Westoff model) 08 Study of unmet need.pmd 2/1/2006, 1:02 PM598 Eastern Mediterranean Health Journal, Vol. 11, No. 4, 2005 599 defined. Many women may not state their real reason for non-use, e.g. husband’s op- position [9]. Focus group discussion may reveal attitudes and opinions and may help to explain unmet need. The possible rea- sons behind unmet need can be summa- rized as: lack of good information on family planning, difficulties with access to and quality of family planning services and sup- plies, desire for children and lack of com- munity participation. Inaccessibility inclu- des lack of supplies, non-availability of pre- ferred method, personal cost, travel time and monetary outlay. Knowledge of avail- ability (perceived availability) is as impor- tant as knowledge on family planning and is even more important than the woman’s lev- el of education [10]. Conclusion Unmet need for family planning is still high in spite of the high level of knowledge on family planning. This knowledge may be deficient or it is possible that family plan- ning services are not accessible, unafford- able or not acceptable to those with unmet need. Recommendations Unmet need could be reduced by providing an integrated family planning service and through the collaboration of service provid- ers with other medical and social service providers in the area, e.g. school teachers, social workers, women’s union leaders and religious leaders. Training of providers on information, counselling and distribution of family planning services could be included. Community-based distribution could be im- proved by expanding the role of village midwives and female teachers. Encourag- ing female providers would minimize social barriers. References 1. UNICEF. The state of the world’s children. New York, Oxford University Press, 1995. 2. Sudan demographic and health survey, 1989–1990. Ministry of Economic and National Planning, Khartoum, Sudan, 1991:33–74. 3. Westoff CF, Bankole A. Unmet need: 1990–1994. Calverton, Maryland, Macro International, 1995 (Demographic and health survey comparative reports No. 16). 4. Sudan fertility survey, 1979. Principal re- port, vol. 1. Khartoum, Sudan, Ministry of Economic and National Planning, 1982. 5. Central bureau of statistics. Sudan na- tional safe motherhood survey, 1999. In: Statistical yearbook 2000. Khartoum; Ministry of Finance and Economy, 2000. 6. Vanlandingham M, Trussel J, Grummer- Strawn L. Contraceptive and health ben- efits of breast-feeding: a review of the recent evidence. International family planning perspectives, 1991, 17(4): 131–6. 7. Westoff CF, Ochoa LH. Unmet need and demand for family planning. Colombia, Maryland, Institute for Resource Devel- opment and Macro International, 1991 (Demographic and health survey com- parative reports No. 5):43. 8. Ross JA, Frankenberg E. Findings from two decades of family planning re- 08 Study of unmet need.pmd 2/1/2006, 1:02 PM599 600 La Revue de Santé de la Méditerranée orientale, Vol. 11, No 4, 2005 search. New York, Population Council, 1993. 9. Robey B, Ross J, Bhushan I. Meeting unmet need: new strategies. Baltimore, Maryland, Johns Hopkins School of Pub- lic Health, Population Information Pro- gram, 1996 (Population Reports, Series J, No. 43). 10. Janowitz B et al. service availability and the unmet need for contraceptive and sterilization services in Sao Paolo State, Brazil. International family planning per- spectives, 1980, 6(1):10–20. There are still some 123 million women around the world, mostly in developing countries, who are not using contraception in spite of an expressed desire to space or limit the numbers of their births. An estimated 38% of all pregnancies occurring around the world every year are unintended. A woman’s ability to space or limit the number of her pregnancies has a direct impact on her health and well-being as well as the out- come of her pregnancy. In enabling women to exercise their repro- ductive rights, family planning programmes can also improve the social and economic circumstances of women and their families. The reasons why family planning needs are often not met are var- ied, but include: poor access to quality services, a limited choice of methods, lack of information, concerns about safety or side-effects and partner disapproval. WHO is currently addressing some of these needs in working to help: • improve the safety and effectiveness of contraceptives meth- ods; • widen the range of family planning methods available to women and men. Further information about WHO’s work in the area of family planning can be found at: family_planning/index.html 08 Study of unmet need.pmd 2/1/2006, 1:02 PM600 << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /All /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveEPSInfo true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile () /PDFXOutputCondition () /PDFXRegistryName ( /PDFXTrapped /Unknown /Description << /FRA <FEFF004f007000740069006f006e00730020007000650072006d0065007400740061006e007400200064006500200063007200e900650072002000640065007300200064006f00630075006d0065006e00740073002000500044004600200064006f007400e900730020006400270075006e00650020007200e90073006f006c007500740069006f006e002000e9006c0065007600e9006500200070006f0075007200200075006e00650020007100750061006c0069007400e90020006400270069006d007000720065007300730069006f006e00200061006d00e9006c0069006f007200e90065002e00200049006c002000650073007400200070006f0073007300690062006c0065002000640027006f00750076007200690072002000630065007300200064006f00630075006d0065006e007400730020005000440046002000640061006e00730020004100630072006f0062006100740020006500740020005200650061006400650072002c002000760065007200730069006f006e002000200035002e00300020006f007500200075006c007400e9007200690065007500720065002e> /ENU (Use these settings to create PDF documents with higher image resolution for improved printing quality. 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