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Research article

A.I. Mahadeen,¹ A.O. Khalil,¹ A.M. Hamdan-Mansour,² T. Sato³ and A. Imoto³

المعارف والمواقف والممارسات نحو تنظيم الأسرة بين النساء في المناطق الريفية الجنوبية في الأردن

عليا محادين، أريج خليل، أيمن حمدان منصور، توكيكو ساتو، أتسوكو إيموتو

الخلاصة: هناك نقص في المعطيات حول تنظيم الأسرة بين النساء في المناطق الريفية والنائية في الأردن. وقد استكشفت هذه الدراسة انتشار الاستفادة من المعارف والمواقف في مجال تنظيم الأسرة بين النساء الريفيات في الأردن. وأجريَت دراسة وصفية لـ 807 امرأة متزوجة في عمر 49-15 سنة في مسح منـزلي في تسع وعشرين قرية في المنطقة الجنوبية من الأردن. وكانت أكثر وسائل منع الحمل المستخدمة هي أقراص منع الحمل الفموية (%31.1)، واللوالب (%24.8)، والعزل (بسحب القضيب) (%19.5). ومن النساء اللاتي تم مقابلتهن، كان هناك %37 يلجأن حالياً إلى منع الحمل، وكان أهم مبرِّرَيْن لعدم استخدام موانع الحمل هو حمل المرأة (%11) أو قيامها بالإرضاع من الثدي (%10)، ولم تبلغ أي من النساء عن أن الحصول على موانع الحمل أو أن تكلفتها هي العائق أمام استخدامها، في حين أن معارضة الزوج أو أفراد الأسرة أو الأسباب الدينية كانت سبباً لدى أقل من %1 من النساء. ووافقت حوالي %95 من النساء على أن اللجوء إلى تنظيم الأسرة له فوائد صحية إيجابية. وتدل هذه النتائج على الحاجة إلى مزيد من التوعية بين هؤلاء النساء.

ABSTRACT Data about family planning among women in rural and remote areas of Jordan are lacking. This study explored the prevalence of use and knowledge and attitudes towards family planning among rural Jordanian women. A descriptive study was conducted with 807 ever-married women aged 15–49 years in a household survey of 29 villages in the southern region of Jordan. The most common contraceptive methods ever used were oral contraceptive pills (31.1%), intrauterine device (24.8%) and withdrawal (19.5%). Of the women interviewed, 37% were currently using contraception. Being pregnant (11%) and breastfeeding (10%) were the most reported reasons for not using contraceptives. None of the women reported obtaining supplies or the cost of them as barriers, while opposition from husband or family members or religious reasons were reported by less than 1% of the women. About 95% of the women agreed that using family planning had positive advantages for health. The results highlight some educational needs among these women.

Connaissances, attitudes et pratiques des femmes en matière de planification familiale dans le sud rural de la Jordanie

RÉSUMÉ Les données des femmes habitant dans des zones rurales et reculées de la Jordanie sur la planification familiale sont insuffisantes. La présente étude a évalué la prévalence de l'utilisation de la planification familiale par des femmes jordaniennes en milieu rural, ainsi que leurs connaissances et leurs attitudes en la matière. Une étude descriptive a été menée auprès de 807 femmes mariées ou l'ayant été, âgées entre 15 et 49 ans lors d'une enquête auprès des ménages dans 29 villages de la région sud de la Jordanie. Les méthodes de contraception les plus fréquemment utilisées étaient les contraceptifs oraux (31,1 %), les dispositifs intra-utérins (24,8 %) ou le retrait (19,5 %). Pendant l'étude, 37 % des femmes interrogées utilisaient une méthode de contraception. Être enceinte (11 %) et allaiter (10 %) étaient les raisons les plus fréquentes pour ne pas utiliser de méthode contraceptive. Aucune des femmes n'a déclaré que l'obtention des produits contraceptifs ou leur coût représentait un obstacle, alors qu'une opposition de l'époux ou de membres de la famille, ou des motifs religieux constituaient des entraves pour moins de 1 % des femmes. Environ 95 % des femmes étaient d'accord pour affirmer que le recours à la planification familiale représentait un avantage positif pour la santé. Les résultats mettent en évidence certains besoins éducatifs des femmes interrogées.

¹Department of Maternal and Child Health Nursing, Faculty of Nursing, University of Jordan, Amman, Jordan (Correspondence to A.I. Mahadeen: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). ²Psychiatric and Mental Health Nursing, Department of Community Health Nursing, Faculty of Nursing, University of Jordan, Amman, Jordan. ³The Integrating Health and Empowerment of Women in the South Region Project, Amman, Jordan.

Received: 28/04/10; accepted: 22/07/10

EMHJ, 2012, 18(6): 567-572

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Introduction

The literature provides considerable baseline data on the benefits of family planning on women’s health. The practice of family planning helps in reducing the rates of unintended pregnancies, of maternal and child mortality and of induced abortions [1]. In addition, using contraceptives has been shown to promote a woman’s sense of autonomy and increase her ability to make decisions in other areas of her life [2–4].

Reproductive health for a woman includes her ability to space, delay or limit children, as well as her experience with infertility, child loss or planned or unplanned childlessness [2,3]. Although around half of married women worldwide now use a modern method of contraception, an estimated 200 million women in the world who wish to stop having children or delay their next birth for at least 2 years are not using an effective contraceptive method [5,6]. According to the Jordan Population and Family Health Survey (JPFHS) [7], 57% of ever-married women in the country are currently using a method of family planning, and of them 42% are using modern contraceptives. Contraceptive use demonstrates regional variability when rural and urban areas are compared. The level of contraceptive use was higher among women living in urban areas (57%) than those in rural areas (51%) [8]. Women in urban areas tended to use modern methods more than those living in rural areas (43% and 36% respectively). The intrauterine device (IUD) was the method most used by married women (22%) followed by the oral contraceptive pill (8%).

Although studies have been made about contraceptive use and related issues in the urban areas of Jordan, data about women in rural and remote areas of the country are lacking. Women living in rural areas may be more influenced by traditional gender roles than women in urban areas, and this might affect their family planning and pregnancy decisions. The aims of this study were to explore the level of knowledge about family planning methods among rural Jordanian women, the prevalence of use, preferences and reasons for using family planning methods and their attitudes towards family planning.

Methods

Study design

The study utilized a descriptive design to gather information related to use, knowledge and attitudes toward family planning methods among rural women in the southern region of Jordan. Data were collected using structured interviews.

Sample and setting

Prior to data collection, ethical approval of the study was obtained from the Higher Population Council and Ministry of Health. A stratified random sampling technique was used to recruit the women. The inclusion criteria were ever-married women aged 15–49 years. No exclusion criteria were used, in order to maximize participation and the range of responses. The Jordan Department of Statistics provided household lists of 29 villages using stratified random sampling of 74 villages located in the southern Jordan governorates where village health centres operated. Twelve villages from Karak, 4 villages from Tafieleh, 9 villages from Ma’an and 4 villages from Aqaba were chosen according to the population size of the governorate. The Department of Statistics provided the housing block maps and the name list of the household heads that lived in these houses. Eleven households were randomly selected from each 80 blocks. Each interviewing team was assigned 2 to 3 blocks per day in the study area. The interviewers visited the assigned households and interviewed eligible respondents; if there were no eligible respondents at the household visited the house next door was visited. If no eligible women were found, the interview was abandoned.

In the field, a total of 915 ever-married women were selected for interviews from the selected households in Al-Karak (n = 364), Al-Tafielah (n = 89), Ma’an (n = 328) and Aqaba (n = 134). Among them, 10 women declined to be interviewed and another 98 women were not interviewed as they claimed to be outside the eligible age range, away from home or sick. A total of 807 women were successfully interviewed by trained interviewers at their home.

Data collection

The trained interviewers explained to the women the purpose of the study, its significance and what was expected from them and answered the women’s questions. Women were assured about the confidentiality of the study data and informed that they would be asked questions related to their reproductive health. On receiving the signed consent form, the data were collected using a structured interview.

The interviews took 30 minutes to complete. The survey was developed by the research team utilizing a thorough review of the literature and a review of tools available at the Ministry of Health and the Higher Population Council in Jordan. The survey was in Arabic language. Pilot testing of the survey was carried out to check for understanding and clarity. The women were asked about what family planning methods they had ever used, their knowledge related to contraceptive use (25 items) and their attitudes toward using contraceptive methods (15 items). In addition,. The survey also collected information about the demographic characteristics of the women (age, woman’s level of education, working status, marital status, length of stay in the present address, husband’s level of education, relationship to members of household, numbers of live births and infant mortality). The demographic information was obtained from an investigator-developed subject profile.

Statistical analysis

The data were analysed using SPSS, version 15.0. Descriptive statistics are reported: frequency distributions and mean and standard deviation (SD). Student t-test for 2 independent samples was used to test differences among reproductive health domains in relation to selected demographic characteristics of the women.

Results

Demographic characteristics of study participants

The mean age of the women was 34.6 (SD 8.5) years. Among the 807 women who responded to the survey, 85.0% were married, 2.7% were widowed and 0.4% were divorced. Many of these women had lived in other villages prior to their current residence (16.6%), while 1.7% had lived in Amman (the capital) and 10.3% had lived in a city other than Amman. With regards to education, 71.6% had ever been to school while 28.4% had not. Among those who had schooling, about three-quarters had high secondary or lower level of education. Of the women’s husbands 73.0% had received some schooling.

Knowledge about concept of family planning

The women were asked an open-ended question about what family planning meant to them. The results showed that the concept of family planning was not well understood by women in the southern region of Jordan. Some women said that family planning meant spacing between births (338, 36.9%) and others reported that it meant spacing between pregnancies (225, 24.8%). However, 80 (8.7%) of the women said that they did not know what family planning was. The women were then asked if they had hear about any method of family planning. While 727 of the total respondents (91.4%) knew at least one method of contraception, 77 (8.4%) of the women did not know any methods (the remainder answered “don’t know”).

Prevalence of contraceptive use

The survey showed that 336 (37.0%) of the women had ever used a contraceptive method compared with 397 (43.8%) who never used any method (the remaining women did not respond).

Women who had used family planning were asked what method they had ever used. Ever-use of contraceptive methods showed that oral contraceptive pills and the IUD were the most used methods (31.1% and 24.6% respectively) (Table 1). One-fifth of the women (n = 176, 19.4%) had ever used withdrawal (external ejaculation) as a family planning method. Injections as a method of contraception were not common among the women (10.1%). Female and male sterilization were rarely used methods (4.2% and 0.4% respectively)

The IUD and withdrawal were the most commonly used current methods, by 89 (27.7%) and 72 (22.4%) women respectively.

Knowledge about side-effects of contraceptives

Table 1  shows that 36.6% and 33.2% of the women had knowledge about the side-effects of oral contraceptive pills and the IUD respectively. These proportions were similar to the frequencies of women who had ever-used these methods. However, a slightly higher proportion of women (16.4%) stated that they had knowledge about the side-effects of injections than those who had ever-used this method.

Reasons for not using contraceptives

Reasons for not using contraceptives were investigated in an open-ended question to women not using them (Table 2). The reasons were categorized into 4 major categories: fertility-related reasons, methods-related reasons, opposition to use and lack of knowledge. The most common reasons were fertility-related (318 women, 39.4%). Within this category, pregnancy and breastfeeding were the most reported reasons for not using contraception (12.8% and 10.9% respectively). None of the women reported that lack of knowledge about contraceptive methods or obtaining them were a barrier to contraception use. Only 3 women (0.37%) reported their husbands’ opposition to using contraceptives as a reason and only 1 woman (0.12%) was not using contraceptives for religious reasons. None of the women mentioned availability of health care services as a possible reason for not using contraceptives, while only 4 women (0.5 %) identified difficulties in reaching a health care centre.

Attitudes towards family planning

In general, the women expressed a positive attitude towards family planning (Table 3). Over 95% agreed about the benefits of spacing children and family planning for the health of the child and mother. However, there was some disagreement about the time to start family planning, as 63.7% of them agreed to start family planning immediately only after the birth of the first child.

Of 417 women who answered the question about husband’s support, a majority reported that their husbands supported the use of family planning (78.2%). Both they and their husband agreed on the number of children they were planning for in 61.4% of cases (492/801).

Sources of information about family planning

Of the 540 women who answered the question about sources of information on family planning, television was the most commonly reported source of information about family planning (61.9%), followed by health workers (60.3%) and newspapers (16.1%) and radio (10.6%). Other sources made a minimal contribution (workers in family planning, workers in other organizations, husband, relatives, friends, school or library) (11.4%).

Discussion

This study addressed issues related to the health of Jordanian women in rural areas and attempted to understand these women’s family planning needs. The study revealed that women in rural areas of the southern region of Jordan had incomplete knowledge about the concept of family planning and some women (8.7%) stated that they did not know what family planning referred to. In addition, 8.4% of them claimed never to have heard about any method of avoiding pregnancy. The study indicated that the most reported source of information about family planning was television, while health workers were the second most common source of information. This indicates a pressing need to educate these women about the concept of family planning and available methods to avoid pregnancy. The 2007 JPFHS revealed that 12% of married women in Jordan had an unmet need for family planning, 5% for spacing and 7% for limiting births [7]. Unmet need was highest among those with no education, and among those in the poorest households. It also varied by governorate.

Nevertheless, the great majority of the women in this study were familiar with the concept of family planning; 91.4% had ever heard of methods to avoid pregnancy and more than one-third were currently using a contraceptive method. However, almost half of women (43.4%) of reproductive age were not using any family planning method. When women were asked to state their reasons for not using contraceptive methods, none of them reported not knowing about family planning methods or where to get them. This indicates that these women had access to information related to contraceptive use and knew where to obtain them. Cost and lack of family planning services were also not reported as barriers, while reasons such as family members’ or husbands’ opposition or religious reasons were reported by less than 1% of women.

The prevalence of contraceptive use showed that the most commonly used methods of contraception among women in southern rural Jordan were oral contraceptives, IUD and withdrawal. Female sterilization was only used by 4.2% of women, suggesting a possible lack of knowledge about this method. These findings are consistent with a previous study which found that Jordanian Muslim women preferred IUD as a contraceptive method and that they believed that the IUD had fewer side-effects than oral contraceptives [9].

Although women reported using predominantly modern methods, a high proportion (19.5%) relied on the withdrawal method. Interestingly among this study sample 32.3% and 29.5% had knowledge about the side-effects of oral contraceptive pills and the IUD respectively. The similar frequencies of using methods and having knowledge about their side-effects indicate that women had good knowledge about the methods of contraceptives that they use. However, the high frequency of knowledge about the most used methods and the very low frequency of knowledge about the least used methods also indicates that women might lack knowledge about the options available for contraception. This may be related to the types of services and supplies at the health centres and family planning centres. Women are coming from areas of rural poverty and this may explain the tendency to use the cheapest or free contraceptive methods such as oral contraceptives pills, condoms and withdrawal, and avoid using more costly methods. Although the ministry of health provides family planning services at all primary and comprehensive health care services, only 54% of women in Jordan used this service [7]. This raises the issue whether women have sufficient knowledge about the availability of family planning services and whether enough importance is given to postpartum follow-up in which women have the opportunity to be introduced to family planning methods. These questions need further investigation.

Although women in our study had a positive attitude toward contraceptive use, a high percentage of women actually did not practise it. Some reasons were logical and related to pregnancy and menopause; however, other reasons, such as health reasons, might need further investigation.

Conclusion

Women in the southern region of Jordan showed positive attitudes and knowledge about contraceptive use. However, the prevalence of use of different methods highlight some educational needs among the women; fro example, women may lack the appropriate information and knowledge about female sterilization. Although women value family planning for the health of the mother and the child, they still may have problems of understanding reasons for using family planning. Health professionals should seize the opportunity to plan for educational programmes and counselling sessions for women in these areas.

Acknowledgement

This study was funded by the Japan International Cooperation Agency, Amman, Jordan.

References

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Maternal, child and adolescent mental health: challenges and strategic directions for the Eastern Mediterranean Region

Maternal, child and adolescent mental disorders constitute a public health problem. The estimated prevalence of 15%-36% for maternal mental disorders and 10%-36% for child and adolescent mental disorders in the WHO Eastern Mediterranean Region is significantly higher than the estimates for developed countries. Mental disorders among mothers, children and adolescents are inextricably linked, at the causal as well as at the intervention level, making it imperative to address the issue in an integrated manner. Maternal, child and adolescent mental health: challenges and strategic directions for the Eastern Mediterranean Region provides an overview of the situation globally and regionally, identifies the major challenges and suggests strategic directions and actions to promote maternal, child and adolescent mental health in the Region. The strategic directions outlined were endorsed by the WHO Regional Committee for the Eastern Mediterranean in 2010. The publication is aimed at policy-makers, health system managers, mental health professionals and others interested in mental health in general, and maternal, child and adolescent mental health issues in particular. It will help countries in developing national strategies and action plans based on evidence and in charting progress in provision of integrated mental health services for maternal, child and adolescents. In turn, this will help in achievement of the Millennium Development Goals.

This full text of this publication can be accessed online at: http://www.emro.who.int/dsaf/dsa1214.pdf