Contraceptive practices and associated social covariates : an experience from two districts of West Bengal , India

A community based cross-sectional study was conducted among four thousand eligible couples in Howrah and Paschim Midnapore districts of state of West Bengal, India from March to September 2009. By stratified multistage random sampling technique, 32 areas were selected from two districts; villages of sub-centre zone and wards of municipality; from each selected area; 125 eligible couples were interviewed by house to house survey.


Introduction
Family planning is a process of thinking and a life style.Attitude is an important factor in choosing suitable contraceptive methods 1 .A small family infrastructure is preferred and encouraged in our middle class society as it is considered to promote happiness and well-being.
It is universally accepted that family planning services are essential for promoting birth spacing to reduce maternal and infant mortality.If these services were more widely available, up to 42 percent of maternal deaths could be prevented in developing countries.The mean proportion of maternal deaths that could have been averted was 24 percent 2, 3, 4 .
Family planning services are given from indoor and also from outdoor camp services.It was seen that these camps expanded the availability and accessibility to sterilization services without jeopardizing the quality of sterilization services.Yet there is a need to reinforce access to information about other contraceptive methods and to make them available 5 .
Family planning is regarded as a significant achievement of public health and worldwide acceptance has risen to threefifths of exposed couples.However, acceptance of modern contraception is constrained by limited access and weak service delivery in many developing countries and the burden of unwanted pregnancy is still large.Another crucial issue is that of adolescent women who are at a high risk of unwanted pregnancy.Currently, there is little data available to them concerning their choice to initiate long-acting reversible contraception 6 .Contraceptive measures are highly relevant to the adolescent age group and researches are going on their preference for specific methods to prevent pregnancies and their health burden .A related review to identify the most effective measures to save newborn lives also concluded with an integrated approach to safe motherhood and newborn health and emphasized the importance of health systems research and evaluation.

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Although India has the distinction of initiating an official family planning programme way back in 1952, most couples in India adopt a terminal method only after they have had three or more children.Current users of family planning are by and large those who have achieved their desired family size and do not want any additional children.Furthermore, due to emphasis on sterilization, spacing methods have not been actively promoted nor are they easily available to those who are willing to adopt them 9 .So temporary methods should be promoted to space or limit births 10 .
There is a need to promote different spacing methods by policy and decision makers and field workers in order to motivate couples to accept these methods for themselves and for overall national development 11 .Side effects, religious or spousal objections, or desire to conceive are found as reasons for stoppage of contraception in area with poorer health indices 12 .This should be taken care of.
Many women may like to use contraceptives, but they are not aware of its availability, thus there may be unplanned pregnancies and women may seek abortion.Women of necessity and health care providers are poorly educated about contraception and the availability of legal and safe abortion services.Women need better access to safe abortion and post-abortion services.Desperate women, facing the financial burdens and burden of unwanted pregnancy and believing they have no other option, continue to risk their lives by undergoing unsafe illegal abortions 13 .To reduce the number of repeated unsafe abortions, high-quality contraceptive service counseling can induce women to use contraception after having had an unsafe abortion 14 .
Easy accessibility to good quality family planning services is basic right of all women to prevent pregnancy, unsafe abortions, child birth related deaths and long term morbidity 15 .The extent of acceptance of contraceptive methods still varies within and between societies and also among different religion groups.The factors responsible for such a varied picture operate at the individual, family and community levels with their roots in the socio-economic and cultural milieu of Indian society 16 .Factors such as older ages, education of husband and subject, and the number of male children were observed and these were positively related to use of any methods and also permanent methods of contraception 17 .Adoption of policies for a low fertility rate, the control of timing and spacing of pregnancies, and greater access to family planning can help to reduce the maternal mortality rate.These generally reduce the number of unwanted pregnancies.Hence women need access to medical and social services available at an easy reach 18 .Mothers adopt contraceptive methods after completion of family or birth of male children.Low usage rates of long term methods are mostly due to fear of side-effects, lack of proper knowledge about methods, followed by husbands' objection, desire for more children and health reasons 19 .
With the above perspectives the present study was undertaken to assess the current status of contraceptive practice among the eligible couples, to determine social covariates influencing it, and to recommend suggestive measures for promotion of contraceptive acceptance.

Study design and the participants
A community based cross-sectional observational study was carried out in two districts of West Bengal in Eastern India during the month of March to October 2009.Two districts were Howrah and Paschim Midnapore.Female members of eligible couples were the participants in the study.

Data collection
Data was collected from a total of four thousand eligible couples by interview technique from the participating respondents through a predesigned and pretested schedule, by house to house survey.Faculty members and interns of the Department of Community medicine from different medical colleges participated in the survey.A two-day workshop was held for hands-on-training of 30 surveyors for data collection by interview technique.This was done to ensure uniformity in data collection throughout the study.The primary and co-investigators actively supervised the data collection by the surveyors in the field.

Inclusion criteria
Consenting members of eligible couples, physically and mentally fit persons, and only residents of the surveyed locality were taken as inclusion criteria for the study population.

Exclusion criteria
Physically and mentally unfit persons, those not giving consent and visitors in the area surveyed were the exclusion criteria of the selected population.

Sample size calculation
The sample size was calculated from the present national data of Couple Protection Rate of 46 percent 20 .The sample size came up to 1879 considering an allowable error of 5 percent at 95% confidence limit 21 .For the two districts, four thousand eligible couples were considered (two thousand from each district) adequate sample size in order to overcome a non-response rate of five percent.

Sampling design:
By stratified multistage random sampling, the villages and municipality wards of Howrah & Paschim Midnapore districts were selected for the study.From nineteen districts in West Bengal, two districts were randomly selected; out of total blocks in each district, three blocks were selected randomly.From each rural block two sub-centers and from each sub centre area two villages were selected randomly.Among the total municipalities of each district, two municipalities were selected randomly; from each municipality two municipal wards were selected randomly.So, altogether sixteen areas were selected from and within each district (twelve villages and four municipal wards) for the purpose of the study.The urban and rural population was in the ratio of 1:3, thus 16 clusters selected from each district were also distributed in the same ratio, i.e. 4 urban wards from Municipality areas and 12 villages from rural blocks.

Outcome Variables
Contraceptive prevalence, Couple protection rate and proportion of different contraceptive methods were the response or outcome variables in this study.

Explanatory variables
Religion, type of family, age-group of female partners, educational status, socio-economic status were the independent or explanatory predictors.

Ethical committee approval
Calcutta National Medical College Ethics committee had been contacted through proper channels prior to commencement of the study and the team was permitted to conduct the study.

Data management and statistical analysis
Data for all parameters were analyzed manually and by computer using Epi-Info.χ 2 and p value have been calculated to see the statistical association among the variables

Results
Our study revealed that 76.9% of our study population were Hindus (comparable to national demography), more than two thirds (69.8%) were members of a nuclear family, more than half (56.2%) were in the age group of 29 years, about half of them (40.1%) had no formal education and a sizeable proportion lived below the poverty line (BPL).In Howrah district, acceptance of contraceptive rate was more among Hindus (64.9%) than Muslims (59.9%) and the difference was statistically significant (p < 0.05).But in Paschim Midnapore district, acceptance rate of contraceptives was higher in case of Muslims (74.6%) than Hindu (66.3%) which was also statistically significant.Acceptability of contraceptive methods in relation to type of family was higher among the couples of nuclear families in both the districts (p < 0.05).Age of wives, literacy also influenced the acceptance of contraceptives (p < 0.05 in both the districts).Acceptability of contraceptive was not influenced (p > 0.05) by different social class [Table - The literacy status of female partners was inversely proportional to contraceptive acceptance (contraceptive prevalence) by any method (modern and traditional methods) and couple protection rate.This was statistically significant.The reason might be explored here .
In Howrah district, 40 percent contraceptive acceptors used to consume oral contraceptive pill (OCP), 29.3 percent adopted permanent family planning methods (vasectomy and tubectomy), but contrary to this in Paschim Midnapore district most of the couples (57.7%) adopted permanent family planning methods (tubectomy and vasectomy) followed by OCP (28.7%) [Figure 1].Contraceptive prevalence rate, approved methods and traditional methods all inclusive here, among currently married women (aged 15-49 yrs) was 65.3 percent.Traditional methods were found among 6.9 percent couples.So couple protection rate was less than 60.0 percent [Figure 2].

Discussion
The current status of contraceptive practice by the eligible couples and social covariates which may influence the contraceptive practice have been taken care of in this study.

Contraceptive prevalence rate:
In our study, contraceptive practice by any method among currently married women was less than in NFHS-3 of West Bengal (71.2%), but higher than NFHS-3 national data (56.3%) and other studies 16,19,24,25 .Contraceptive acceptance rate was higher among higher income groups in both districts; but this was contrary to the findings of the earlier studies 17,26 .

Couple protection rate:
The couple protection rate in the present study (58.4%) was higher than that for NFHS-3 of West Bengal (50 %) and national figure (48.5%) 24,25 .The couple protection rate was found to be less (43.4%) in Sharma AK et al study (1997) 27 .Again this was found higher (82.55%) by Chankapa YD et al (2010) 12 .The contraceptive acceptance rates, the couple protection rates and fertility rates were higher in Paschim Midnapore district than in Howrah district.This may be due to adoption of permanent methods after completion of family size in Paschim Midnapore district.Similar findings were observed in earlier studies that might be due to male dominance in Indian society (which prevailed in the study area) and was corroborated by observations of Sharma A K et al (1997) and Shobha J (1990) 27,28 .

Contraceptive methods:
Our study noted that oral contraceptive pill use was higher (22.3%)

Socio-demographic variables:
Institutional education, nuclear family structure, religious values and higher ages of married women were found to have a significant positive influence on contraceptive practice by the eligible couples 30 .There was inter-district variation of observation in two districts in the present study.Acceptance of contraceptive methods was significantly higher among nuclear families in both the districts, which did not corroborate with findings from an earlier study done by Bhattacharya M et al (1984) 31 .One Bangladesh study found no socio-economic difference among acceptors and non-acceptors of family planning method 19 .Adoption of family planning measures was significantly higher among those respondents who acquired education from institutions than illiterate and just literate group in both the districts.A similar observation was made by Sharma et al in South Delhi

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. All the findings were comparable with one study at Hyderabad by Shobha J 28 .

Inter-district variation:
In Paschim Midnapore district, the literacy rate (59.9%) was lower than in Howrah district (66.7%).The total fertility rate (2.02) was higher in Paschim Midnapore district in spite of higher couple protection rate (62.6%) and contraceptive acceptance / prevalence rate (67.2%) than Howrah district.It might be due to adoption of permanent methods (57.7%) in Paschim Midnapore which is nearly double than in Howrah (29.3%).Similar observations were also noted by the previous Chankapa YD et al (2010), Mohanan P et al (2003) and Oni GA et al (1991) 12,32,33 .In Paschim Midnapore, the reason for adoption of permanent method may be due to wanting more children like in Punjab 34 .

Conclusion:
From the present study it can be concluded that couple protection rate as well as contraceptive acceptance (by any method) was far better in both the districts of West Bengal than National averages.Due to more emphasis on permanent methods, adoptions of temporary methods are neglected in Paschim Midnapore district.Awareness about small family norm, adoption of both temporary and permanent methods at the appropriate time as well as improvement of literacy status is indispensible for reduction of population growth.Area specific sustained and coherent Behavior Change Communication (BCC) efforts are needed for better utilization of both temporary and permanent family planning services, as recommended in the Hyderabad study done by Shobha J

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. The countrywide aspiration of achieving population control, which even now is considered a distant dream, can be achieved only through proper utilization of contraception 35 .

Limitation of the study:
The findings of our study have limited external validity as the sample size and geographic area of the study population in the context of eastern India was restricted.

Future scope of study:
Inter-district variation was noted; broader scope is relevant at the state or the national level.

22 . 7 .* 23 .*
Few terms had been used in the study as defined below: *Eligible Couples -Currently married couples with wives aged between 15-49 years who were in need of Family Planning services are referred to as eligible couples Couple protection Rate -Percent of eligible couples effectively protected against child birth by one or the other approved methods of family planning viz.-sterilization, IUCD, Condom or Oral pills Contraceptive acceptance rate (prevalence rate) -Percent of eligible couples protected against child birth by any method of family planning (modern methods and traditional methods) 24 .

Fig. 1 :
Fig. 1: Bar diagram showing the practice of different family planning methods by eligible couples in two different districts

Figure 2 :
Figure 2: Pie chart showing distribution of total eligible couples according to family planning practice methods

Table 1 : Table 1: Current Contraceptive Practices in relation to social covariates [Howrah (n=2000)]
* Statistically significant, x statistically not significant

Table 2 : Comparison of indicators in respect of two districts
* Statistically significant, x statistically not significant

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than the national figure (3.1%) Miscellaneous methods practiced by the eligible couples in our study were 6.9% whereas it was 21.3 percent in West Bengal in NFHS-3 24.