Knowledge and use of modern family planning methods by rural women in Zambia

ModoTiTcoiitraceptives Abstract: Curationis 33 (1): 17-22 Knowledge, Use, Rural women, ZamThe main aim of the study was to determine knowledge and use of modem contrac|3ja tive methods among reproductive age group rural women in Zambia. The study is a descriptive cross-sectional study of 105 randomly selected rural women. Data was collected using semi-structured interview schedule and analyzed using EPI Info ver­ sion 6 statistical packages. The findings revealed that 63% of the respondents were within the age group 21-35 years, 65% were married and 64% were peasant farmers. 90% of the respondents had heard about modem contraceptives and their main source of information was the Health worker (62%). 76% of the respondents stated that modem contraceptive methods could be obtained from public health facilities. 56% of the respondents were currently using modem contraceptive methods and 46% were not using modem contraceptive methods.


Introduction
Zambia is among the sub-Saharan Af rican countries with a high fertility rate o f 5.9 births per woman (Central Statis tical Office, 2002:6).It is located in the southern part o f the sub-Saharan Afri can Region and it is a landlocked coun try.It shares borders with the Demo cratic Republic o f Congo (DRC) and Tanzania in the north, Malawi and Mozambique in the east, Zimbabwe and Botswana in the south, Namibia in the south-west and Angola in the west.Zambia lies between 8 and 18 degrees south latitude and between 20 and 35 degrees east latitude.The country has a population of 10.3 million inhabitants' (Central Statistical Office, 2002:48) and the population growth rate in 1990 and 2000 was 2.9% per annum.The country's family planning pro gramme came into being in 1970 and family planning services were first in troduced in the urban areas and ex panded to the rural areas very slowly.Family planning was integrated in Ma ternal and Child Health care services in 1973 and even today it still an integral part o f the country's reproductive health program (M inistry o f Health 2002:24).Despite the integration of fam ily planning services in the reproduc tive health program, there has been a slow decline in fertility level for in stance, from 6.5 births per woman in 1992 to 6.1 in 1996 to the current level o f 5.9 births per woman.The increase in contraceptive use over the past dec ade has also been slow (from 26% in 1992 to 34% in 2002).Furthermore, about one in three o f currently married women still have an unmet need for family planning (Central Statistics Of fice, 2002:276).
Zambia developed a national family planning policy in 1989 which was adopted as part o f its fourth National Development plan (Ministry of Health 2002: 15).This policy recognizes the effects of rapid population growth on Zambia's socioeconomic development and the need to incorporate population concerns into the national development and planning process (PATH, 2005: 3).
The main objective is to ensure that all couples and individuals have basic rights to decide freely and responsibly the number and spacing o f their chil dren and have the information, educa tion and means to do so (Ministry of Health 2002: 15).Other specific objec tives include slow ing the n ation's population growth rate, initiate, im prove and sustain measures to arrive at slowing down the nation's high population growth rate, enhance the health and welfare o f all and prevent premature death and illness, especially among high-risk groups o f mothers and children (Ministry of Health 2002:15).
The national family planning pro gramme has strived to achieve the above stated objectives.To help the national and district levels in planning and implementation o f the family plan ning component o f their reproductive health programs, a policy framework was developed.
With regards to knowledge levels, the 2002 and 2007 Zambia Demographic and H ealth Surveys reported high knowledge levels o f modem contra ceptive method among the Zambian population but despite this, there is still low utilization of family planning serv ices am ong w om en in Z am bia (N sem ukila, Phiri, D iallo, Banda, Benaya & Kitahara 1998: 26;Central Statistic Office, 2002:278).

Literature review
According to the 2007 World Bank re port, contraception is a best buy for development.By helping individuals to choose when to have children, family planning saves lives, it prevents unin tended pregnancies, averts maternal and child deaths and prevents abor tions (Smith, Ashford, Gribble & Clifton, 2009: 6).Family planning also saves public sector resources; for $ 1 a gov ernment spends on family planning service delivery, $2 to $6 can be saved in providing other interventions includ ing basic health and education for fewer children, maternal health services and improvements in water and sanita tion (United Nations Population Divi sion, 2009:4).
Sub-Saharan Africa has the highest fer tility o f any world region which is 5.4 births per woman on average (Clifton, Kaneda & Ashford, 2008:2).Birth rates in the region are so high that even in the face of high AIDS mortality in some countries, the region's 2008 population of 809 million is projected to increase to 1.2 billion by 2025 (Haub & Kent, 2008: 9).The major factor underlying high birth rates is low family planning use for instance only 18% o f married women in sub-Saharan Africa use mod em methods of family planning (Clifton et al, 2008: 3).However, there are subregion differences in modem contra ceptive use, for example, modem con traceptive use is 58% in Southern Af rica, 22% in East Africa, 7% and 9% in Central and Western Africa respec tively (Clifton et al, 2008: 3).It is also estimated that 35 million women in sub-Saharan Africa have an unmet need for family planning (Clifton et al, 2008:2).They want to delay or stop childbear ing but are not using any contracep tive method.
C onde -A gudelo and B alizan (2000:1255) state that, in sub-Saharan Africa, rural women tend to use fewer contraceptives and have more children than their urban counterparts.In addi tion many rural women have gaps in their knowledge about available con traceptive methods and how effective each m ethod prevents p regnancy (Conde -Agudelo & Balizan, 2000: 1255).Previous studies have shown that knowledge o f modem contracep tive methods is an important determi nant of contraceptive use (CSO, 2002: 278).Women who are well informed about the benefits of family planning tend to use it.However, women's per ception that their husbands oppose family planning is a dominant factor discouraging contraceptive practice in a wide variety o f settings (Joesoef, Baughman & Budi, 1988;Khalifa, 1988:236;Mbizvo&Adamchak, 1991: 32;Koblinsky,Timyan&Gay, 1993:10;Grady, 1996: 221;Asturias de Barries, Rods, Nieves, Matula, & Yinger, 1998: 15;Elzanary, Sunita, & Casterline, 1999: 23)  There was a variation in contraception knowledge levels and education for in stance, only 49% o f illiterate women knew a method of contraception com pared to 99% o f women with second ary or higher education and 80% of women with primary school education.The most striking differences in knowl edge of contraceptive method were by source information.Ninety five percent (95%) of women whose source of in formation was the Health workers were more knowledgeable about contracep tive methods, than those who had the family as their source of information (48%).
Fifty four percent (54%) o f the women in this study were currently using a modem contraceptive method and the majority (62%) of the women who were currently using contraceptives were within the age group 21-35 years and most (62%) of these women had sec ondary school education (Chi-square 7.83, df = 3, P<0.05).In addition, the use of modem contraceptive method was significantly higher among women who were 21-35 years than women be tween 36 -49 years (Chi-square test 3.38, df = 2, P< 0.05).Among the women who were using modem contraceptive m ethods, 80% w ere u sin g a pill (Microgynon).The study has shown that women who had good knowledge about contraceptive m ethods were more likely to use a contraceptive method than those with poor knowl edge.
Forty six percent (46%) o f the women were not using any modem contracep tive method (Table3) and these were within the age group 36 -49 years and were illiterate (49%).The reasons for non-use o f modem contraceptive meth ods are illustrated in table 3 and these included religious beliefs (50%), Part ner disapprove (30%), and fear o f side effects (20%).
In this study, women whose spouses approved (68%) of use of modem con traceptive method were more likely to use modem contraceptive method (Chisquare = df = 6, P< 0.05) than those whose husbands disapprove (32%).

Discussion
Knowledge o f family planning is con sidered the first stage toward the adop tion o f a contraceptive method (CSO, 2002:279).This study has revealed that a large num ber o f the respondents (90%) had heard about modem contra ceptive methods mainly from a Health worker.This could be due to the fact that one o f the Health worker's roles involves giving health information to women whenever an opportunity arises and most of them have trust in them.
Health workers especially nurses and midwives in particular are grass root w orkers providing health care to populations in the remote parts o f the country, therefore they are easily ac cessible.The current study has also revealed that knowledge o f m odem methods of contraception and where the methods could be obtain was good, for example, many women could men tion at least one method o f contracep tion and stated that modem contracep tive methods could be obtained from a health facility.However, there is need for continued sensitization on the ben efits o f family planning especially among women who are illiterate.
The most popularly known and used method o f contraceptive among the respondents was a male condom fol lowed by a pill.These contraceptive methods were popular among the re spondents because the methods are readily available and accessible in the Government health care facilities than other methods of family planning such as injections.In addition, condom use is currently being promoted by the HIV/ AIDS program as one of the methods o f prevention.However, knowledge of methods of modem contraceptives is necessary but it is not sufficient to en courage use of methods of contracep tion.For instance 46% of the women in this study were not using any meth ods of contraception despite them hav ing good knowledge o f modem con traceptive method.
In this study, women who were younger were more likely to use a modem con traceptive method than older women.This could be attributed to the fact that younger women were more enlighten on family planning than older women.An association was found between educational level and use of contracep tion.Respondents' who had second ary school education were using con traception than those who have never been to school.Education is the most consistent reported determinants o f reproductive health services utilization; for instance, a Mexican study found an independent association between lack of any schooling and the use o f contraceptives among women (Nazar-Beuteelspacheretal, 1999:67).Similarly, the 2001-2002 Zambian Demographic Health Survey reported similar findings that women who were educated were more likely to utilize modem family planning methods.A nother study con ducted in Pakistan by Hamid and Stephenson (2006: 121) confirmed the findings that women who have been to school are more likely to use modem contraceptive methods.In a population based Turkish survey, women with sec ond level primary school and higher education were better informed than wom en with little or no education (Unalan et al, 2003: 8).Furthermore, higher educational level and better socio-econom ical status have been shown to be associated with better knowledge about contraception in a study from Brazil (Espejo et al, 2003: 583).This could be due to the fact that educated women are able to articulate their fertility desires.
The barriers to modem contraceptive use expressed by women in this study include religious beliefs, spouse ap proval and side effects.Half (50%) of the respondents believed that children are given and determined by God there fore they could not use contraceptive otherwise they would go against God's will.Although it is difficulty to ascer tain the importance of religion in an in dividuals' decision making process, it quite clear from this study that religion could have a negative influence on the women's use o f contraception.This result confirms the findings of a Yemen study which identified religious beliefs as a reason for non use of modem con traceptive method (Ba-Hubaish, 1999: 4).
Another barrier to contraceptive use revealed in this study is unwillingness for contraception by the spouse or husband.Husband's opinion on fam ily planning can be strong to determine their wives use o f family planning (Koblinsky, et al, 1993:10).In Zimba bwe, a study o f males' family planning knowledge, attitudes and practices found that 80.6% o f the sample had used contraception with their partners and 83.5% approved of family planning in general (Mbizvo & Adamchak, 1991: 31).O f the men who had ever used fam ily planning, 58.8% said the male part ner should have a major say to practice family planning; 48.3% said they were responsible for the decision to use a method; and 53.3% said that they de cided on the number o f children to have.Women had little involvement in the decision.A study o f Sudanese men's attitudes, knowledge and prac tice concerning family planning sug gested that men made the decision about contraceptive use and were re sponsible for obtaining the method (Khalifa, 1988: 236).In Indonesia hus bands' approval was the most impor tant factor in whether or not wives used contraception as husbands are seen as the protector and provider for the household and the decision m aker (Joesoefetal 1991;162).
As in most Sub-Saharan cultures, men in Zambia tend to dominate a couples' decision about family size and whether to use contraception.A husband is re garded as a decision maker in the home and if he opposes contraceptive use by the wife there is nothing a wife can do otherwise she risks a divorce or be ing beaten.Culturally men usually want their wives to have more children so as to earn respect.It is also perceived by husbands that use o f contraception could encourage infidelity among wives.
This study has also shown that women whose spouses approved o f use of contraceptive methods were more likely to use the modem methods than those whose spouses disproves o f modem contractive use.This finding confirms results from a study conducted by Grady (1996: 222) which also found a positive association between spouse approval and contraceptive use.There fore, it is clear; there is an urgent need to involve men in reproductive health matters because of the role they play in reproductive decision of their fami lies.This information could be used to design messages targeted at men.Bradford & Mason (1989: 69), one of the most commonly cited reason for discontinuing contraceptive use is the perceived side-effects.These could be side-effects that are regarded as nor mal by health care professionals but may be o f great personal or cultural importance to women (Koblinsky et al, 1993:9).In addition women may blame any type o f health problem, especially reproductive-tract problems on their contraceptives (Koblinsky et al, 1993: 10).This reaction results in part from poor counseling and information, edu cation and communication and from information women receive about other women's experiences (Koblinsky et al, 1993:10).Therefore health care profes sionals need to provide information, education and communication regu larly to the women in order to encour age use o f modem contraceptive meth ods.

Conclusion
A . Another determinant for use or non use o f contraceptives is lack o f school ing (C atrol-M artin 1995:187, Espejo, T sunechiro, O sis, D u arte, Bahamondese, & De Sousa, 2003:583, Hamid & Stephenson, 2006:121,Nazar-Beuteelspacher, M onalisa-R oseles, Salvatierral-Zaba, Zapata-Martelo & Halperin 1999: 134, Unalan, Koc & Tezcan, 2003:8).Religious belief is also one o f the reasons for non use o f mod ern co n tracep tiv e m ethods ((B a- The other reason cited by women in this study for non use o f contracep tion was side-effects o f modem meth ods o f contraception.According to Wasserheit, Harris, Chakraborty, Kay,

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BIVZO, M T & ADAMCHAK, DJ 1991: Family planning knowledge, at titu d e s and p ra ctices o f m en in Zimbambwe.Studies in Family Planning.22:31-38.MINISTRY OF HEALTH 2002: Inte grated technical guidelines for frontline Health workers.2nd edition.Lusaka: Ministry of Health.NA ZA R-BEU TEELSPACHER, A; M O N A L IS A -R O S A L E S , D; SA L V A T IE R A I -Z A B A , B & ZAPATA-MATRTELO, E; HALPERIN, D 1999: Education and non use of con traceptives am ong poor wom en in Chiapas, Mexico.International Family Planning Perspectives.25 (3): 132-138.N S E M U K IL A , G B ; P H IR I, DS; DIALLO, HM; BANDA, SS; BENAYA, W K & KITAHRA, N 1998: Factors as sociated with maternal m ortality in Zambia: Ministry o f Health, United Nations Population fund, Central Board of Health and University o f Zambia.PATH 2005: RHO archives.Family p lan n in g program issues, h ttp :// www.rho.org/html/fppprogexamples.html.Accessed 6th No vember 2007 SMITH, R ASHFORD, L; GRIBBLE, J & C LIFTO N , D 2009: Family Plan ning saves lives.4th ed.Washington, DC; Population Reference Bureau.UNALAN,T; KOC, I & TEZCAN, S 2003: Hacettepe University Institute o f Population Studies, Turkey Demo graphic and Health survey.Hacettepe University of population Studies, Min istry o f Health General Directorate of Mother and Child Health and Family planning, state planning organization and European Union.Ankara.Turkey.UNITED NATIONS POPULATION DIV ISIO N 2009:World Population prospects, medium variant projection series.Washington, DC: United N a tions population Division.W O RLD BANK 2007: Why contra ception is a Best Buy.Disease Control Priorities Project Policy Brief.Washing ton DC: DCP2.

Table 3 Use and Reasons for nonuse of modern contraceptive methods Characteristic Frequency Percentage Use of modern contraceptive methods
dom, 24% mentioned a pill and 5% men tioned inject able contraceptive (Table2).Only 5% o f the respondents did not know any modem method of contra ception.There was a small difference that existed in knowledge o f modem contraceptive m ethods among the women in this study.Ninety two per cent (92%) o f women in the age group 21-35 years, 89% o f the women in the age group 15-20 and 85% of the women with the age group 36-49 had hear of a modem method o f family planning.