Factors influencing the uptake of family planning services in the Talensi District, Ghana

Introduction Usage of family planning services in developing countries have been found to avert unintended pregnancies, reduce maternal and child mortality, however, it's usage still remains low. Hence, the objective of this study was to investigate the factors that influence the decision of women in fertility age to go for family planning services. Methods This was a descriptive cross-sectional study conducted in Talensi district in the Upper East Region of Ghana. Systematic random sampling was used to recruit 280 residents aged 15-49 years and data was analysed using SPSS version 21.0. Results The study revealed that 89% (249/280), of respondents were aware of family planning services, 18% (50/280) of respondents had used family planning services in the past. Parity and educational level of respondents were positively associated with usage of family planning services (P<0.05). Major motivating factors to the usage of family planning service were to space children, 94% (47/50) and to prevent pregnancy and sexual transmitted infections 84% (42/50). Major reasons for not accessing family planning services were opposition from husbands, 90% (207/230) and misconceptions about family planning, 83% (191/230). Conclusion Although most women were aware of family planning services in the Talensi district, the uptake of the service was low. Thus, there is the need for the office of the district health directorate to intensify health education on the benefits of family planning with male involvement. The government should also scale up family planning services in the district to make it more accessible.


Introduction
Family planning is widely acknowledged as an important intervention towards achieving Millennium Development Goals (MDGs) four (4) and five (5) as it has proven to reduce maternal and child mortality [1][2][3]. Family planning can prevent unwanted pregnancies and unsafe abortions. Some family planning methods such as condom usage can protect individuals from Sexually Transmitted Infections (STIs) including HIV/AIDS [1][2][3]. Family planning has also been found to promote gender equality as well as promote educational and economic empowerment for women [4].
Despite the enormous benefits of family planning services, the uptake of the service still remains low in Sub-Saharan Africa [1].
This has resulted into high rates of unwanted pregnancies, unplanned deliveries, unsafe abortions and maternal mortalities in Sub-Saharan Africa of which Ghana is no exception [1,5]. The low uptake of family planning is largely blamed on many factors. It has been observed that the awareness of the availability of family planning services has a great influence on the uptake of family planning services [6]. Additionally, even though some women are aware of the availability of family planning services, they are not properly informed about the various forms of family planning methods and how they work [7]. Some of the women who went for family planning services were not adequately counselled on the side effects of some of the family planning methods [7]. For example, in Uganda, some women stopped using contraceptives after they experienced what they perceived were side effects of the contraceptives [8].
Although most people are aware of the benefits of family planning services, they complained that it was difficult to access family planning services as such services were provided by health facilities that were far from their homes [9]. In addition, religious inclination has been noted to be a major constrain to the uptake of family planning services in Africa [9,10]. Also, some individuals perceived that family planning services were meant for only married couples whilst others fear that they will become sexually promiscuous if they go for family planning services once they cannot become pregnant [1,9,10]. In Ghana, some efforts have been made by the government of Ghana and non-governmental organizations through the implementation of various programmes to improve the coverage of family planning services in the country [9]. Although some successes have been chucked in the area of awareness of family planning services in the country, the unmet need for family planning still remains high [1,9]. The Ghana Demographic and Health Survey (GDHS) observed that a large number of women have an unmet need for family planning as the acceptor rate for family planning services remains low [11]. It is on this note the Ghana Health Service argues that the lives of mothers and children will be improved and maternal mortality reduced if family planning acceptor rate is improved [1,11].
Similarly, the Talensi district in Upper East Region (UER) of Ghana is not spared from this predicament as the acceptor rate for family planning services also remains low. The Talensi district offers free family planning services to clients in most of the health facilities in the district [12]. Despite the provision of free family planning services, the district reported 19% family planning acceptor rate in 2013, which is currently below the Ghana Health Service national family planning acceptor target rate of 23.3% [12]. The regional annual health report showed an increase in teenage pregnancies as well as unsafe abortions in the Talensi district [12]. Three maternal deaths were recorded in the Talensi district in 2011 as a result of unsafe abortions [12]. The increase in teenage pregnancies and unsafe abortions as well as the maternal mortalities that occurred could have been prevented if uptake of family planning services were improved. The decision to investigate the factors that influence the uptake of family planning services in the Talensi district is imperative as very little is known about the factors that influence the decision of people to go for family planning services in the Talensi district. Some of the family planning methods that are currently being offered include; Jadelle, Norplant, Condoms, Depo-provera, combined oral contraceptive pills etc [12].

Sample size
A sample size of 280 was derived using sample size formula for a single population. The assumptions made were using a 95% confidence interval , 5% margin of error and 23.3% national expected proportion of uptake of family planning service among Women In Fertility Age (WIFA).

Sampling method
A total of 280 of women aged 15-49years were recruited for the study using systematic random sampling technique. The 280 participants recruited were from households in the 8 sub-districts that make up the Talensi district (35 households from each subdistrict) with one participant from each household. The 280 participants were recruited by the researchers themselves with the help of a community volunteer from each sub-district. The community volunteer helped researchers to approach community leaders to inform them about the purpose of the study and to obtain permission from them to recruit and interview potential participants as this is standard community entry protocol for conducting research within local community context in Ghana [13]. The presence of community volunteers in the team may have influenced the high response rate of 100% as they are highly respected with good knowledge of local residents. All households were numbered and a sampling interval, n=5 was used to select the first household.
Subsequent selection of every 5th household then followed in same direction. Using this technique about 284 households was selected but 4 households were dropped because no one was available at the house to be recruited at the time of the survey.

Measurement
The questionnaires were structured with closed ended pre-coded questions and administered to participants by the Researchers. The questionnaires were divided into four parts. The first part was the socio-demographics whilst the second part was the awareness and usage of family planning services. The third part of the questionnaire provided various reasons that motivated women to access family planning services and the fourth part provided various reasons that discouraged women from using the service. The questionnaires were administered in a language that participants were comfortable to respond. The questionnaires were first piloted on ten (10) participants in the Nabdam district, a neighbouring district which shares border with the Talensi district. Piloting of the questions was done to ensure that the questions were more refined for participants to respond without difficulties [14].

Data analysis
All data were entered into SPSS version 21.0 and analyzed. The Pvalue of 0.05 was taken for statistical significance. The association between the binary outcome, usage of family planning services (yes or no) with independent categorical variables such as marital status, age, religion, parity and educational level were investigated using chi-squared test. Binary logistic regression model with the outcome, those who had used family planning services was used to investigate the influence of independent variables such marital status, age, religion, parity and educational level on the uptake of family planning services. Descriptive summary statistics was also used to report various reasons that motivated respondents to go for family planning services as well as reasons why some respondents did not use the service in the district.

Ethics issues
This study was approved by the Ethics committee board of the Catholic University college of Ghana and the Talensi district health directorate. Written consent was obtained from participants and for participants who were within the ages of 15-17years written consent was obtained from their guardians on behalf of them. All participants who consented to take part in the survey were well informed about the purpose of the study and why they were being asked to participate. They were also informed that participation was voluntary and they had the right to withdraw from the study even after they had participated.  Table 1 also shows the results of the association between sociodemographic characteristics and the binary outcome, having used family planning services (yes or no) using chi-squared test. It showed that educational level and parity of respondents were positively associated with usage of family planning services (p<0.05) whereas marital status, age group and religion were not statistically significant. Table 2 shows a further logistic regression model that have demonstrated that educated women are more likely to use family planning services as compared their peers who did not receive formal education (P=0.01). Similarly, the higher the parity of women the more likely they are to use the service as compared to people with lower parity (p=0.03). However, the association between age, marital status, religion and usage of family planning services were not statistically significant (P>0.05).

Discussion
The study was a cross-sectional study that investigated the factors that influence the utilization of family planning services among women within the age group of 15-49 years in the Talensi district.
The findings suggest that although majority of the women were generally aware of family planning services in the district, usage of the service was low. Major reasons cited for not using service included husbands opposition against their wives using family planning services, this argument is in line with the observation made by Allen et al. (2014) in Uganda [15]. This is a major constrain as women in Ghana cannot take decisions for themselves without the approval of their husbands, who are regarded as the head of the family. Therefore it makes women more unlikely to use contraceptives if their husbands disagree. Another major reason that was reported were some perceived misconceptions about family planning services. Some of these misconceptions included respondents who did not go for family planning services because they perceived that it was meant for only married people whilst others perceived that contraceptives were harmful to the womb. Pakistan which observed that despite the high awareness of family planning services in the community, very few people used the service [20]. However, the high awareness of family planning services in the Talensi district may be attributed to the Communitybased health planning and services (CHPS) compounds concept that was introduced to make health care more accessible to the rural communities as well as empowering them to have greater control of their own health [21,22].
In this study, it was found that the educational level of respondents was positively associated with utilization of family planning services.
This finding suggests that people with higher education are more likely to go for family planning services than their counterparts with lower education. This agrees with other studies that revealed that women with higher education tends to be better informed about family planning services and are more likely to use the service than their peers with lower education [9,[23][24][25]. Parity was also positively associated with usage of family planning services. This conforms to similar studies reported in Nigeria where women are more likely to use family planning service if they have three or more children [26]. Region as a whole. However, some weakness in the study design limits the generalisation of findings to entire population of Talensi district as participants were conveniently selected from households rather than adopting a random sampling approach, which may not be representative of the general population. However, we ensured that participants were recruited randomly from households to address any problem of selection bias. Also, husbands should be involved in further research to investigate their perceptions about usage of family planning services.

Conclusion
In conclusion, this study has provided evidence to demonstrate that although the awareness of family planning services among community members could be high, it does not necessarily increase the uptake of family planning services if community members are not well informed about the benefits of family planning. It is therefore essential to organise educational campaigns on the awareness of family planning services by emphasising on the benefits of the services as it will help reduce misconceptions, and increase access and utilization of family planning services. Males should also be educated on the benefits of family planning services so as to reduce opposition from husbands. Furthermore, if women have the desire to space their children as well as prevent pregnancy and STIs, they are more likely to use the service.

Competing interests
The authors declare no competing interests.

Authors' contributions
Mathew Ayamba Adam and Paschal Awingura Apanga  Table 1: utilization of family planning services in relation to sociodemographic characteristics (n=280)    To have sex without children 6 12 Fear of pregnancy 22 44

Tables
To prevent pregnancy and STIs 42 84 Reasons for not accessing family planning services n (230) %

Against my religious faith 69 30
Fear of sexual promiscuity 14 6 Opposition from husbands 207 90 Distance to accessing the service 28 12 Poor health staff attitude 18 8 Side effects 32 14 Misconceptions 191 83 n=frequency %=percentage NB: Some respondents gave more than one reason