Contraceptive Utilisation Among Mothers of Reproductive Age in Ajman , United Arab Emirates

Objectives: This study aimed to determine contraceptive utilisation among mothers aged 18–49 years old in Ajman, United Arab Emirates (UAE). Methods: This cross-sectional study was carried out from May to November 2013. A total of 400 participants were recruited from two primary healthcare centres and one private hospital in Ajman. An interviewer-administered validated questionnaire was used for data collection. Results: The frequency of previous and current contraceptive use was 68.0% and 61.8%, respectively. Expatriates more frequently used contraceptives in comparison to Emiratis (77.3% versus 54.3%, respectively). Contraceptive use increased significantly with age (75.5% among >35-year-olds versus 57.3% among ≤25-year-olds; P <0.050) and education level (83.3% among postgraduates versus 60.0% among those with primary education; P <0.050). In addition, contraceptive use was significantly higher among those living in a nuclear family system (P <0.050). A univariate analysis indicated significant associations between contraceptive use and age, nationality, education level, type of family system, employment sector, parity, knowledge of birth control measures and source of birth control information (P <0.050 each). However, no significant associations were found via multivariate analysis. Conclusion: Healthcare practitioners can play a pivotal role in providing contraceptive advice which could lead to an improvement in contraceptive utilisation. Efforts are recommended to raise awareness regarding newer forms of contraceptives among mothers of reproductive age in the UAE.

A time period of two years is recommended between births to prevent adverse pregnancy outcomes and to aid optimal child growth. 1 Contraceptives are family planning methods which can help individuals to control the timing, birth spacing and number of children they have, as necessary. 1][4] Recently, high-quality family welfare programmes have been established in order to make contraception available, accessible, affordable and acceptable. 5,6At the World Summit of 2005, various countries pledged their commitment to achieving universal access to reproductive healthcare by 2015; however, these goals are still far from being fully realised, with an estimated 143 million women worldwide still lacking access to contraception. 7Population growth rates in less developed countries are greater than those of more developed countries, due in part to a lack of access to reproductive healthcare services. 2etween 1970 and 2000, the worldwide fertility rate dropped from 4.7 to 2.6; this rapid decrease has been attributed to increased contraceptive usage in recent years. 8In 2011, it was estimated that 63% of women of reproductive age worldwide used various family planning methods. 7However, even in the USA, approximately 10-15% of all sexually active women do not use contraceptive measures, contributing to an unintentional pregnancy rate of ≈50%. 2,9][12] As such, failures in adequate family planning measures can adversely affect the health of the mother and family as a whole. 1,13n the United Arab Emirates (UAE), considerable improvements have been made with regards to the availability of contraceptive measures in both public and private sectors in response to growing consumer demand. 14In 1995, the estimated prevalence of contraceptive use in the UAE among married women between 15-49 years old was 27.5%. 7Other studies have reported rates of contraception use of 41.5% and 27% in 2001 and 2002, respectively. 15,16nfortunately, there are no recent empirical studies on contraceptive utilisation in the UAE and previous findings are complicated by the existence of a diverse and multicultural society in which contraceptive use differs between population groups.This study therefore aimed to determine contraceptive utilisation among mothers of reproductive age in Ajman, UAE.

Methods
This cross-sectional study was carried out from May to November 2013 at two primary healthcare centres and one private hospital in Ajman.These locations were chosen so that the study participants would represent the diverse population of the UAE, as primary health care centres generally cater to the local Emirati population while expatriates typically seek healthcare services from private hospitals.The inclusion criteria consisted of married women between 18-49 years old who had given birth to at least one child previously, as women were considered less likely to use contraceptive measures immediately after marriage.Women who were currently pregnant, had previously undergone a hysterectomy or who could not comprehend the questions were excluded.For this study, as contraceptive prevalence varies among different ethnicities, a contraceptive utilisation prevalence of 50% was assumed with a marginal error of 5%, resulting in a minimum required sample size of 400. 15As such, a total of 400 participants were recruited via a convenience sampling method from the Department of Obstetrics & Gynaecology and the Paediatric & Immunization Clinic of the GMC Hospital and the female outpatient departments of the Al Madina Primary Health Care Centre and Al Mushrif Primary Health Care Centre.
An interviewer-administered questionnaire was developed to collect information from the participants regarding their demographic characteristics (age, nationality, education level and duration of marriage), socioeconomic characteristics (employment status and sector as well as monthly income and type of family), reproductive history (number of pregnancies, live births and miscarriages) and contraceptive utilisation (current/previous use of contraceptives and preferred method of contraception).The questionnaire was originally developed in English before being translated into Arabic using back translation methods.For the purposes of the study, current contraceptive utilisation was defined as the use of any modern or traditional method to delay or avoid pregnancy within the preceding 30 days. 17This period was chosen to minimise recall bias.The use of contraception more than one month beforehand was considered to denote previous use.Family systems were categorised as either nuclear (i.e. a father, mother and their unmarried children), joint (i.e. a father, mother and their married sons or daughters, respective daughters-in-law or sons-in-law and any grandchildren in the same household) or threegeneration (i.e. a father, mother, only one married daughter or son, their respective daughter-in-law or son-in-law and their children) systems.
In addition, the questionnaire also included items designed to assess factors influencing choice of contraceptive method (e.g.satisfaction with current contraceptive method, perceived vulnerability of becoming pregnant, concerns about side-effects, economic considerations, comfort with and access to contraceptives and associated embarrassment in discussing/buying contraceptives), reasons for using contraceptives (e.g.limiting family size, spacing pregnancies, financial or medical concerns, complications during previous pregnancies, genetic defects in older children and a desire to work outside of the home) and factors influencing discontinuation of birth control (e.g.hazards to health, refusal of the husband to cooperate in contraceptive use, secondary infertility, side-effects, cultural reasons, medical concerns and pressure from other family members not to use contraception).Knowledge of birth control measures was assessed by whether the participants knew about the existence of different contraceptives and, if so, the source of their information regarding contraceptives.The content validity of the questionnaire was assessed by public health experts and a gynaecologist.A pilot study was subsequently carried out to finalise the questionnaire items, assess the time needed to complete the questionnaire and determine whether participants could easily understand the questions.As a result, questions regarding husbands' age, education level and employment status were removed and a question assessing type of family system was included.The pilot study sample included five women recruited from the same study locations and using the same inclusion criteria as previously described; these women were not subsequently included in the full study.
Data were entered into a Microsoft Excel spreadsheet, Version 2007 (Microsoft Corp., Redmond, Washington, USA) and transferred for analysis to the Statistical Package for the Social Sciences (SPSS), Version 20 (IBM Corp., Chicago, Illinois, USA).Descriptive statistics, including frequencies and percentages, were used to describe the characteristics of the study population.A Chi-squared test was used to assess associations between independent and dependent variables.Significant variables were subsequently included in univariate and multivariate analyses.A P value of <0.050 was considered statistically significant.
This study received ethical approval from the Ethics & Research Committees of the Gulf Medical University, Ajman, and the UAE Ministry of Health (#57/2013-06-27).All of the women gave written informed consent before participating in the study.Participants were assured of their anonymity and were informed that their responses would be kept confidential and used only for research purposes.1].
Among previous contraceptive users, decisions relating to contraceptive choice (n = 141; 51.8%)     among women with nuclear families versus 62.3% among those with joint families and 52.0%among those with three-generation families; P <0.050).A sta-tistically significant positive association was observed between number of children and the use of contraceptives (P <0.010).Employment status was not significantly associated with the use of contraceptives [Table 3].In terms of associations between source of contraceptive knowledge and use of contraception, doctors were the only information source which showed a significant association with contraceptive use (P <0.050) [Table 4].
A univariate analysis was conducted to determine factors affecting the probability of not using contraception.Among women >35 years of age, there was a 56% lower chance of not using contraceptives in comparison to those ≤25 years old (odds ratio [OR]: 0.44, confidence interval [CI]: 0.23-0.83).Among Emiratis, the likelihood of not using contraceptives was three times higher than for expatriates (OR: 2.87, CI: 1.86-4.42).Women with primarylevel education were three times more likely not to use contraception in comparison to postgraduates (OR: 3.33, CI: 1.16-9.62).Similarly, among women with a secondary education, the likelihood of not using contraceptives was 3.2 times higher compared to postgraduates (OR: 3.20, CI: 1. 25-8.18).Women from a three-generation family system had a 2.4 times higher chance of not using contraception compared to those with a nuclear family system (OR: 2.40, CI: 1.30-4.43).Working in the government sector resulted in a five times increased chance of not using contraceptives compared to the private sector (OR: 4.89, CI: 1.90-12.56).Women with one child were 2.6 times more likely to not use contraception as compared to those with ≥6 children (OR: 2.63, CI: 1.10-6.27).Women who knew about birth control measures were 99% more likely to use contraceptives (OR: 0.01, CI: 0.01-0.03).Among participants whose primary source of information about contraceptives was doctors, there was a 57% lower chance of not using contraceptives (OR: 0.43, CI: 0.20-0.91)[Table 5].However, none of these variables were significantly associated with contraceptive use according to a multivariate analysis [Table 6].

Discussion
Preventing an unplanned pregnancy is an important global issue. 17Effective contraceptives benefit both mothers and their children by decreasing morbidity and mortality rates and improving their social and economic status. 18In the UAE, there is high parity and social acceptance of birth control is limited for cultural and religious reasons. 15The current study aimed to determine contraceptive utilisation among mothers Rates of contraceptive use vary in Arab countries.In the current study, the current and previous use of contraceptives was found to be 61.8% and 68.0%, respectively.Use of contraceptives was noted to be 44.8% and 47.8% in Saudi Arabia and Qatar, respectively. 20,21Higher rates have been observed in Bahrain (61.8%),Syria (58.3%) and Lebanon (58%), while lower rates have been reported from Qatar (43.2%),Oman (31.7%),Yemen (27.7%) and Saudi Arabia (23.8%). 7This variation in findings could be attributed to differences in local cultural attitudes in these countries towards the use of contraceptives.In the current study, previous use of contraceptives was higher among expatriates than Emiratis and the probability of not using contraceptives was three times higher among Emiratis; this rate was higher than that reported in previous research. 15ge was found to have a significant relationship with contraceptive use in the current study, with older women more likely to use contraceptives in comparison to younger women.This observation is in accordance with previous research conducted in Saudi Arabia and Qatar. 20,21This finding may be due to the fact that older women are more likely to use contraceptives if their fertility goals have already been met or to ensure a greater amount of time between births to preserve their health.Among women under 25 years old, contraceptive use was less frequent; this might be explained by an increased desire to have more children, as noted in previous studies conducted in the UAE and Saudi Arabia. 15,20In addition, the current study found that contraceptive use increased with education level; this finding is similar to that of previous research conducted in the Gulf region. 15,20,21However, studies conducted in India have found that education was not associated positively with contraceptive use. 22,23In general, improving women's education has been reported as a method of increasing their status and autonomy, which in turn can help to improve contraceptive practices. 24t is possible that less educated women have fewer educational and career-oriented aspirations and have lower levels of understanding of their health as compared to more educated women. 25mployment status and contraceptive use were not found to be significantly associated in the present study.This is contrary to findings from Saudi Arabia, where contraceptive use was reportedly four times higher among working women. 20However, mothers working in the private sector in the current study were five times more likely to use contraceptives compared to government sector workers.This may be because employment decisions among mothers often depend on family and child care responsibilities; as such, women may prefer government professions over those in the private sector due to increased job and income security, more desirable working conditions and shorter working hours. 26A significant association between type of family system and use of contraceptives was noted in the current study.Women within a three-generation family system were less likely to use contraceptives compared to those within a nuclear family system.8][29] In addition, individuals in a joint family system often depend financially on the head of the family and therefore may not be limited by financial concerns when making family planning decisions. 29Moreover, in a joint family system, a woman's social position can be elevated after the birth of a child and they may not be solely responsible for making the decision to have more children. 29In general, most women prefer to use contraceptives after they have reached their ideal family size. 20,30owever, the ideal family size differs according to culture and society.In the current study, women with one child were less likely to use contraception compared to those with six children or more.This finding is consistent with previous research from Saudi Arabia, which has similar religious and cultural characteristics to the UAE; contraceptive usage was reportedly to be higher among women with higher parity. 20he majority of participants in the current study were aware of birth control measures; in addition, knowledge of birth control measures was significantly associated with contraceptive use.In contrast, research conducted in Qatar indicated that the majority of participants were aware of contraceptives but had a negative attitude towards contraceptive use due to their sociocultural norms and religious beliefs. 21In Saudi Arabia and Qatar, family members and friends were found to be the most common source of contraceptive information. 20,21However, in the current study, doctors were reported to be the main source of information about contraceptives; moreover, mothers who reported doctors as a source of contraceptive information had an increased probability of using contraceptives as compared to those who did not.This observation is in line with previously reported research in the region. 15This result clearly demonstrates the importance of doctors in providing advice to women about contra-ceptives and influencing decisions to use contraceptives.Therefore, sustained efforts to raise awareness of the proper use of contraceptives is highly recommended in the UAE, for instance through the implementation of doctor-led community outreach/ awareness campaigns.
In the present study, women who were currently using contraceptives primarily used modern methods of contraception.This is a key finding as previous research in the UAE reported a greater frequency of use of traditional contraceptive methods, followed by the IUD. 15However, the current study's results were in accordance with research from Qatar, where the practice of modern contraceptive methods was higher among current contraceptive users, probably due to the influence of economic development and the increased availability of information. 21In the current study, the most preferred birth control method was found to be male condoms followed by IUDs and the withdrawal method.Potentially, more women might prefer condoms as compared to other methods of contraception because of their easy availability without a prescription or due to concerns about the possible side-effects of other contraceptive methods.Few women in the current study were aware of newer forms of contraceptives (e.g.transdermal patches, implants and rings); as such there is an urgent need to increase awareness of contraceptive availability and options among women of reproductive age in the UAE.
The current study is subject to certain limitations.The findings are not generalisable to all women in the UAE due to the non-probability sampling method used to recruit participants.Moreover, as the participants were recruited from women attending primary healthcare centres and private hospitals in Ajman, the study cohort is not representative of the general population.In addition, the findings do not include contraceptive use among sexually-active single women as the aim of the study focused on contraceptive use among married women; however, it is important to note that extramarital relations are prohibited in predominantly Islamic countries, such as the UAE, and are henceforth not usually openly discussed. 15Further research is recommended in order to compare the findings of the current study to those of the general population in the UAE.

Figure 1 :
Figure 1: Sources of contraceptive information among a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 293).EM = educational material.

Table 1 :
Sociodemographic characteristics of a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 400) *Defined as contraceptive use within the previous 30 days.† Defined as contraceptive use before the preceding 30 days.Naila Kanwal, Jayakumary Muttappallymyalil, Shatha Al-Sharbatti and Iman Ismail Clinical and Basic Research | e53 Results

Table 2 :
Type of contraceptive used and preferred contraceptive method among current contraceptive users* in a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 247) *Defined as contraceptive use within the previous 30 days.†Including the withdrawal and rhythm methods.‡ Including barriers (e.g.male condoms), intrauterine contraceptive devices, oral contraceptive pills, injections and tubal ligation.

Table 3 :
Relationships between previous contraceptive use* and sociodemographic characteristics and source of contraceptive information in a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 400)Contraceptive Utilisation Among Mothers of Reproductive Age in Ajman, United Arab Emirates e54 | SQU Medical Journal, February 2017, Volume 17, Issue 1

Table 4 :
Relationships between previous contraceptive use* and source of contraceptive information in a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 293) *Defined as contraceptive use before the preceding 30 days.

Table 5 :
Univariate analysis of relationships between significant variables and previous contraceptive use* in a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 272) Naila Kanwal, Jayakumary Muttappallymyalil, Shatha Al-Sharbatti and Iman Ismail Clinical and Basic Research | e55

Table 6 :
19ltivariate analysis of relationships between significant variables and previous contraceptive use* in a cohort of married mothers of reproductive age in Ajman, United Arab Emirates (N = 272) Contraceptive Utilisation Among Mothers of Reproductive Age in Ajman, United Arab Emirates e56 | SQU Medical Journal, February 2017, Volume 17, Issue 1of reproductive age in Ajman.According to the 2005 census, the total number of women of reproductive age in Ajman was 47,191; of these, 10,687 were Emiratis (22.6%) and 36,504 were expatriates (77.4%).19