Evaluation of the Effective Factors on State of Women Aged Between 18-49 Years to Continue and Discontinue the Use of Contraceptive Method

One of the principal indicators showing the health level of the woman is the family planning [1]. Family Planning (FP) concept is defined as all couples and individuals’ having desired number of children, deciding intervals between them freely, and having information. education and tools needed for this purpose [2]. By using FP practices it is tried: to prevent the unintended pregnancies, to terminate the pregnancies healthily, and to enable the couples to have the children in the desired number and at the desired time and intervals [3]. Today the family planning is an integral part of the general woman health and safe maternity programs [4]. Not using the contraceptive methods at the sufficient level brings along many health problems and social problems [5]. Thousands of mothers and children lose their lives every year because of the deficiency of the FP practices [3]. The unintended pregnancy is an important health problem for women all over the world [6]. According to literature; more than 100 million sexual intercourses take place every day in the world, about one million of such figure result in pregnancy, 25 % of the pregnancies are unplanned pregnancies and 25% are unintended pregnancies [7].


Introduction
One of the principal indicators showing the health level of the woman is the family planning [1]. Family Planning (FP) concept is defined as all couples and individuals' having desired number of children, deciding intervals between them freely, and having information. education and tools needed for this purpose [2]. By using FP practices it is tried: to prevent the unintended pregnancies, to terminate the pregnancies healthily, and to enable the couples to have the children in the desired number and at the desired time and intervals [3]. Today the family planning is an integral part of the general woman health and safe maternity programs [4]. Not using the contraceptive methods at the sufficient level brings along many health problems and social problems [5]. Thousands of mothers and children lose their lives every year because of the deficiency of the FP practices [3]. The unintended pregnancy is an important health problem for women all over the world [6]. According to literature; more than 100 million sexual intercourses take place every day in the world, about one million of such figure result in pregnancy, 25 % of the pregnancies are unplanned pregnancies and 25% are unintended pregnancies [7].
Additionally, 300 million couples do not use any contraceptive method. 120-150 million married women do not use any family planning method although they do not want to have any other child or intend to postpone their next pregnancies [8]. According to the data of Turkish Demographic and Health Survey (TDHS), 27% of women bearing still the risk of getting pregnant do not use any method. While rate of women using the modern method are 47%, rate of women using the traditional method are 26%. While the rate of using the modern method is 47% in West, this rate is 39% in Eastern Anatolia [9]. Under the light of these data, it is possible to say that there are some problems in delivery and use of FP services in Turkey. It is a known fact that women and their family members are psychologically and economically affected by the births given after unintended pregnancies as a result of using inefficient contraceptive methods or not taking any contraceptive precaution [10].
In order to deliver the efficient FP services it is required to know the factors affecting the use of FP methods and determine the attitude towards FP. This study was conducted to evaluate the effective factors on state of women aged of 18-49 years to continue and discontinue the use of contraceptive method.

Study design
This cross-sectional study was conducted to evaluate the effective factors on state of women aged of 18-49 years to continue and discontinue the use of contraceptive method.

Setting and sample
The women in the age group of 18-49 years. who were hospitalised in the gynaecology service of the xxx Hospital located in the province of Istanbul between 25.10.2015 and 25.01.2016. were included in the study. Without sample selection. the whole population was included in the study. 180 women who were capable to communicate verbally and agreed to participate in the study constituted the study group. This study was conducted in accordance with the principles of the Declaration of Helsinki. Before filling in the questionnaire, the women were informed about the purpose of the study and the voluntary basis was taken into account for participation in the study.

Ethical consideration
Attention was paid to comply with ethical principles in every stage of the study. Primarily, permission was received from University Medical Faculty Ethics Committee in order to conduct the study. Approval of the Ethics Committee of the xxx University was obtained. Written consent was received from the hospital where the study was conducted. Participant women were informed about the purpose of the study and their written consents were received with Informed Consent Form. Participants were firstly informed about the study. their consents were received and it was assured that their identities would never be disclosed.

Data collection tools
The data were collected through face-to-face interview and by using a questionnaire prepared by the researchers upon the literature review. In this study. a questionnaire with 55 questions developed by the researchers was used to determine socio-demographic characteristics of the women and the effective factors on their state of continuing and discontinuing the use of the contraceptive method. The questionnaire involved questions about demographic characteristics of the women such as age. educational level. marital status. as well as number of children. abortion. stillbirth. number of unintended pregnancies. the places supplying the contraceptive methods and reasons for using or not using the contraceptive methods.

Data analysis
The data of the study was analyzed on computer in SPSS 22.0 (IBM Inc., Chicago, IL, USA) Statistical Package for Social Sciences software package. Descriptive data of women were given in tables as numbers and percentage distributions. Means were given with standard deviation. The collected data were assessed by using arithmetic mean, percentage analysis and chi square test. In comparisons. confidence interval was taken as 95% and p significance level was accepted as p<0.05.  Table 1 illustrates demographic characteristics of the women. 35.6 % of the women were in the age group of 30-39 years, 53.3% were the primary school graduates, 95.0% were housewives, 83.9% were residing in the city centres, 46.7% had less income than expenditure, 61.1% had social security, 66.7% had a nuclear family, and the first marriage age of 60.6% was 19 years old or younger. When the husbands of the women were examined it was observed that 11.1% were literate, 44.4% were primary school graduate, 24.4% were secondary school graduate, 12.2% were high school graduate, and 1.7% were university graduate. When the occupations of their husbands were examined: 56.1% were workers, 17.8% were craftsman, 3.3% were civil servants, 2.2% were retired, 7.8 % were from other occupational groups (self-employment. etc.), and 12.8% were unemployed (Table 1).

Results
When pregnancy and fertility characteristics of the women in Table 2 were examined, it was observed that while 74.4% of the women had planned pregnancies, 26.1% had unintended pregnancies. 15.6% of the women with unintended pregnancy became pregnant because of not using the contraceptive method; whereas, 10.6% became pregnant because their contraceptive method failed (Table 2). 72.2% of the women participating in the study did not have any abortion and 80.0% did not undergo an abortion. 180 women included in the study had an average live birth of +1.59, and living children of +2.53. When the question "Do you want to have any other child?" was asked, 38.9% answered "No. I do not", 36.1% "Yes. I do", 24.4% "I do not want for the moment", and 0.6% "I am undecided. The reasons for desiring another child were stated as follows: 17.2% of the women "I love kids very much", 11.7% "because my husband wants to have",and 7.2% "because I want to have a baby boy". The question "who should decide the number of the children in family?" was answered by 78.9% as "the spouses should decide together." When the question "who decided the number of the children in your family?" was asked, 80.0% answered as "My spouse and me decided together". The period between the two births were stated as follows: 67.2% "3 years and more", and 27.2% "2 years". The reason of this period was explained as follows: 58.9% "the children shall grow to some extent", 15.6% "the mother shall get back her strength", 15% «the child and mother shall get up» 5.6% "to be strong enough for caring the child properly", and 5% "for overcoming economic difficulty" ( Table 2). When characteristics of the women regarding the use of the contraceptive method in Table 3 were examined, it was found that 28.3% of the women participating in the study stated that they did not use any family planning method, 30% used intrauterine devices, 15% used condom, 13.3% used pills, 10% used the coitus interruptus method and 2.8% underwent the tubal ligation operation (Table 3). In 46.1% of the women using the contraceptive methods, their husbands decided the use of the contraceptive method, 28.3% stated that they were using their methods for «2-4 years», 21.1% for «5-10 years», and 18.3% for 1-6 months. 24.4% of the women expressed that they chose their method upon advice of the midwife, 15% upon advice of the physician, 14.4% upon advice of the husband,9.4% upon advice of the friend/relative, and 8.3% upon advice of the nurse; 30% stated that they obtained the contraceptive method «from health centres» (Table 3). Reasons stated for not using the family planning method were stated as follows: 13.3% stated that "I desire to have a baby", 7.2% "my husband did not approve to use the contraceptive method", 4.4% "I believe that they are unhealthy", and 2.8% "I am infertile". Reason for preferring the intrauterine devices (IUD) was stated as follows: "Reliable" by 46.3%, "Easy to use" by 20.4%, "Protecting well" by 18.5%, and "No problem occurred" by 14.8%. Reason for preferring the condom was stated as follows: "it is the only method to use for me" by 25.9%, "Easy to use" by 25.9%, "it is the choice of the husband" by 22.2%, "it is the advice of the doctor" by 14.8%, and "reliable" by 11.1%. Reason for preferring the oral contraceptives was stated as follows: "Reliable" by 41.7%, and "it is the choice of the husband" by 33.3%. Reason for preferring the coitus interruptus method was stated as follows: "it is the choice of the husband" by 61.1%, "it is economical" by 22.2%, and "I have no other method to use" by 16.7%. Reason for preferring the tubal ligation method was stated as follows: "I do not want any more child" by 80%, and "My doctor prohibited the pregnancy for me" by 20%. It was determined that 15.6% of the women participating in the study became pregnant while using some contraceptive methods; 46.4% of them became pregnant while using "coitus interruptus method", 21.4% while using "pills", 14.3% while using "condom", 3.6% while using "the intrauterine devices" and also 14.3% became pregnant while "breastfeeding". 26.7% of the women changed their contraceptive methods. and 41.7 % of them explained the reason for changing the method by saying "I considered the method as non-reliable. Table 4 illustrates the relationship between the status of education and demographic characteristics and fertility. A significant correlation was found between the status of education and demographic characteristics and fertility (p<0.05). Accordingly; while the number of pregnancies in women who were primary school graduates were respectively 46.0%, 60.0% and 50.0%, these rates in women who were secondary school, highschool level education and above were respectively 19.0%, 9.5%, 4.8%, and 16.0%, 5.0%, 0.0% and 7.1%, 0.0% , 0.0% (Table 4). The group of patients who were primary school graduates wanted to have another children (56.9%, 0.0%) and were thought only husband should decide using of family planning methods (92.9%, 0.0%) compared to the group of patients who had secondary school level education and above ( Table 4, p=.000, p=.029).  Table 5 illustrates the relationship between the age groups and demographic characteristics and fertility. A significant correlation was found between the age groups and demographic characteristics and fertility (Table 5, p<0.05). While the number of pregnancies increased (5 and over) in the age group of 40-49 years (64.3%), the desire to have another child (33.8%) were observed more in the age group of 20-29 years and getting pregnant when using family planning (50.0%) were observed more in the age group of 30-39 years ( Table 5, p=.000).

Discussion
In the present study it was determined that rate of the women using any family planning method was 71.7%; whereas, the rate of those using no family planning method was 28.3% (the rate of using modern contraceptive method was 61.7% and the rate of using traditional contraceptive method was 10.0%). According to the 2013 data of TDHS, in Turkey the rate of the women using the family planning method was 74 %, the rate of using modern contraceptive method was 47% and the rate of using traditional contraceptive method was 26%, and the rate of the women not using any method was 27% [9]. In the study conducted by Özdemir et al. [11] in Düzce, the rate of women using any family planning method was 80.5 %, the rate of using modern contraceptive method was 53.9% and the rate of using traditional contraceptive method was 26.6%. On the other hand, the rate of women not using any contraceptive method was 19.5%. Although the populations of the studies have not been overlapped, it could be asserted that there has been an improvement in using the family planning method in Turkey.
In the present study, the contraceptive methods mostly preferred by women were IUD (30.0%) and condom (15%). The least preferred method was the contraceptives injected (0.6%). The rate of those using the coitus interruptus method was found to be 10.0%. In the study conducted by Oltuoğlu and Başer in Malatya in 2012, it was determined that among all methods, protection with the coitus interruptus method was the first preferred method with the rate of 35.5 %, which was followed by IUD (25.1%) and condom (20.3%) [12]. According to results of the study conducted by Tokuç et al. [13], the contraceptive methods mostly preferred by women are the intrauterine devices (20.9%) and condom (16.3%). The rate of using IUD in the present study was found to be higher than the rate reported in other studies; and the rate of the coitus interruptus method was lower. In the study conducted by Kutlu et al. [14], the contraceptive methods mostly preferred by women were condom (42.3%) and IUD (17.1%).
Determining the reason behind why women preferred their contraceptive method is very important to shed light medical staff on planning the service. It is very significant to teach the women the reasons of using an efficient contraceptive method, its advantages for mothers, children and society, to extend the related trainings and to prevent the reasons of preferring inefficient methods. That's why it is crucial for doctors, nurses and midwives, who work in the preventive health services, to reach the families in a regular and planned way, to inform them about modern contraceptive methods, and to consult them about choosing the contraceptive method suitable for the woman and her husband [15].
It was found that the women were affected by various factors while preferring the family planning methods. In the present study, the women whose husbands used the condom as family planning method stated that they continued to use the condom due to following reasons: 25.9% «it is the most suitable method», 25.9% «it is easy to use», 22.2% «it is the choice of her husband», and 11.1% «I considered this method as reliable». The women using the pills stated that they continued to use the pills due to following reasons: 41.7% «it is reliable», 33.3% «it is the choice of her husband», 8.3% «it is easy to use», and 16.7% «it is advice of the doctor». Reasons for using the coitus interruptus method were stated as follows: "it is the choice of the husband" by 61.1%, "it is economical" by 22.2%, and "I have no other method to use" by 16.7 %. In the study conducted by Tanrıverdi et. al. in Çanakkale in 2008 the similar results were obtained. In their study, women whose husbands used the condom as family planning method stated that they continued to use the condom due to following reasons: 43.4% «it is reliable, 30.1% «it is easy to use», 16.9% « it is the most suitable method», and 9.6% «it is the choice of the husband» [16]. In the same study, the women using the pills stated that they continued to use the pills due to following reasons: 36.6% «it is reliable», 34.1% «it is easy to use», 24.4% «it is advice of the doctor», and 4.9% «it is the choice of the husband». The women used the coitus interruptus method due to following reasons: 39.4% «it is the choice of the husband», 38.0% «it is reliable», 11.3% «they do know any other method», 5.6% «it is economic», and 5.6% «they recently have aborted/delivered a baby [16].
In the present study, the reasons for not using the family planning method were stated as follows: 13.3 % stated that "I desire to have a baby", 7.2% "my husband did not approve to use the contraceptive method", 4.4% "I believe that they are unhealthy", 2.8% "I am infertile", and 0.6% "I am pregnant". In the study conducted by Kaya et al. [17], the similar results were also obtained. In their study, the reasons for not using the contraceptive methods were stated as follows: 39.6% stated that «I desired to have a baby», 12.5% «I am in lactation period», 6.2% "I believe that they are unhealthy", and 4.2% «my husband did not want to use those methods» [17].
In the present study, 15.6 % of the women participating in the study became pregnant while using the family planning method; 46.4% became pregnant while using "coitus interruptus method", 21.4% while using "pills", 14.3% while "breastfeeding", 14.3% while using "condom", and 3.6% while using "IUD". 26.7 % of the women changed the contraceptive method, and 41.7% of them explained the reason for changing the method by saying "I considered the method as non-reliable". In the study conducted by Bülbül and Pasinlioğlu in Erzurum in 2003 it was also found that 50.8% of the women participating in the study became pregnant unintentionally and 93.3% were using a FP method while becoming pregnant. Examining FP methods used among women becoming pregnant while using a FP method; the coitus interruptus method was 44.7%, the condom is 25%, and pills was 12.5%. The results of the study conducted by Bülbül and Pasinlioğlu 2001 were similar to the results of the present study [18].
A significant correlation was found between the status of education and demographic characteristics and fertility ( Table  5, p<0.05). Accordingly; while the number of pregnancies in women who were primary school graduates were respectively 46.0%, 60.0% and 50.0%, these rates in women who were secondary school, highschool level education and above were respectively 19.0%, 9.5%, 4.8%, and 16.0%, 5.0%, 0.0% and 7.1%, 0.0%, 0.0% (Table 5). In the study conducted by Kutlu et al. [14], similar results were reached. According to these results, while the prevelance of not using family planning methods were increased in women who were illiterate, the prevalance of using family planning methods were increased in women who were primary school graduates and above [14].
According to results of this study, becoming pregnant while using condom (14.3%), pills (21.4%) and IUD (3.6 %), which are the efficient and modern methods, could make those methods questionable at first view; however, it is a fact that these methods are not used in a correct and efficient way.
As a consequence, it was determined that IUD, pills and condom were commonly used because the women considered them as reliable; whereas, the coitus interruptus method was used by the women because it was the choice of their husbands. In accordance with these results, it can be recommended to explain the family planning methods to all the women, to prepare training programs including the men, and to train husbands using the coitus interruptus method.