KNOWLEDGE, ATTITUDE AND PRACTICE OF FAMILY PLANNING AMONG WOMEN IN BASRAH CITY SOUTH OF IRAQ

Objectives: to estimate the prevalence of contraceptive use, and investigate the factors associated with knowledge, attitudes and practices of family planning. Method: A cross sectional, household multi-stage sampling. A sample of 900 currently married non pregnant women aged 15-49 years were selected from 30 household clusters in Basrah city, south of Iraq. Results: Current prevalence of contraceptive use (any method) among 900 non-pregnant women was 53.7%, use of modern methods was 37% and traditional methods was 16.7%. The use of traditional methods of contraceptives was significantly associated with older age, higher educational level. The main cause for not using contraceptives was health reasons. Husband's objection and cost of contraceptives also had role in non use of contraception methods. Conclusions: The rate of use of contraceptives was low for both any method and for modern types. The pill was the most popular method of contraceptives and the next more popular method was the withdrawal method. The study reveals good knowledge about family planning. Recommendations: Establishment of sensitive and modern family planning services through all primary health care services in all districts of Basrah. Increase Community awareness of family planning and the advantages of child spacing through mass media, Coordination between public and private sector to provide adequate family planning services and supplies and Policy-makers and health providers should target men since they are primary decision-


INTRODUCTION
arge families and rapidly growing populations hold back development at both the household and national level. ]1[ In many countries, women's ability to control their fertility is limited. Even where family planning methods are available, a woman may not use them because of financial constraints, personal beliefs, opposition from family members or concerns about the perceived adverse effects on health or future fertility. ]2[ Appropriate family planning is essential to the health of women and children by: Preventing pregnancies that are too early or too late, extending the period between births and limiting the number of children. ]3[ Promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and avert 32% of all maternal deaths and nearly 10% of childhood deaths. ]4[ National policy in Iraq on family planning and access to contraception has been in place since 1993 but there has been little or no updating of the policy since then. ]5[ Apart from private services, the current family planning program in Basrah governorate which is the second major governorate in Iraq after the Capital Baghdad is limited to only 2 governmental clinics according to data from public health department. Multiple cluster survey in 2006 showed that the rate of using any method of contraceptives for Basrah governorate was 56.1%,the use of modern methods was 39.3% and 16.8% of women used traditional methods. [3] The aim of this study was to help the development of family planning services in the area by estimation of the prevalence of contraceptive use among currently married non pregnant women aged 15-49 years in Basrah city. The study was the first household study in Basrah city since the national multiple cluster survey in 2006, that included an investigation of factors associated with knowledge, attitudes and practices about family planning methods.

METHODOLOGY
The study was a cross-sectional multi stage "probability proportionate to size" (PPS) cluster sampling, a methodology widely used for health indicators conducted in Basrah city, which is one of the seven administrative districts, located in the center of Basrah governorate/south of Iraq. The study was conducted during April, May and June 2011. The sample was 900 currently married non pregnant women aged 15-49 years were derived from 30 household clusters. Data taken from immunization unit in the public health department about household numbers and total population of target area showed that the number of household was 105457. Basrah city was divided into 34 areas which represent the catchments areas of the 34 health centers. The sample is divided into 30 clusters in order to ensure a valid prevalence estimate. The clusters were selected with probability proportional to size "PPS" (systematic sampling with a random start), each cluster was divided into segments based on roads. Each segment has approximately the same number of households. Once divided, one segment was randomly selected; again the chosen segment was again divided into sub segments of approximately 60 households and then 30 household were systematically selected from each segment by selecting every other household. From each household currently married non pregnant women aged 15-49 years was selected. In the areas selected, the two field teams coordinated closely with female health visitor of local primary health care center to identify, invite and encourage each of 30 females who were participated in the study to the assessments. Prior to field work, each team was trained in interviewing techniques, standardized coding and completion of questionnaire forms. The questionnaire form collected information about Personal particulars, and fertility experience of each woman. All respondents were asked about their knowledge of the socio-economic benefits of family planning, contraceptive methods and the main source of such information. Currently nonpregnant women were asked about any contraception they were using at the time of the survey, its type and source. Non-users were asked about the reasons for not using contraceptive. All data were expressed as numbers and percentages. SPSS version 16 was used for the statistical analysis. Chi-squared test was used to examine the association between the groups and a probability of less than 0.05 was considered to be significant

RESULTS
Regarding the characteristics of the female respondents. (Table-1), shows that 53.8% of all women had married before the age of 20 years. The ages of 74.9% of respondents were between 20-40 years at the time of the survey, 7.4% of the respondents were incapable of reading and writing. Only 14.3% of the respondents were employed, 51.4% of the women had 4 children and more. Overall 72.2% knew about some of the social and health benefits of family planning and that all the respondents were aware of at least one method of contraception (Table-2). It was noticed that the main source of knowledge, about different contraceptive methods was from health personnel as reported by 54% of the respondents. Relatives were the source of knowledge in 41.2% of the respondents and 4.8% knew about these methods from friends. Current prevalence of contraceptive use (any method) among 900 non-pregnant women was 53.7%, the use of modern methods was 37% and traditional methods was 16.7% (Table-2). Non-public sources in form of private pharmacies, represented the major source (74.7%) of family planning services, followed by private clinics and local markets (9.5% & 8% respectively). The role of public institutions was limited as shown in (Table-3). Contraceptive pills was the main type of family planning method used followed by the withdrawal method (30.2% and 12.3% respectively) as shown in (Table-4). The rate of using contraceptives increased significantly after the age of 20 then dropped again at the age of 40 years and above. Women with higher educational level significantly use contraceptive methods lower than those with lower education while as shown in (Table-5), there was no significant effect of women employment on the rate of use of contraceptives. Out of (483) respondents with current use of family planning 68.9% were using modern methods and 31.1% were using traditional methods, namely, lactation amenorrhea, periodic abstinence and withdrawal. The use of traditional methods of contraceptives significantly associated with older age, higher educational level and women employment as shown in (Table-6).

DISCUSSION
In many parts of the developing world, girls marry shortly after puberty. Because of societal pressures to prove their fertility and the increased status that motherhood brings, many young women become pregnant soon after marriage. [6] Additionally, the previous Iraqi government, particularly in the 1980s, encouraged high fertility to compensate for human loss during its wars. Until the middle of the last decade, therefore, the Iraqi Ministry of Health neglected family planning in the country. This explains why Iraq's crude birth rate was among the highest in the world. [4,7,8[ At the time of the survey, health services in Iraq, including family planning, were almost free of charge at government clinics, when these were accessible, but expensive at private clinics and pharmacies. The socio-demographic and fertility characteristics of our study population are consistent with the above. The notable features include high teenage marriage, and fertility rates and low employment rate of mothers. The rate of practicing family planning in the present study was similar to that for rural population in Pakistan (53%), higher than for Urban population of North India (37.6%), and lower than what was reported for Dohuk district North of Iraq (60.6%). [8-10[ In this study, Knowledge about family planning was good (72.2%), which was higher than what was reported in Urban population of North India (55.2%), but lower than what was reported for rural population in Pakistan (81%) and Dohuk (82.4%). ]8-10[ Information was mainly derived from health personnel and relatives but there was no role for mass media. This may be related that the government didn't play role in mass education of the population about the importance of family planning. While in other countries Mass media plays an important role in promotion and acceptability of contraception. ]10[ For many mothers, sources of family planning services was mainly from private pharmacies and clinics and, due to the limited and centralized nature of related public services. Similar finding reported in Egypt and Turkey. ]4[ Current use of modern contraception in this study (37%) was low compared with countries such the Islamic Republic of Iran (56%) and Egypt (53.9%), but was higher than that for Yemen (9.8%), Azerbaijan (11.9%) and Sudan (7%) as mentioned in WHO references. ]11,12[ As in some other developing countries, people in Basrah still value early marriage, large families and a role for woman inside the house. Adolescent mothers got a long fertile life to spend, at the same time they want to complete their families or most of it within the first five years of marriage. This could explain the lower rate of using contraceptives in this age group as shown in the present study. While the lower rate of using contraceptives among women of 40 years and older could be explained by that they had low perceived risk of pregnancy. However, in the study population, women were using traditional methods of contraceptives almost similar to south and center governorates (16.1%) and lower than in Kurdistan region governorates (23.6%) in the north of Iraq. ]3[ Worldwide, levels of use of traditional contraception are generally much lower than that of modern methods. ]13[ In this study, the use of traditional methods of contraceptives increased with women age, education and employment. This could be explained by that older women may be more familiar with traditional methods when they were young and they still prefer to use them, or new users may forgo use of traditional methods because modern methods are more readily available than in past years. ]14[ Educated women are frequently conservative, think about side effects of modern contraceptives more seriously than those with lower education, ]15[ and most of the employed women were educated. Apart from the desire to have more children, non-use of contraception among the studied population reflected local norms and religious beliefs similar to what was found for other areas of Iraq. ]3[ Health reasons and side effects were on the top of the list of non use of family planning methods which reach 44.4%, similar finding was found in a cross sectional study done in Mosul city north of Iraq. This may be explained by the fact that Iraqi women may become easily affected from side effects of the modern contraceptives regardless of the types which may be due to circumstances that they have been living with during the last decades such as low standards of living as results of successive wars in addition to the sanction which affected all aspects of life particularly of women of child bearing age, children as well as elderly. ]15[ In this study, big proportion of women with unmet need are forced by the husband and his family to follow their commands and bring as many children as they want. So unmet need from this reason, is considered as an indicator of violation of the women rights to participate in decision of the desired size of her family. [

Conclusions
The rate of use contraceptives was low for both any method and for modern types. However, the study revealed good knowledge about family planning. The main cause for not using contraceptives was health reasons. Husbands objection and cost of contraceptives also had role in non use of contraception methods.

Recommendations
-Establishment of sensitive and modern family planning services through all primary health care services in all districts of Basrah. -Increase Community awareness of family planning and the advantages of child spacing through mass media -Coordination between public and private sector to provide adequate family planning services and supplies -Policy-makers and health providers should target men since they are primary decisionmakers in the home.