Family Planning Perspectives

### **Chapter 7**

## Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods

*Panagiotis Tsikouras, Athanasia Hatzilazarou, Anastasia Bothou, Ethimios Oikonomou, Dimitrios Kyriakou, Athanasia Kassapi, Alexios Alexiou, John Arabatzis, Maria Georgada, Theopi Nalbanti, Natalia Sachnova, Konstantinos Nikolettos, Georgios Iatrakis and Nikolaos Nikolettos*

#### **Abstract**

The sexual liberation of women can now be taken for granted, and access to information is particularly easy, but even today there is still many lack of information about contraceptive methods. No method of contraception has a 100% guaranteed result as success depends on many factors such as faithful adherence to the instructions of family planning centers, age of the woman, the frequency of the sexual act, and of course the type of contraception. Emergency contraception refers to any method of contraception used after intercourse and before implantation. It differs from the medical termination of pregnancy, which has 75–89% effectiveness and copper IUDs. Contraception is used to stop the sperm from fertilizing the egg or to stop the fertilized egg from implantation in the uterus. All contraceptive methods require educational awareness and emergency contraception should not be used as normal contraceptive treatment. It does not fall into the sphere of moral dilemmas if it is taught correctly at the levels of primary and secondary education and in the family sphere. Undoubtedly, the organization of family planning centers for women of reproductive age as well as for teenagers is deemed necessary and should become a priority of every government.

**Keywords:** emergency contraception, methods, safety, effectiveness, medical contraceptives, cooper IUDs

#### **1. Introduction**

Despite the existence of highly effective contraceptive methods, many pregnancies occur unplanned and the majority of them are unwanted. These pregnancies put women at increased risk of morbidity and mortality and are often artificially terminated without the necessary safety. The risk of conception after a free intercourse is about 25%, depending on the day of the menstrual cycle. Emergency contraception is the method that reduces the risk of pregnancy if administered after unprotected intercourse and before conception [1–3].

It is usually used when no contraceptive method is followed, mistakes were made in using a method or sex without consent, or rape without contraception. The conditions for spontaneous conception pregnancy include: fertile sperm in the fallopian tube, live spermatozoa up to 5 days, and eggs capable of fertilization in the uterus within 12–24 hours. Pregnancy begins when implantation is achieved. Fertile days are the 6 days preceding and including the day of ovulation [3–6]. One intercourse during this period has a 30% risk of conception, and a single unprotected intercourse in the cycle has a 25% chance of occurring on fertile days. On each day of the cycle, there is a theoretical possibility of conception and emergency contraception must be administered to each unprotected contact [1–6].

The purpose of this study is to publish the results of nine-year follow-up from the Family Planning Center of the Democritus University of Thrace and review international literature.

#### **1.1 Contraception**

Since the 1960s, the use of specific steroid oral contraceptive hormones has been shown to be effective in preventing unwanted pregnancy. Also, copper IUDs are highly effective as emergency contraception, while mifepristone is an antiprogestogen whose role in emergency contraception has been considered controversial [7].

Emergency contraception refers to an occasional method of contraception that prevents pregnancy after intercourse without or with inadequate contraceptive measures. Currently, available emergency contraception methods are the combined contraceptive pill containing ethinylestradiol and levonorgestrel (Yuzpe method), the progestogen pill, copper IUDs, and mifepristone or ulipristal acetate. The success rate of the Yuzpe method is 75%, while levonorgestrel administration prevents unwanted pregnancy in 85% of cases. As far as hormonal emergency contraception is concerned, there are no contraindications for its use, so it can be administered without hesitation. The use of a copper intrauterine coil for emergency contraception is very effective, with success rates greater than 99% [8–10].

Emergency contraception is applied and works before fertilization, so it is not an abortion. In the past and in limited cases, but even today for the same purpose, intrauterine devices are also used. Emergency contraception or the morning-after pill is the medicine that can be used after unprotected intercourse or where the contraceptive method has failed (e.g., the condom has broken) in order to prevent a possible pregnancy.

#### *1.1.1 Indications for applying emergency contraception*

Emergency contraception works by one of the following processes, depending on the stage of the cycle it is used:

By decreasing LH, it either delays or inhibits ovulation, preventing partial or total yellowing of the follicle depending on when EA (emergency contraception) is administered (**Table 1**).

It prevents the formation of the corpus luteum.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*


**Table 1.**

*Indications for applying emergency contraception.*

It causes histological or biochemical changes in the endometrium with the result that implantation is prevented.

Emergency contraception stops pregnancy before it starts. It is not an abortion, it is applied and works before the pregnancy test is positive. It is ineffective in established pregnancy, against which it has no potential for action and should not be taken [7–12].

#### **2. Emergency contraception methods**

#### **2.1 Hormonal contraception**

#### *2.1.1 Estrogen*

High doses of estrogen when administered within 72 hours of intercourse prevent pregnancy. This is an older method that is not used now.

#### *2.1.1.1 Mechanism of action of estrogens*

Alteration of the intrinsic motility of the fallopian tubes. Inhibition of the function of the corpus luteum at the level of prostaglandins.

#### *2.1.1.2 Endometrial changes*

In the past, tablets containing a large amount of estrogen were mainly used. The method required taking two oral tablets (containing 50 μg of ethinylestradiol and 0.5 mg of norgestrel) as soon as possible after intercourse and another two tablets after 12 hours. However, nausea is a common symptom with these dosages. The total hormonal dose received in this way is less than the total dose received in a cycle with administrated oral dose (AOD), and only the absolute contraindications of AOD were usually taken into account [13–16].

#### *2.1.1.3 Estrogen/progestogen combination*

The combined contraceptive pill containing ethinylestradiol and levonorgestrel can be given for emergency contraception according to a protocol described as the Yuzpe method.

Dosage regimen: 100 μg ethinylestradiol +500 μg levonorgestrel (Yuzpe).

Taken 2 times within 12 hours and within 72 hours of contact. Pregnancy rate reduced to 2/3 (56–89%).

#### *2.1.2 Progestogen-only preparations*

#### *2.1.2.1 Levonorgestrel*

Levonorgestrel remains the first choice for patients as emergency contraception, 0 to 72 hours after unprotected intercourse.

In recent years, levonorgestrel 0.75 mg was released as an emergency contraceptive in two tablets and then in one tablet (Norlevo, Postinor, 1500 μg). This method has fewer side effects, mainly in terms of nausea and vomiting, than using contraceptive pills.

In the original packaging, the first tablet (as is generally the case in emergency contraception) was taken as early as possible after intercourse, with best effectiveness if taken within the first 12 hours. The first tablet should not be taken if the effectiveness of ulipristal acetate is greater than that of levonorgestrel [17–23].

The mechanism of action is largely unknown. However, levonorgestrel is thought to:

It suppresses ovulation, preventing fertilization.

It alters the endometrium, preventing implantation of the fertilized egg.

Dosage regimen: Levonorgestrel (LNG) 1.5 mg within the first 72 hours although there are data for action up to 120 hours. Failure has been estimated at 1.1–2% with the risk of an unwanted pregnancy being reduced to 60–93%.

Thus, it prevents a pregnancy, regardless of the phase of the cycle in which the woman is. However, if the process of implantation of the fertilized egg in the uterus has already begun, the preparation will have no effect; that is, it will not cause a miscarriage [13–16, 24–27].

#### **2.2 Effectiveness**

Levonorgestrel should be delivered as soon as feasible, ideally within 12 hours, following a sexual encounter during which measures were not followed or were unsuccessful, and no later than 72 hours (3 days) after the encounter in order to attain the method's optimum efficiency.

If taken within 24 hours of "suspected" intercourse, it is 95% effective at preventing an unwanted pregnancy.

If given within 24 to 48 hours, it is 85%, while if taken within 48 to 72 hours, it drops to 58%. Therefore, the sooner it is taken after suspected contact, the more effective it is. It can be used at any time during the cycle if contact occurs without protection.

In no case should emergency contraception replace regular methods of contraception. It should not be used on a permanent basis, but only in exceptional cases, as the repeated intake of the preparations can cause cycle disturbances due to the high hormonal load it causes.

#### **2.3 Unwanted actions**

The most common side effects that have been reported after its use are nausea in a percentage of 20%, as well as headaches or vomiting in smaller percentages. In addition, breast irritation, future ectopic pregnancy, thrombosis, and infertility may occur. In cases of vomiting less than two hours after taking the contraceptive dose, a repeat dose is recommended.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

It has not been demonstrated, though, that this strategy improves contraception's efficacy. The likelihood that the vomiting was brought on by the pill's absorption is very high.

However, if vomiting prevents oral medication administration, the medication may be given vaginally.

Contraceptive tablets administered vaginally have not been proven to be successful, although it is known that the vaginal epithelium is a great receptor for steroid hormones used as contraceptives.

Atypical stomach pain, feeling exhaustion, headaches, dizziness, breast tenderness, blood spots, or vaginal bleeding are some more adverse effects [17, 28–30].

#### **2.4 Contraindications**

Other than pregnancy, using emergency contraception is not contraindicated. Interactions with other medications.

When prescribing emergency contraception to women using rifampicin, griseofulvin, anticonvulsants, or barbiturates, many doctors choose twice the required dose. This tactic is based on observations of the pharmacokinetics of combined hormonal contraceptive pills, but there is no scientific evidence to justify its application in emergency contraception. It seems that increasing the dosage does not cause any particular side effects, apart from increasing the possibility of nausea and vomiting.

#### **2.5 Frequency of use of hormonal emergency contraception**

The use of hormonal emergency contraceptive pills should not replace the use of regular combined hormonal contraception. At the same time, pregnancy rates with the use of emergency contraception are higher compared to normal hormonal contraception. However, in cases where intercourse occurs a second time without precautions and in the same cycle the couple has already received hormonal emergency contraception once, they can use them again.

The woman should know that the use of hormonal emergency contraception does not protect her from unwanted pregnancy if she has unprotected intercourse later in the same menstrual cycle. In cycles where more than one intercourse has occurred the effectiveness of hormonal emergency contraception is affected by the time interval between taking the tablets and the first intercourse. The woman should know that if there is already a pregnancy, hormonal emergency contraception is not effective [17, 27–30].

#### **2.6 Time of menstruation after taking the morning-after pill**

Ulipristal (ellaOne, HRA Pharma) is an emergency oral contraceptive that has recently been launched on the UK market and has been licensed for use across Europe. ellaOne consists of one tablet containing 30 mg of ulipristal acetate (also known as CDB-2914 and VA2914). Ulipristal is a synthetic steroid, derived from 19-norprogesterone, and is a selective progesterone receptor modulator (SPRM), a class of tissueselective compounds that act as complete agonists, antagonists, or partial agonists of the progesterone receptor.

Ulipristal acetate also exhibits high affinity for the glucocorticoid receptor and *in vivo* antiglucocorticoid effects have been observed in animals. However, no such effects have been observed in humans, even after repeated administration of a daily dose of 10 mg. Ulipristal acetate has little affinity for androgen receptors and no affinity for human estrogen or corticosteroid receptors [17–21].

The first SPRM, mifepristone, is used in abortions and is also an effective emergency contraceptive. A Cochrane review concluded that mifepristone is more effective than progesterone emergency contraception up to 120 hours after intercourse; however, it has not been developed for this indication in the UK and is not licensed for use as emergency contraception in no European country. It has been said that ulipristal is a second-generation SPRM. Due to variations in their active metabolites, ulipristal has substantially less antiglucocorticoid action than mifepristone *in vivo*.

The important difference of ulipristal from emergency contraceptives based on levonorgestrel is that it maintains its effectiveness for 5 days after unprotected intercourse, while the safety and tolerability of the drug have been shown to be comparable to that of levonorgestrel [17–21].

#### **2.7 Action mechanism**

The main mechanism of action of ulipristal is thought to be the prevention or delay of ovulation. A single dose has been shown to suppress the development of the dominant follicle.

Ovulation can be prevented by ulipristal administration immediately before or, in certain situations, just after the peak of luteinizing hormone. Changes in the endometrium might also be important. Administration of ulipristal during the early luteal phase results in delayed endometrial maturation and changes in progesterone-dependent markers of implantation. If given in the mid-luteal phase it has been shown to cause premature endometrial bleeding in a dose-dependent manner.

It is possible that these changes in the endometrium inhibit implantation, making it less receptive to the trophoblast. However, it is not known whether ulipristal has a direct effect on the endometrium or whether the observed changes are a result of the effect on the ovaries.

Levonorgestrel works by blocking the LH surge but does not appear to interfere with follicular rupture when taken near ovulation when intercourse is most likely to result in conception.

In contrast, ulipristal has been shown to prevent ovulation even after the LH surge has begun. This may be the reason why ulipristal remains effective up to the 5th day after contact [21–23].

#### **2.8 Current recommendations**

Ulipristal acetate is recommended as a treatment option for patients presenting between 72 and 120 hours after unprotected intercourse or failure of contraceptive measures.

#### **2.9 Contraindications**

Ulipristal acetate is contraindicated in pregnancy as data on the health of the fetus after exposure to the substance is extremely limited. If pregnancy is suspected, a pregnancy test must be performed before taking the substance.

Administration of the substance is contraindicated in people who show hypersensitivity to it or to its excipients.

Special precautions and warnings during use.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

Emergency contraception is an occasional method of contraception. Data on the safety and effectiveness of repeated administration of ulipristal acetate are limited and for this reason, it is not recommended to take the substance more than once during the menstrual cycle.

It is not advised to be used in females who have a history of severe asthma that was not successfully managed by oral glucocorticoids.

Patients with renal or hepatic impairment are not advised to take the medication due to the lack of particular research that would provide dosage recommendations. Patients with hereditary problems of lactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption should not take the medicine due to its content of lactose monohydrate [17–23].

Clinical studies on the safety and effectiveness of the drug are limited to women over 18 years of age.

Ulipristal acetate is a lipophilic compound and theoretically, despite the lack of reliable data, it is excreted in breast milk. Consequently, breastfeeding is not recommended after taking the medicine and can be safely continued after 36 hours. After the administration of the drug, the onset of menstruation may be observed a few days earlier or later than expected. In 6% of women, menstruation was observed more than 7 days earlier than expected [17–23].

In approximately 20%, a delay in onset was observed for more than 7 days, while only in 5.1%, more than 20 days.

Ulipristal acetate may have a minor or moderate effect on the ability to drive or use machines: Mild-to-moderate dizziness is common after taking: ulipristal acetate, while drowsiness and blurred vision are uncommon, and impaired attention is rarely reported [17–23, 28–30].

#### **2.10 Interactions with other medicinal substances**

Cytochrome P450, more specifically CYP3A4, breaks down ulipristal acetate *in vitro*. There has not been any specific *in vivo* drug interaction research.

Ulipristal acetate plasma concentrations may be decreased by inducers of CYP3A4 (such as rifampicin, phenytoin, phenobarbital, carbamazepine, ritonavir, and lichen planus/hypertrophic) and this may reduce the drug's effectiveness.

Therefore, their concomitant administration is not recommended. Enzyme induction wears off gradually and effects on ulipristal acetate plasma concentrations may occur even if the woman has stopped taking enzyme inducers within the previous 2–3 weeks.

Strong inhibitors of CYP3A4 (e.g., ketoconazole, itraconazole, telithromycin, clarithromycin, and nefazodone) may increase exposure to ulipristal acetate.

The clinical relevance is not known. Concomitant administration of medicinal products that increase gastric pH (proton pump inhibitors, antacids, and H2 receptor antagonists) may decrease plasma concentrations of ulipristal acetate and reduce drug efficacy.

Due to its strong affinity for the progesterone receptor, ulipristal acetate may reduce the effectiveness of progestogen-only and combined hormonal contraceptives. It is also not advised to use ulipristal acetate in conjunction with emergency contraception that contains levonorgestrel.

The study's side effects are described below. The great majority of negative side effects were mild or moderate and went away on their own.

There were no significant adverse events recorded in the study, and no patients were removed because of bad effects [17–23].

The side effects listed below are classified by frequency of occurrence. Very common (1/10) Abdominal pain Menstrual disorders.

Common (=1/100, <1/10), The following infections have been reported: Mood disorders Headache nasopharyngitis, urinary tract infection, fungal infection, bacterial vaginitis, infectious conjunctivitis, pelvic inflammatory disease Nausea - vomiting - dyspepsia menorrhagia - uterine bleeding.

Ninety-eight percent of the women who took part in the study had their next period start on schedule or within seven days of that date, while 6.1% had their period start more than seven days earlier than expected and 19.2% had their period start more than seven days later than expected. In total, 5.1% of women had a delay of at least 20 days, and 0.5% had a delay of at least 60 days from the anticipated start of menstruation. The majority of women (79%), 16.0%, reported normal blood flow, and 5.0%, increased blood flow (=1/1.000, 1/100) [17–23].

Appetite disorders, Depression—anxiety symptoms—insomnia—sexual drive disorders—irritability, Sleepiness—tremors, Hot flashes, Diarrhea—constipation dry mouth—flatulence, Mastodynia—genital pain—uterine spasm—premenstrual syndrome—genital itching—vaginal discharge.

Rare (=1/10,000, <1/1000).

Dehydration, Impaired attention—dysgeusia—lethargy, Facial sinus congestion cough—epistaxis—dry pharynx, Gastroesophageal Reflux—glossitis—toothache, chest discomfort—inflammation—malaise—pyrexia—thirst—chills.

#### **3. Experience in our Greece center**

The effectiveness of a single dose of 30 mg of ulipristal acetate and 1.5 mg of levonorgestrel was assessed in 90 women aged 16 to 29 years and older who presented for emergency contraception, 24–120 hours (1–5 days) after unprotected intercourse, in prospective studies conducted at the Center for Family Planning, Democritus University of Thrace, Greece, from March 2014 in 60 women.

In addition, intrauterine copper coils were used in 40 women aged 19–24 years for emergency contraception. Women with a stable cycle of 24–35 (+/−5) days, without recent use of hormonal contraception, participated. The reasons for attending the family planning center were problems with the condom (70%, 105 women), forgotten the pill (12%, 18 women), and unprotected contact (18%, 27 women).

In the main efficacy analysis, the pregnancy rate was significantly lower than what would be expected in the absence of emergency contraception (0.9% vs. 6.8%). The data showed that both ulipristal acetate and levonorgestrel prevented 99% of expected pregnancies. One pregnancy was recorded in both the levonorgestrel group and the ulipristal acetate group, while no pregnancy and no side effects were observed in the endometrial group.

#### **3.1 Clinical studies**

According to literature data, the effectiveness of the drug was maintained over time and is presented as follows:

reported pregnancy rate of 0.3% when used 48–72 hours (on day 3) after intercourse, reported pregnancy rate of 0.9% if used 72–96 hours (on day 4) and reported pregnancy rate of 1.3% when taken during the 96–120 hour period (on day 5).

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

During the prospective study, 16 female participants (5.0%) experienced an adverse event, most commonly headache (19.5%), nausea (12.2%), or abdominal pain (6.7%). Cycle length increased by an average of 2.8 days, while menstrual length did not change.

Limited information is available based on literature data regarding the effects of ulipristal acetate on pregnancies that are preexisting or occur despite treatment. Consequently, the use of the drug in women who are already pregnant is contraindicated.

#### **3.2 Dosage and method of administration**

As soon as feasible, but no later than 120 hours following unprotected sexual activity or the failure of any used contraceptive measures, a tablet should be given orally.

Ulipristal can be taken at any point throughout the menstrual cycle, with or without food. A second tablet should be given if vomiting develops within three hours after the first one.

It is not recommended to use it more than once per cycle, as the safety and effectiveness of repeated exposure has not been established.

The possibility of pregnancy must always be excluded before administration.

Despite the fact that after taking ulipristal it is not contraindicated to continue the usual hormonal contraception, ulipristal may reduce the contraceptive effect of this method.

Therefore, after the use of emergency contraception and until the start of the next menstruation, it is recommended that sexual intercourse be carried out using a reliable method of mechanical contraception.

The effectiveness and safety of the preparation have been established in women over 18 years of age; therefore, its use in younger ages should be done with caution.

#### **3.3 Allocation**

Ulipristal acetate is highly bound (>98%) to plasma proteins, including albumin, alpha-1-acid glycoprotein, and high-density lipoprotein.

#### **3.4 Metabolism/excretion**

Ulipristal acetate is extensively metabolized to mono-demethylated, di-demethylated, and hydroxylated metabolites. The mono-demethylated metabolite is pharmacologically active. *In vitro* data indicate that this is mainly due to CYP3A4 and to a lesser extent to CYP1A2 and CYP2D6. The terminal half-life of ulipristal acetate in plasma after a single 30 mg dose is estimated to be 32.4 ± 6.3 hours, with a mean oral clearance (CL/F) of 76.8 ± 64.0 L/hour [17–23, 28–30].

#### **3.5 Ulipristal acetate vs. levonorgestrel comparative study**

A total of 150 women participated in a comparative study (prospective randomized) between levonorgestrel 90 women and ulipristal acetate 60.

The main subject of the study was the number of pregnancies after using each method and the side effects of the two methods. The doses used were: 1.5 mg of levonogestrel and 30 mg of ulipristal acetate (once).

The participants in the study were divided into two groups. In each group, one of the two compared methods of emergency contraception was used:

Group A: Levonogestrel use (n = 90).

Group B: Use of ulipristal acetate (n = 60).

The use of medicinal substances took place in the period between three to five days (72 to 120 hours) after contact, during which no contraceptive method was used or there was a failure of it.

Ten women who:

Follow-up either was not completed. Or with unknown follow-up.

The follow-up was done 5 to 7 days after the expected menstruation.

The most frequently reported side effect in both groups was headache: In group A, there were 17 events (18.9%), and in group B, 12 events (19.3%). From this comparative study, it follows that the action of ulipristal acetate is significantly superior to that of levonorgestrel, in the period of 3 to 5 days (72 to 120 hours).

From the mentioned comparative studies and meta-analyses, it becomes clear the superiority of ulipristal acetate in the prevention of pregnancies after failed or nonuse of a contraceptive method, during intercourse, after 72 to 120 hours, while in our study the corresponding results ranged at the same levels.

According to the scientific organization Planned Parenthood Federation of America, if emergency contraception methods were widely implemented in the US, at least 1.7 million unwanted pregnancies and 800,000 abortions could have been avoided. A similar picture exists in our country, where the number of abortions is very close to that of births, while many Greek women have had the experience of an abortion.

This pill contains the same active substances that are included in ordinary contraceptive pills but in different amounts. Some of them have hormones, specifically estrogen and progestinoids, while others only have progestinoids.

It is worth noting that large comparative clinical studies carried out in countries such as Great Britain demonstrate that the "morning-after pills" containing only progestinoids are more effective [17–23, 28–30].

#### **3.6 Mifepristone (RU486)**

Mifepristone was approved in Greece in 2014 for the following indications: Medical termination of a continuing intrauterine pregnancy (for use in amenorrhea for up to 63 days when used consecutively with a prostaglandin analog).

Cervical ripening and dilatation prior to surgical pregnancy termination in the first trimester.

Induction of labor in case of intrauterine death of the fetus (for patients in whom prostaglandin or oxytocin cannot be used).

There are indications that mifepristone at a dosage of 10 mg has great effectiveness as a method of emergency contraception. Mifepristone is a well-known antiprogesterone agent that, in combination with prostaglandins, terminates pregnancy [17–23, 28–30].

#### *3.6.1 Dosage regimen*

In total, 10 mg of mifepristone has the same efficacy (1.2% failure rate) as 50 mg or 600 mg of mifepristone if given within five days.

The potency of 10 mg (RU486) does not differ from the levonorgestrel (LNG) regimen.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

#### **3.7 Action mechanism**

It inhibits the growth of the dominant follicle.

It antagonizes the positive feedback of estradiol, preventing the secretory peak of LH, and inhibiting ovulation.

In a percentage (9–18%), there is a delay in the appearance of the period beyond 5 days. Mifepristone (RU 486) also seems to have good results in preventing pregnancy after intercourse. Mifepristone, which is a progesterone antagonist, is also used as an abortion drug. When administered at the beginning of pregnancy, it acts against implantation. In experimental animals, mifepristone appeared to cause an acceleration of the fallopian tube transport of the fetus and to have a deleterious effect on the development of the fetus and its retention in the uterus. The administration of mifepristone to be done later than 72 hours after contact.

The second tablet was taken between 12 hours at the earliest and 24 hours at the latest after the first tablet. With today's single-tablet packaging, the recommendation is to take it promptly and no later than the first 72 hours after contact. Since the first twelve hours after contact is considered the best time to start the method, it could be recommended to procure some package of this type of contraception in time to be present in "case of error." Advance care for procuring hormonal EC also arises from the fact that in some countries, hormonal EC is not readily available in many pharmacies [17–23, 28–30].

Ulipristal acetate is a SPRM with a primary antiprogesterone effect. However, in some countries, despite its wide availability, there did not seem to be sufficient: information on its use at a daily dose of 5 mg for 3 months, was also used successfully in reducing fibroid size) [19–23, 31–36].

#### **3.8 Effectiveness**

The effectiveness of the method is higher the earlier after sexual intercourse, which was done without protection, the hormones are administered. For the method containing ethinylestradiol, when taken within the first 72 hours, the probability of failure ranged from 7 to 26% [33].

Using the levonogestrel method within 2 hours of contact, the failure rate is 0.4%, and every 12 hours of delay increases the probability of failure by 50% [33]. It has been estimated that with the wider use of emergency contraception, almost half of all unplanned pregnancies and abortions could be avoided [33].

#### **3.9 Intrauterine contraceptive devices**

#### *3.9.1 Endometrial copper coils*

Emergency contraception can be achieved by inserting a copper coil into the endometrial cavity within 5 days of unprotected intercourse.

The glomeruli can be inserted within 5 to 7 days after unprotected intercourse and the chance of a pregnancy is reduced to over 99%. It is indicated as a method of emergency contraception in women who have passed 120 hours and in whom hormonal emergency contraception can no longer be used.

IUD mechanism of action


#### **3.10 Effectiveness**

The failure rates during the first year of use are 0.7% and overall in 1 to 2 years of use, the rates are 1.4% to 1.9%. Most women can be candidates for an IUD, including those with serious medical conditions, such as hypertension, morbid obesity, diabetes mellitus, stroke, myocardial infarction, and cancer [19–23, 31–36].

The only absolute contraindication to immediate IUD placement is active cervicotida, cervical or endometrial cancer, or a uterine cavity that is insufficiently sized (6 to 9 cm deep) to accommodate the device.

The copper IUD device works as a contraceptive method by immobilizing sperm. Women using this device should check the device tapes monthly to confirm that the device is in place. They should also know that their periods will be heavier and longer in duration.

#### **3.11 Behavioral methods**

Withdrawal or intermittent intercourse is the most effective method of behavior. The male intercourse position allows the man to remove his penis from the female reproductive system before ejaculating.

For women who have recently breastfed, lactational amenorrhea is also ineffective. When the woman exclusively breastfeeds and does not menstruate for the first six months after giving birth, failure rates are 2%. After six months it is wise to use another method.

The method of calculating fertile days involves a variety of techniques to calculate dangerous days. When these days are determined, couples can practice periodic abstinence or adopt some other method of either behavior or barrier at that time. The historical rhythm method has been replaced by other methods of natural family planning such as basic day counting methods, luteinizing hormone urine tests, and estrogen predictors of ovulation [36–40].

Emergency contraception (EC) is applied in cases of sexual intercourse on the "dangerous" days (i.e., a few days before and around ovulation). If, in order to avoid pregnancy, hormonal preparations (by mouth) are used, the method is also called behavioral methods post-coital hormonal contraception or "the morning-after pill".

The method is available without a medical prescription in some countries. However, many women choose not to use the method, even when it is readily available. It is the taking of −3 contraceptive pills in a short period of time in a large quantity to avoid a possible pregnancy. EC inhibits or delays ovulation. In the past, it has been suggested that it may also affect the receptivity of the endometrium [36–40].

However, this does not appear to be the case for levonorgestrel (LG) and ulipristal acetate (OG). LG and OG also do not affect embryo implantation Other potential contraceptive mechanisms, previously advocated, include effects on corpus luteum function, cervical mucus density, and sperm, egg, or embryo transport. Negative factors in method use appear to be women's lack of knowledge and confusion about how the method works and insufficient information provided to them by doctors.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

#### **4. Discussion**

Sexual intercourse is a spontaneous, pleasurable, instinctive, and physiological act. It is often unpremeditated and in many instances unprotected. Methods that aim to control the timing of pregnancy have been in use since time immemorial. Ideally, they should not interfere with the spontaneity or pleasure of the sexual act but at the same time should operate when the need arises. Numerous contraceptive techniques ranging from the primitive to the highly sophisticated have tried to achieve this goal. As yet, none has been totally successful; systemic methods of contraception aim mainly at inhibiting ovulation and need to be taken for substantial periods of time regardless of the frequency of sexual activity of the woman concerned; methods linked to coitus, that is, barriers, by their nature need planning and premeditation [32–46].

First coital encounters are notorious for being unprotected through complete omission or inadequate use of contraception. The other contraceptive emergency where backup is essential is when method failure such as condom rupture, diaphragm displacement, or pill omission (especially around the pill-free week) occurs. The emergency postcoital consultation is a suitable opportunity to introduce and discuss with the woman the different contraceptive options available, allowing her to make an informed choice.

In Greece, morals have changed rapidly in the recent decades and the new generation, adopting modern trends, is determined to control their fertility. With this in mind, the goal should be to enlighten more individualized choices of the best contraceptive method and to fundamentally change public opinion against abortion. It seems that there are so many abortions in Greece because they are seen as an easy solution, like an analysis without medical and moral dimensions [38–46].

Another difficult area is the moral and ethical implications of postcoital contraception. A couple may accept a method that works pre-fertilization but may reject a post-fertilization form of therapy. It is desirable, therefore, to discuss the mode of action of these agents with the patient beforehand. There is a general consensus that postcoital agents are contraceptive (acting postovulation but preimplantation) rather than abortifacient, but this definition has not been tested in court.

Another anxiety on the part of the medical profession is that the existing postcoital drugs can be misused as a regular rather than an emergency method of fertility control. This is unlikely to be acceptable to the patient, as the total dose of hormones taken by a sexually active woman will be much higher than a conventional contraceptive pill. In addition, the efficacy of postcoital drugs is inferior to the conventional pill. Furthermore, side effects in the form of nausea and vomiting or menstrual irregularities would make regular use of these agents unacceptable to the majority of women [41–48].

Our country has a serious genetic deficit and fortunately, it has been perceived by Greek society as a consequence of avoiding misunderstandings that reduce the value of this institution.

The family planning center is not only about contraception and population policy but about eugenics and youth sex education. According to the WHO, unsafe abortion is a "solution" for many women, including teenagers, when they have an unwanted pregnancy and cannot access services [48–52].

Obstacles that prevent a "safe" abortion can include restrictive legislation, low availability of services, high costs, "stigma," dealing with health professionals and misinformation, manipulative counseling, medically unnecessary tests, and others that delay any necessary care. In our country, unwanted pregnancy leading to

abortion causes many problems for doctors, theologians, legislators, sociologists, and psychologists and problems that leave almost no person, of any social class, religion, or spirituality, untouched.

Family planning allows people to have the desired number of children and determine the spacing between pregnancies, practices that help individuals or couples avoid unwanted pregnancies, due to desired births, adjust the intervals between pregnancies, control the time of birth depending on the age of the parents, and determine the number of children in the family. Family planning allows people to make informed choices about their sexual and reproductive health [48–52]. Contraception enables the couple to decide voluntarily, responsibly, and consciously about the desired size of their family, because the size of the family should not be a matter of luck, but of choice of the couple. The use of contraceptive methods is necessary both in casual relationships and in long-term healthy relationships. In our country, the methods of contraception used are distinguished by natural methods, hormonal methods, intrauterine devices, and barrier methods.

The first full-fledged sexual encounter is crucial to women's sexual development, especially in adolescence. They have a sense of sexual fulfillment, but it also exposes them to risks if there is not adequate sex education. The most important risks may be unwanted pregnancy and accompanying problems that are often caused, such as psychological, fertility problems, interruption of the educational process, social isolation, the spread of sexually transmitted diseases (STDs), and the increasing use of alcohol and other substances related to sexual activity [48–52].

Other factors related to the early age of First Complete Sexual Contact are parents' education, parents' marital status (single or divorced parents), origin from Northern European countries, or other countries with more "open" social perceptions. These factors also influence the type of relationship (whether it was evening/casual or not), the age of the partner (whether same age or not), the type of contraception used for the first time, and the number of sexual partners.

Adolescents' knowledge and implementation of safe "sexual health" practices are influenced by factors other than individual factors such as age, gender, education, family, functional counseling-support structures, and the wider social environment.

In Greece, as a "conservative" society, the family does not easily discuss sex education issues with teenagers, and the primary health care structures that work on issues that concern young people are insufficient.

Nevertheless, it is encouraging that a large number of teenagers use prophylactic methods during sex, although their knowledge of contraception, STIs, and family planning lags behind young people from other European countries. The implementation of effective sex education programs requires the collection and evaluation of important information about the sexual life of adolescents, which will mainly be from the individual reports of the interested parties, to be anonymous, and the process that precedes the initiation of their sexual behavior.

This topic causes embarrassment to families, health professionals, government officials, civil servants, and young people themselves. Extensive efforts have been made to increase the use of contraceptive methods and, in particular, the condom, to prevent unwanted events, pregnancies, and sexually transmitted diseases. WHO classifies the "eligibility" of contraceptive methods into four categories according to their possible contraindications:

The 1st category includes the situations in which there is no restriction for the contraceptive method.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

In category 2, the benefits of the contraceptive method generally outweigh the risks.

In category 3, the risks outweigh the benefits of the contraceptive method. In the 3rd category, clinical assessment and/or referral to a contraceptive specialist is required, since the method is usually not recommended except in cases where more appropriate methods are not available or they are not acceptable [40–48].

The 4th category includes the situations that involve an unacceptable health risk from the use of the contraceptive method.

The same classification is adopted by various countries and organizations (indicative: UK Medical Eligibility Criteria for Contraceptive Use [UKMEC] categories/ Faculty of Sexual & Reproductive Healthcare Clinical Guidance 2019) [40–48].

Based on the previous data, the classification of a method may vary depending on age, new pathological condition, etc. The ideal contraceptive method will prevent an unwanted pregnancy, but will also protect against sexually transmitted diseases, and have a low-risk rate high reliability, excellent tolerance predictable menstrual cycles, and additional benefits for skin hair well-being and quality of life. Emergency contraception in particular with the mechanism of action recapitulating which is the following the IUD works by preventing fertilization and implantation. This makes the IUD the most efficient postcoital contraceptive. This method seems to apply particularly to multiple coital exposures, where an IUD can be inserted with every chance of success up to 5 days after the calculated day of ovulation. Other instances where an IUD may be used are when estrogens are contraindicated, when treatment is delayed beyond 72 h, or for the multiparous patient who wishes to use the IUD as an ongoing method of contraception. It is less than ideal for the young nullipara, especially one with multiple sexual partners. In the latter case, IUD use may predispose to serious complications such as the development of pelvic inflammatory disease. The IUD may increase the risk of exacerbating quiescent PID or predispose to its development. Careful selection of patients helps reduce complications, thus encouraging the user to keep the IUD as an ongoing method of contraception. On the other hand, removal with the next menstruation may minimize the risk and be acceptable to an otherwise anxious patient [52–56].

According to our results, 90% of the women participating in our study would recommend it to their friends. There are certainly problems in assessing effectiveness, as the pregnancy rate in a cycle in the general population cannot be calculated because it is shaped by many factors.

Most work is done by showing the percentage of follicles that are canceled comparing treatment with placebo.

EC users with pills have a 5–12% risk of getting pregnant within the next year. Compared to levonorgestrel, ulipristal UPA reduces the chances of pregnancy by 75% [52–56]. Pregnancy 1.2–1.8%, probability 1.8% against 5.5% of the expected (in 941 women), Surpasses LNGEA. In cases of breastfeeding, if in partial breastfeeding there is a risk of conception from the 21st day after delivery, administration after breastfeeding is recommended, stopping breastfeeding for 8 hours of ulipristal acetate, and after taking it stop breastfeeding for 8 days. Ulipristal acetate is excreted in milk and levonogestrel has no effect [52–56].

IUD slightly has higher risk of uterine perforation during insertion (6/1000). After EA administration, the risk remains high immediately and in the future if continued without contraception.

The suitable time to discuss permanent contraception.

Sexual transmitted disease risk and appropriate laboratory testing.

Forensic examination in case of suspected rape and administration of EA and antibiotics and HIV. Rapid initiation of permanent contraception.

The availability of emergency contraception does not appear to affect the use of permanent contraception or increase risky sexual behaviors. Its availability does not appear statistically in the population to have reduced unintended pregnancies [52–57]. Women who are at risk for unwanted pregnancies frequently utilize no method or use emergency contraception late. Although it is a safe and reliable form of prevention, emergency contraception is less effective than permanent contraception. Teenage usage of EC is not medically contraindicated. The Food and Drug Administration (FDA) explained in its statement that it had approved the progestin-only method for nonprescription status that it could only be used by women 18 and older and that "Barr had not established that the projestin-only method could be used safely and effectively by young adolescents—girls 16 and younger—or EC without the professional supervision of a practitioner licensed by law to administer the drug [54–56].

The best method of effectiveness is IUD placement. The medicinal methods of EC have no contraindications and no significant side effects in all age groups. Its failure is related to the time of taking, body weight, and repeated contact without protection in the cycle. EC counseling should aim to initiate permanent contraception and protect against STIs.

It is undoubtedly necessary to organize family planning centers for teenagers and this should be a priority of every government.

The targeted intervention will provide teenagers with critical thinking, responsibility, and knowledge, with the aim of preventing unwanted pregnancy at the first sexual contact with the appropriate use of contraceptive methods, thereby reducing the risk of sexually transmitted diseases. The sexual behavior of young people is constantly changing, reflecting the times of the society in which they live and the level of education they possess. Family planning centers provide an effective sexual health service and especially help young women to have a healthy sex life without sacrificing contraceptive effectiveness.

### **Author details**

Panagiotis Tsikouras\*, Athanasia Hatzilazarou, Anastasia Bothou, Ethimios Oikonomou, Dimitrios Kyriakou, Athanasia Kassapi, Alexios Alexiou, John Arabatzis, Maria Georgada, Theopi Nalbanti, Natalia Sachnova, Konstantinos Nikolettos, Georgios Iatrakis and Nikolaos Nikolettos Department of Obstetrics and Gynecology, Democritus University of Thrace, Greece

\*Address all correspondence to: tsikouraspanagiotis@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Emergency Contraception: Literature Review, Experience in a Greek Center and Greece Used Methods DOI: http://dx.doi.org/10.5772/intechopen.113112*

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#### **Chapter 8**

## Family Planning and Young and Low Parity Couples: Learnings from Rural India

*Priyanka Rani Garg, Leena Uppal and Sunil Mehra*

#### **Abstract**

This chapter presents a research study on contraception among young and lowparity couples in India. It used the community scorecard method to understand their knowledge, attitude, perception, and use of contraception, and the barriers they face in accessing and obtaining contraceptive methods. The study also examined partner involvement and inter-spousal communication. The study reported higher awareness of FP methods among women than among men but poor knowledge of FP method availability and accessibility among both. Further, there was a positive perception of CHW's role and a high perception of barriers in terms of social norms, lack of knowledge, and limited access to services among women. A bidirectional relationship between spousal support and method satisfaction was observed. The inter-spousal communication and decision-making by women were moderately reported by women. Findings provide insights for policymakers to address family planning needs. Focusing on young couples is important due to their higher unmet need for family planning. The study emphasizes the role of men in family planning decision-making highlighting the need for improved communication between partners. In summary, this chapter presents a scientifically rigorous study on contraception among young couples in India, offering insights to address their family planning needs using robust research methods.

**Keywords:** family planning, young and low parity couples, male partner involvement, rural India, modern methods

#### **1. Introduction**

India's family planning program was launched in 1952 to control population growth and improve maternal and child health outcomes. The program initially focused on providing maternal and child health services, including antenatal and postnatal care, immunization, and family planning services, through a network of government-run health facilities. Over the years, the family planning program has undergone several changes in policies, strategies, and approaches to address emerging challenges and meet the evolving needs of the population. The program's key components include increasing access to contraceptive methods, promoting maternal and child health, and providing sexual and reproductive health education and counseling services.

Despite these efforts, the unmet need for family planning remains high, particularly among young and low-parity couples. According to the National Family Health Survey (NFHS-4), the percentage of unmet needs for family planning among currently married women aged 15–49 years was 12.9%, with the highest proportion of unmet needs reported among women aged 15–24 years. The unmet need for family planning is associated with several factors, including limited access to contraceptive methods, inadequate quality of family planning services, sociocultural norms and beliefs, and gender inequality.

In recent years, the Government of India has taken several initiatives to address the unmet need for family planning and improve the quality of family planning services. These initiatives include expanding the range of contraceptive methods, strengthening the delivery of family planning services through public-private partnerships, increasing the involvement of men in family planning decision-making, and promoting the use of technology and social media for family planning education and counseling. Given the high unmet need for family planning among young and lowparity couples in India, it is essential to understand their knowledge, attitudes, and perceptions of contraception and family planning services. The existing literature provides limited insights into the experiences of young couples regarding family planning, especially from a community perspective. Moreover, men's role in family planning decision-making is often overlooked in such studies, despite their significant influence on family planning outcomes. While we say this, it is important to consider an effective method that can help increase the chances of improving these outcomes.

Community Score-Card is a tool for bridging the gaps by strengthening the relationship between the community and government engagement on improving QoC. This suffices with the findings from various studies, like Ho et al. [1] analyzed the impact of community scorecards in the conflict-affected provinces of two provinces of eastern Democratic Republic of Congo where village development committee, health committee, community members and healthcare providers were the stakeholders. Blake et al. [2] analyzed a pilot intervention by Evidence for Action (E4A) programme (2011–2015) done to improve maternal and new born health services using a social accountability approach in two regions of Ghana. Gullo et al. [3] evaluated the effects of CARE's CSC in Malawi using a cluster-randomized control design. The study evaluated the effects of CARE's community score card on reproductive health outcomes including modern contraceptive use, antenatal and postnatal care service utilization, and service satisfaction. It is very evident that community score card has a direct impact on increasing the transparency and community participation in health facility management, and improving quality of care in terms of increased access to services, improving patient-provider relationships, improved performance of service providers, and improving maintenance of physical infrastructure. In addition, changes occurred through many different mechanisms including provider actions in response to information, pressure from community representatives, or supervisors; and joint action and improved collaboration by health facility committees and providers.

Judith Bruce [4] in her paper outlined quality of care standards which according to her are the neglected dimensions of family planning programme monitoring and evaluation. Hence for the community-led score card, a detailed tool was developed the taking into consideration the Judith Bruce framework of quality of care which focuses on the clients' perspectives on quality of care in family planning, service provider's self-evaluation on provision of quality of care and facility readiness.

### **2. Overview of family planning in India**

Therefore, this study aimed to examine the knowledge, attitude, perception, and use of contraception among young and low-parity couples in India, with a particular focus on partner/husbands' involvement in family planning decision-making, using community score card method. The study also explored the perceived barriers to accessibility and availability of current contraceptive methods, providing valuable insights for policymakers and program makers to address the unmet need for family planning among this demographic group. The study used a rigorous research design to ensure scientific soundness and contribute to the existing literature on family planning in India.

#### **The study explored the following research questions.**


The objectives of the study were:


India's pace of decline in childbearing throughout the country's population has been significant since the past two decades [5, 6]. The percentage decline in population growth rate was the sharpest in 1991–2001, with a decrease of 2.52 percentage points [5]. Since then, a steady decline in population growth has been continuing [5]. India witnessed a population growth rate of about 1.6 percent per year between the Census periods 2001–2011 [5]. Many states, such as Kerala, Goa, Andhra Pradesh, and Tamil Nadu, have reached the replacement level of fertility of 2.1, which was the key objective of the Population Policy of India [5]. Uttar Pradesh alone contributes to 16% of India's population as of the 2011 census, with an average population of 199.8 million [5]. The total fertility rate of Uttar Pradesh stands at 2.4, and it is among the top five states in India where girls are married before the age of 18 years [7]. About 15.8 percent of women aged 20–24 years in the state are married before the age of 18 years [7]. Studies have indicated that Uttar Pradesh presents the biggest challenge towards meeting SDG 3.7 in terms of absolute numbers [8].

When it comes to the choice of spacing methods, traditional methods are the most accepted methods by currently married women aged 15–49 years in Uttar Pradesh compared to the country as a whole (22 percent vs. 9 percent, respectively) [8]. However, evidence suggests that greater reliance on traditional methods of family planning and low demand for modern contraception translate into lesser utilization of modern contraceptives [8]. Family planning and dropping fertility rate have farreaching benefits that go beyond health, impacting all 17 Sustainable Development Goals (SDGs) [9].

The government of Uttar Pradesh has been working towards achieving the FP2020 goals and recently launched new methods of contraception like 'Antara' and 'Chayya' [8]. However, the state still has much ground to cover in terms of achieving the desired population and development goals, especially in promoting the nascent 'Mission Parivar Vikas'strategy [8]. The country has taken recent efforts towards addressing Quality of Care (QoC), including access to contraceptive choices, quality counseling services, information, and follow-ups [10]. Community participation has been recognized as a precondition for sustainable development, ensuring good quality care and increased use of contraceptives [11]. The unmet need for family planning among young and low-parity couples, particularly in the context of India, remains a significant challenge [12]. Despite the progress made in recent years, a substantial number of young couples in India continue to lack access to modern contraception methods or face barriers to utilizing them effectively [13]. This unmet need can have far-reaching consequences for individuals, families, and society as a whole. Unplanned and closely spaced pregnancies can lead to increased health risks for both mothers and children, contribute to population growth, strain limited resources, and impede efforts to improve the overall quality of life [14]. It is crucial to address this unmet need through targeted interventions, such as improving awareness about family planning options, expanding access to affordable and quality reproductive healthcare services, and promoting comprehensive sexuality education [15].

Studies have shown that while many young couples in India are aware of contraception, there are gaps in their understanding of the available methods, their effectiveness, and correct usage [16]. Limited knowledge often leads to misconceptions, myths, and fears about contraception, hindering its adoption.

Attitudes towards contraception vary among young couples in India. Some hold positive attitudes, recognizing the importance of family planning for personal wellbeing, economic stability, and maternal and child health [17]. However, cultural and social factors, such as gender norms, traditional beliefs, and pressure from families, can influence negative attitudes towards contraception and limit its use [18].

Perceptions of contraception are influenced by various factors. Cost, accessibility, privacy concerns, and fear of side effects are common barriers reported by young couples in India [19]. Misconceptions about the impact of contraception on fertility and overall health can also affect perceptions and decision-making.

The use of contraception among young couples in India remains suboptimal. Factors contributing to low utilization include limited access to quality services,

#### *Family Planning and Young and Low Parity Couples: Learnings from Rural India DOI: http://dx.doi.org/10.5772/intechopen.111925*

inadequate counseling, lack of awareness about different methods, and sociocultural barriers [16]. Additionally, concerns about method effectiveness, side effects, and discontinuation rates contribute to inconsistent or non-use of contraception among young couples.

Efforts are being made to address these challenges. Comprehensive Sexuality Education programs are being introduced to enhance knowledge and dispel myths surrounding contraception [20]. Initiatives that improve access to affordable and quality reproductive healthcare services, including contraceptive methods, are being implemented. Furthermore, involving men as partners in family planning discussions and decision-making can positively influence contraceptive use among young couples [17]. The role of men in family planning decision-making is crucial and can significantly impact contraceptive use and reproductive choices [17]. Men's involvement and support are essential for effective family planning outcomes [19]. Engaging men in discussions and decision-making regarding contraception helps to foster a sense of shared responsibility and promotes mutual understanding and communication between partners [17]. When men are actively involved, it increases the likelihood of contraceptive use, encourages consistent and effective method use, and reduces the risk of unintended pregnancies [12, 17]. Men's support also influences women's access to reproductive healthcare services, including contraceptive methods, as they can provide financial, emotional, and logistical support [17]. By promoting positive attitudes, addressing gender norms, and involving men as partners in family planning interventions and programs, we can create an enabling environment that empowers couples to make informed choices and promotes reproductive health and well-being for both men and women [16, 17].

In conclusion, addressing the knowledge gaps, promoting positive attitudes, dispelling misconceptions, and improving access to contraception are essential for empowering young couples in India to make informed reproductive choices. By implementing comprehensive and integrated strategies, India can enhance the uptake of contraception, reduce the unmet need for family planning, and contribute to better health outcomes for individuals, families, and society as a whole.

#### **3. Methodology**

The study adopted a Score Card methodology at large, and considered two sets of respondents–the service receivers i.e. the Young and Low Parity Couples (YLPCs) and service providers/community health workers (ASHA and ANM). The beneficiaries included Young and Low Parity Couples (with 0–1 child), between the ages 18– 24 years. All the community health workers from the selected villages were included in the study.

#### **4. Sampling**

A multistage-stage sampling design was used. In the first stage blocks were selected, in the second stage villages were selected and in the third stage eligible respondents from the villages were selected. Based on the sample size, the respondents were selected from the villages with the maximum density of the target population.

#### **5. Selection of districts**

The districts were selected based on a composite index developed using two indicators namely, current use of any modern contraception method and unmet need for spacing from NFHS-42015–16 data for the districts of Uttar Pradesh. For the calculation of the composite index, women in the age group of 15 to 24 were considered. There were 37 districts that presented data above the state average. From the 37 districts, two districts were selected based on the recommendation of the State government, Banda and Kaushambhi.

#### **6. Selection of blocks and villages**

Two blocks from each district were selected based on convenience. The location of the Primary Health Centre (PHC) was the base factor in selecting the blocks – one nearest to the block head quarter and the other furthest from the block head quarter. The sub-centers with the maximum population density were selected in consultation with the Medical Officer In-charge (MOIC) at the selected PHCs. All ASHAs under the selected sub-centers were asked to share the list of YLPCs with the MOICs and the sampling frame was prepared. Finally, villages with a minimum 10 YLPC couples residing in the study area were identified and selected. A total of 12 villages were selected for the study. **Figure 1** details the names of the blocks and villages selected in each study district.

**Figure 1.** *Blocks and villages selected.*

#### **7. Sample size calculation**

In order to determine the optimal sample size, the primary outcome of knowledge of family planning methods and services in the community was considered. Considering the assumption of 50% of the primary outcome, anticipate that the knowledge of family planning methods services in the community for young and low parity couples will increase to 15 percent point during the study duration, with 80% power, 95% confidence interval and design effect 1.2, the sample size was calculated to be 202 for each district. Therefore, a total of 404 Young Low Parity Couples i.e. 806 respondents (403 women and 403 men) were covered in the study at baseline. The sample of 30 Community Health Workers (ASHA, AWW and ANM), i.e. 15 from each district were covered under the study. **Table 1** details the respondent categories and the number of respondents.

#### **8. Ethical considerations**

Before collecting the data, informed written consent was obtained from the respondents. The data collectors explained an informed sheet prepared in Hindi language and asked for consent. Participation in the study was fully voluntary. All information gathered was kept anonymous to protect confidentiality. The ethical clearance of the study was done by Internal Review Board (IRB).

#### **9. Data collection**

The data were collected by young people within the age group 18–24 years, who were identified and trained in data collection. They were residents of the selected villages. Prior to data collection, eighteen data collectors were trained for two days by the MAMTA research team. The training program consisted of an overview of the study objectives, a briefing on the questionnaires, the sampling methodology, mock interviews, ethics, and hands-on practice in the field. Both male and female data collectors were selected from each village. The data collection was completed in 30 days.

The minimum eligibility criteria for data collectors:



**Table 1.**

*Respondents categories and number of respondents.*


#### **10. Quality control mechanism**

The Principal Investigator (PI) and Co-Principal Investigator (Co-PI) led the quality assurance mechanism. Weekly supervisory and field support calls were conducted. Spot checks/Back checks were done. Standard quality checks before data entry (editing, scrutiny, and coding) and during data entry (like double entry, validity, range, and consistency checks) were done.

#### **10.1 Data analysis**

Statistical software CSPRO and Excel were used for data storage and analysis. The data entry was followed by the data crosscheck and data cleaning.

The Community Score Cards Scorings for YLPC (Women and Men) generated through pre-decided benchmarks framed by using results from NFHS-4 (2015–2016) for each indicator and for CHW by using results from MPV guidelines and NFHS-4 (2015–2016) {See Annexure I}. Followed by comparing the State Average based on comparable data from the same referred reports and guidelines. Each indicator is a composition of multiple variables. All indicators are on a 3-point Likert scale and they range from '0' to '2'. Positive responses on the Likert scale were recoded into '2' as a numerical value, Moderate responses were recoded into '1', and negative response was recoded into '0'. The responses were summed up to calculate the minimum and maximum scores. Subsequently, indicators are categorized into 'Green', 'Yellow', and 'Red' on the basis of the pre-decided benchmark.

Based on the pre-decided benchmark, the cut-off percentage for the highest score is decided, from which a cut-off score value is generated as the highest mean percentage score of the maximum score for each indicator which marks the 'Green' color on the CSC scorecard. A moderate cut-off percentage is decided basis of the pre-decided benchmark from which a cut-off for moderate score value is generated which marks the 'Yellow' color. Further, the percentage value below moderate is considered as the lowest value basis and the lowest score value is generated which marks the 'Red' color. For example, for indicator one, there are eight sub-indicators with a minimum (negative) response coded as '0' and a maximum (positive) response coded as '2'. After summing up the responses, the minimum score value is '0' and the maximum score value is '16' (8\*2). Basis the pre-decided benchmark from NFHS-4 (2015–2016), a percentage of 90 or more should be considered as a 'positive response'. Therefore, a cut-off value of 14.4 (90% of 16) is generated as the 'positive'score which marks the 'Green' color on the CSC scorecard. Further, 45–89% marks the moderate response which means a score between 7 and 14 is considered as the 'moderate'score which marks the 'Yellow' color on the CSC scorecard. Therefore, a score below 7 is considered a 'negative/no' response which marks the 'Red' color on the CSC scorecard. Likewise, the cut-offs for all the indicators have been generated and scored on the CSC scorecard.

The facility assessment scorings were done by using the Excel spreadsheet for all the health facilities of the Village, Block and District levels.

#### **11. Results**

Scores on Community Score Card (CSC) for various indicators (eight in number) related to Family Planning among men and women in the Young and Low Parity Couples (YLPCs) are presented in **Table 2**.

Based on the responses from the YLPCs, the aggregate percentages were translated into scorecards in Green, Yellow, and Red to enable a quick visual way of their scores for the respective indicator.


#### **Table 2.**

*Scores on community score card (CSC) for various indicators related to family planning among men and women in the young and low parity couples (YLPCs) in the state of Uttar Pradesh.*

#### **11.1 Indicator one: awareness about family planning methods among young low parity couples**

The results indicate that the overall awareness of family planning methods among young couples in the study area was relatively low. On the scorecard assessing awareness, only 5.7% of couples achieved green scores, indicating a positive response to 7 out of 8 questions. A majority of couples, 40.6%, received yellow scores, indicating a positive response to 3 to 6 out of 8 questions, while 53.7% of couples received red scores, indicating a positive response to less than 3 out of 8 questions. When comparing awareness between men and women, it was observed that women had better awareness overall. Among women, 8.7% achieved green scores compared to only 2.7% of men, and 42.9% of women achieved yellow scores compared to 38.2% of men. These results highlight the need for increased awareness and education about family planning methods among young couples.

#### **11.2 Indicator two: knowledge of availability and accessibility of family planning services among young low parity couples**

The results indicate the knowledge levels regarding the availability and accessibility of family planning (FP) services among young couples in the study area. On the scorecard assessing knowledge, 46.5% of couples achieved green scores, indicating a positive response to 8 out of 9 questions. A significant proportion of couples, 40.6%, received yellow scores, indicating a positive response to 4 to 7 out of 9 questions, while 12.9% of couples received red scores, indicating a positive response to less than 4 out of 9 questions.

In terms of gender-wise comparison, it was observed that men generally had better knowledge about the availability and accessibility of FP services compared to their female counterparts. Among men, 58.8% achieved green scores compared to only 34.2% of women. Additionally, 49.9% of women achieved yellow scores, while 15.9% achieved red scores, compared to 31.3% and 9.9% respectively for men.

The results suggest that there is a relatively balanced distribution of scores for green (46.5%) and yellow (40.6%) among the couples, indicating a moderate level of knowledge about the availability and accessibility of FP services. However, there is still room for improvement as less than 50% of couples have a good level of knowledge. Furthermore, the gender-wise comparison reveals that men generally have better knowledge than their female counterparts. These findings highlight the need to enhance knowledge and awareness regarding FP services, with a focus on reaching and educating women to improve their understanding of available resources and services.

#### **11.3 Indicator three: interpersonal communication and decision-making among women**

To assess husband-wife communication and decision-making on ideal family size and family planning use, only women were asked to score their level of discussion with their husbands regarding various topics, such as the number of children, timing of births, family planning methods, and joint decision-making. They were also asked about the influence of their parents or in-laws on these decisions and their own right to influence the use of contraception.

#### *Family Planning and Young and Low Parity Couples: Learnings from Rural India DOI: http://dx.doi.org/10.5772/intechopen.111925*

On the scorecard, 13.9% of women achieved green scores, indicating a positive response to 9 out of 10 questions. The majority of women, 76.4%, received yellow scores, indicating a positive response to 5 to 8 out of 10 questions, while 9.7% of women received red scores, indicating a positive response to less than 5 out of 10 questions.

The results show that overall, there is room for improvement in husband-wife communication and decision-making, as only a small proportion of women achieved green scores. The majority of women fell into the yellow score category, suggesting some level of discussion and decision-making but with space for further improvement. A smaller proportion of women received red scores, indicating limited involvement in decision-making regarding family size, timing of births, family planning methods, and joint decisions.

These findings highlight the need to enhance communication and decision-making within marital relationships to promote women's autonomy and active participation in family planning decisions. There is a scope for strengthening communication channels between husbands and wives to ensure joint decision-making and involvement of women in determining their reproductive choices.

#### **11.4 Indicator four: role of community health workers among current users young low parity couples**

To assess the role of community health workers (CHWs), the current contraceptive users among young couples were asked to score their experience with counseling about available family planning (FP) methods, clarification on FP methods, and the time provided to make decisions about contraceptive use. Out of the 403 men and 403 women interviewed, 95 men (23.6%) and 227 women (56.3%) were currently using contraceptives, and the scores on the scorecard represent the scores for these users. It is important to note that the total number of respondents differs here (95 men and 227 women) from the total number of respondents for the study (403 men and 403 women).

On the scorecard, 69.2% of couples achieved green scores, indicating a positive response to 3 or more out of 4 questions. The majority of couples, 20%, received yellow scores, indicating a positive response to 2 out of 4 questions, while 10.8% of couples received red scores, indicating a positive response to less than 2 out of 4 questions.

Overall, the results suggest that the role of CHWs in providing FP services was perceived positively by the current contraceptive users. A significant proportion of couples achieved green scores, indicating satisfactory experiences with counseling and information provision. However, there is room for improvement as a notable percentage of couples received yellow scores, suggesting that there are areas where the role of CHWs can be enhanced.

When considering gender differences, women tended to perceive the role of CHWs more positively compared to their male counterparts. A higher proportion of women achieved green scores, indicating a higher level of satisfaction, while men had a slightly higher percentage of yellow scores and red scores.

In conclusion, although the role of CHWs was generally perceived positively among current contraceptive users, there remains potential for further improvement. Efforts should be made to enhance the quality of counseling, clarification, and decision-making support provided by CHWs, ensuring that both men and women

have access to accurate information and can actively participate in making informed choices about family planning.

#### **11.5 Indicator five: methods used among current users young low parity couples**

To evaluate the role of community health workers (CHWs), current contraceptive users among young couples were surveyed regarding their experiences with CHWs. They were asked to rate their interactions based on counseling about available family planning (FP) methods, clarification of FP methods, and the time given to make decisions on FP method use. Out of the 403 interviewed men and 403 women, 95 men (23.6%) and 227 women (56.3%) were currently using contraceptives, and the scores on the scorecard represent their evaluations. It's important to note that the total number of respondents for the scorecard differs from the total number of respondents for the study.

On the scorecard, 69.2% of couples achieved green scores, indicating positive responses to 3 or more out of 4 questions. Yellow scores were obtained by 20% of couples, indicating positive responses to 2 out of 4 questions, while 10.8% of couples received red scores, indicating positive responses to less than 2 out of 4 questions.

Overall, the results indicate that among current contraceptive users, 69.2% of couples perceive a positive role of CHWs based on their counseling, clarification, and decision-making support. These findings emphasize the importance of effective engagement with CHWs to ensure access to accurate information and support for FP methods.

Regarding gender differences, women generally perceive the role of CHWs more positively than men when considering the combined data for both genders. A higher proportion of women achieved green scores (76%) compared to men (67.4%). Women also had a lower proportion of yellow scores (16%) and red scores (8%) compared to men (21.1% and 11.5%, respectively).

In conclusion, the results demonstrate that among current contraceptive users, 69.2% of couples perceive a positive role of CHWs in providing counseling, clarification, and decision-making support. Gender differences exist, with women generally perceiving the role of CHWs more positively. These findings highlight the significance of CHWs in promoting informed decision-making and ensuring access to comprehensive family planning services.

#### **11.6 Indicator six: support from spouse among current users' women**

To assess the support received from spouses regarding contraception use, women who were current users of contraceptives were surveyed and asked to score their experiences. The scores on the scorecard represent the evaluations of 95 men (23.6%) and 227 women (56.3%) who were currently using contraceptives, which is different from the total number of respondents for the study (403 men and 403 women).

On the scorecard, 44% of women achieved green scores, indicating positive responses to 3 out of 3 questions. Yellow scores were obtained by 40% of women, indicating positive responses to 1 to 2 out of 3 questions, while 16% of women received red scores, indicating no positive responses to any of the 3 questions.

Overall, the results indicate a moderate level of support from spouses regarding contraception use among women. Among the current contraceptive users, 44% of women reported receiving support from their husbands, while 40% had partial

support, and 16% had no support. This suggests that there is room for improvement in terms of spousal support for contraception use.

The findings suggest that women's experiences with spousal support varied, with a significant proportion reporting positive support, some reporting partial support, and a minority reporting no support. These results highlight the importance of addressing spousal involvement and support in family planning programs and interventions. Enhancing spousal support can contribute to increased contraceptive use and better reproductive health outcomes for women.

It is crucial to focus on promoting communication and understanding between couples regarding contraception, including discussing the benefits, addressing concerns, and involving husbands in the decision-making process. By providing comprehensive information, education, and support to both men and women, we can foster a supportive environment for contraception use and empower couples to make informed choices about their reproductive health.

#### **11.7 Indicator seven: barriers to accessibility and availability in current use of contraception among young low parity couples**

To assess the hindrances in the accessibility and availability of contraception, current users of contraceptives were asked to score the obstacles they faced. These hindrances included issues related to the facility providing the contraceptive method, delays in the supply of preferred contraceptive methods, shortage of preferred contraceptive methods, and the influence of social norms on family planning decisions. They were also asked to rate their satisfaction with the place where the method was provided, their experience with staff interaction at the facility, the impact of cost factors on contraceptive use, and the influence of distance to health centers from their residence.

Out of the 403 men and 403 women interviewed, 95 men (23.6%) and 227 women (56.3%) were currently using contraceptives, and their scores on the scorecard represent their responses. It's important to note that the total number of respondents for the study differs from the number of current contraceptive users.

On the scorecard, 26.1% of couples achieved green scores, indicating positive responses to 7 out of 8 questions. Yellow scores were obtained by 71.4% of couples, indicating positive responses to 3 to 6 out of 8 questions, while 2.5% of couples received red scores, indicating positive responses to less than 3 out of 8 questions.

In terms of gender, the proportion of men and women with green scores was similar (26.3% for men and 25% for women). However, more men had yellow scores (72.6%) compared to women (66.7%), and a higher proportion of women (8.3%) had red scores compared to men (1.1%).

The results indicate that both men and women face hindrances in the accessibility and availability of contraception. While the overall scorecard shows a moderate level of hindrances, women perceive slightly more barriers compared to men. The scores suggest that there is room for improvement in terms of facility quality, supply availability, social norms, cost factors, and distance to health centers.

#### **11.8 Indicator eight: role of the service provider in family planning use among young low parity couples**

To assess the role of service providers in family planning (FP) use, Young Married Women (YLPC) were asked to score various aspects related to their interaction with

ASHA/ANM/AWW. These aspects included generating awareness of FP methods, counseling on FP methods and delaying childbirth, discussing the side effects of FP methods, and providing information about the places where FP methods are available. They were also asked to rate their perception of the service providers' capacity to address contraceptive needs and suggest solutions to side effects.

On the scorecard, 53.8% of couples achieved green scores, indicating positive responses to 5 or more out of 7 questions. Yellow scores were obtained by 25.4% of couples, indicating positive responses to 2 out of 5 questions, while 20.7% of couples received red scores, indicating positive responses to less than 2 out of 7 questions. The cut-off for these scores was determined based on the percentage of respondents who answered "Yes" to the question "ever told by a health or family planning worker about other methods they could use" in the NFHS-4 survey for the state.

Gender-wise analysis reveals that women perceived the role of service providers in FP use similarly to men. The proportion of men with green scores was 55.8% compared to women with green scores at 51.9%. The proportion of men with yellow scores was 29.5% compared to women with yellow scores at 21.3%. Similarly, the proportion of men with red scores was 14.6% compared to women with red scores at 26.8%.

The results indicate that approximately half of the couples rated the role of service providers in FP use positively, achieving green scores on the scorecard. However, there is a notable difference in the perception of service providers between men and women, with men rating them more positively overall. It is important to consider these gender differences in addressing the role of service providers and their impact on FP use.

#### **12. Discussion**

The findings from this study provide valuable insights into various aspects of family planning (FP) indicators in the rural regions in the state of Uttar Pradesh, India. These findings align with global and Indian contexts, highlighting both similarities and differences in FP-related factors.

The higher awareness of FP methods among women is consistent with studies conducted globally. For example, a study in sub-Saharan Africa found that women generally had higher levels of awareness of modern contraceptive methods compared to men [21]. Similarly, in India, the National Family Health Survey (NFHS-4) reported higher awareness levels among women compared to men [22].

The study reveals that women have poor knowledge of FP method availability and accessibility. This knowledge gap mirrors findings from other studies conducted in low-income countries. For instance, a study in Ethiopia found that women lacked knowledge about the availability of FP services in their community [23]. In the Indian context, regional variations in knowledge and accessibility have been observed, indicating the need for targeted interventions (NFHS-4, [22]).

The moderate level of inter-spousal communication and decision-making reported by women in this study aligns with research conducted globally. Studies have highlighted the importance of involving both partners in FP decision-making to improve contraceptive use [24]. In the Indian context, the NFHS-4 data also reflect a moderate level of spousal communication and decision-making [22].

The positive perception of CHWs' role, especially among women in Kaushambi, resonates with studies conducted globally. CHWs play a crucial role in delivering FP information and services, particularly in resource-limited settings [25]. In India, the

#### *Family Planning and Young and Low Parity Couples: Learnings from Rural India DOI: http://dx.doi.org/10.5772/intechopen.111925*

role of ASHAs (Accredited Social Health Activists) as CHWs has been recognized for their contributions to FP promotion and service delivery [26].

The moderate satisfaction levels reported by both men and women in this study are consistent with findings from other research. Studies have indicated that client satisfaction is influenced by factors such as method effectiveness, side effects, and ease of use [27]. However, it is worth noting that men had slightly higher satisfaction scores in this study, which may reflect their perspectives on method effectiveness and their limited involvement in method use decision-making.

The bidirectional relationship between spousal support and method satisfaction, as observed in this study, has been documented in previous research. Studies have found that spousal support positively influences contraceptive use and continuation [28]. Conversely, lack of support can lead to dissatisfaction and discontinuation of contraceptive methods. This relationship holds true both globally and in the Indian context.

The study highlights the greater perception of barriers among women compared to men. This finding aligns with studies conducted globally, which have identified barriers such as social norms, lack of knowledge, and limited access to services [21]. In the Indian context, regional variations in barriers have been documented, emphasizing the need for context-specific interventions (NFHS-4, [22]).

#### **13. Conclusion**

The findings of this study shed light on various aspects of family planning indicators in rural regions of the state of Uttar Pradesh, India. The results align with both global and Indian contexts, highlighting the importance of addressing factors such as awareness, knowledge, inter-spousal communication, role of community health workers, satisfaction with current methods, spousal support, and barriers to accessibility and availability.

To improve family planning outcomes, interventions should focus on increasing awareness of FP methods, particularly among men. Efforts are needed to bridge the knowledge gap regarding the availability and accessibility of FP services, especially among women in Banda. Promoting inter-spousal communication and decisionmaking can enhance contraceptive use and continuation rates. Strengthening the role of community health workers, such as ASHAs, in providing comprehensive FP services and addressing women's needs is crucial.

While overall satisfaction with current FP methods was moderate, understanding men's perspectives and involving them in method-related discussions can further enhance user satisfaction. Addressing barriers to accessibility and availability, particularly for women, is essential to ensure equitable access to FP services and methods.

Certain limitations of the study are:


Further research is needed to explore the factors influencing FP indicators in different geographic areas and populations. Longitudinal studies and mixed-method approaches can provide a deeper understanding of the dynamic nature of FP decisionmaking, service utilization, and barriers faced by individuals and communities. Addressing the limitations and building upon the insights gained from this study can inform targeted interventions and policies to improve family planning outcomes and contribute to achieving national and global FP goals.

#### **Annexure I: benchmarks for YLPCs (women and men) and CHWs.**

#### **Women**


*Family Planning and Young and Low Parity Couples: Learnings from Rural India DOI: http://dx.doi.org/10.5772/intechopen.111925*





#### **Men**




#### **Author details**

Priyanka Rani Garg\*, Leena Uppal and Sunil Mehra MAMTA-Health Institute for Mother and Child, Delhi, India

\*Address all correspondence to: kittu.dec2007@gmail.com

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Family Planning and Young and Low Parity Couples: Learnings from Rural India DOI: http://dx.doi.org/10.5772/intechopen.111925*

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[14] Sundaram A, Vlassoff M, Bankole A, Remez L, Mugisha F, Singh S. Benefits of meeting the contraceptive needs of Ugandan women. Issues in Brief (Alan Guttmacher Institute). 2017;**2**:1-8

[15] Government of India. Family Planning Division: Annual report 2016– 17. 2017. Retrieved from: https://main. mohfw.gov.in/sites/default/files/AR% 20FP%202016-17.pdf

[16] Upadhyay UD, Gipson JD, Withers M, Lewis S, Ciaraldi EJ, Fraser A, et al. Women's empowerment and fertility: A review of the literature. Social Science & Medicine. 2018;**196**: 160-170. DOI: 10.1016/j.socscimed.2017. 11.038

[17] Sharma V, Mohan U, Das V, Awasthi S, Gupta V. Knowledge, attitude, and practices of contraception among eligible couples in a rural area of Varanasi district. Indian journal of community medicine: official publication of Indian Association of Preventive & Social Medicine. 2018;**43**(1):36

[18] Siddiqui N, Kandpal SD, Sharma R. Community-based study on contraception awareness and utilization among currently married women aged 15–49 years in an urban resettlement colony of Delhi, India. Journal of basic and clinical reproductive sciences. 2017; **6**(2):67-71

[19] Kumar R, Singh R, Sharma A, Gupta R, Sharma M. Factors affecting contraceptive practices among married women in Haryana: A study using decision tree approach. Journal of family medicine and primary care. 2019;**8**(11):3540

[20] Jejeebhoy SJ, Santhya KG, Acharya R. Promoting sexual and reproductive health among young people in India: Emerging evidence and implications. In: Janz NK, Mercer CA, DeMartini S, editors. Global Perspectives on Sexual and Reproductive Health across the Lifecourse. Springer; 2015. pp. 3-25

[21] Cleland J, Ali MM, Shah IH. Trends in protective behavior among single vs. married young women in sub-Saharan Africa: The big picture. Reproductive Health Matters. 2014;**22**(44):17-22. DOI: 10.1016/s0968-8080(14)44753-1

[22] International Institute for Population Sciences. National Family Health Survey

(NFHS-4) 2015–16: India. Mumbai, India: IIPS; 2017

[23] Bogale B, Wondafrash M, Tilahun T, Girma E, Married A. Married women's decision making power on modern contraceptive use in urban and rural southern Ethiopia. BMC Public Health. 2011;**11**(1):342. DOI: 10.1186/1471-2458- 11-342

[24] Shattuck D, Kerner B, Gilles K, Hartmann M, Ng'ombe T. Encouraging contraceptive uptake by motivating men to communicate about family planning: The Malawi male motivator project. American Journal of Public Health. 2011; **101**(6):1089-1095. DOI: 10.2105/ ajph.2010.300059

[25] Haines A, Sanders D, Lehmann U, Rowe AK, Lawn JE, Jan S, et al. Achieving child survival goals: Potential contribution of community health workers. The Lancet. 2007;**369**(9579): 2121-2131. DOI: 10.1016/s0140-6736(07) 60325-0

[26] Saggurti N, Porwal A, RamaRao S, Raghavendra T, Ramarao S, Donta B. Effect of the ASHA program on utilization of reproductive health services: A longitudinal cohort study in Uttar Pradesh, India. BMC Health Services Research. 2018;**18**(1):615. DOI: 10.1186/s12913-018-3412-3

[27] RamaRao S, Lacuesta M, Costello M, Pangolibay B, Jones H. The link between quality of care and contraceptive use. International Family Planning Perspectives. 2003;**29**(2):76-83. DOI: 10.2307/3181065

[28] Gupta N, Bhattacharyya S, Jain RK. Factors influencing contraceptive use: A path analysis of married couples in Haryana. India. Sexual & Reproductive Healthcare. 2020;**24**:100495. DOI: 10.1016/j.srhc.2020.100495

#### **Chapter 9**

## Use of Birth Control Products and Contraceptives by Adult Males: A Case Study of the Amasaman Area Council, Accra, Ghana

*Hanny-Sherry Ayittey*

#### **Abstract**

The study analyzed adult males' use of birth control products and contraceptives in an heterogenous community in Accra using a scientific random sampling survey of 300 persons from 39 rural, semi-rural and urban communities. The results of the analysis indicated that the respondents had no external sources of information with regards to the majority of the nine identified birth control products and contraceptives. Peers and friends were the major source of information about these products. The likelihood of using these products was significantly influenced by the extent of awareness of their availability. Increasing level of awareness of birth control products and contraceptives for men with lower levels of formal educational attainment led to their increased likelihood of using these products suggesting the important role of information about these products to socially-disadvantaged groups of people, Ever use (both present and past use) of birth control products and contraceptives was shown to be linked to higher economic welfare of respondents, particularly for men with higher family sizes.

**Keywords:** birth control products, contraception, family planning, Ghana, male contraceptive use, reproductive health

#### **1. Introduction**

#### **1.1 Background**

The role of men in the acceptance of reproductive health (RH) policies and the use of birth control (BC) products and contraceptives has received scant attention in the empirical literature. This scant attention on the role of men in RH care and delivery is surprising given the important role of men in heterogeneous sexual relationships which are the source of pregnancies. While women have limited biological carrying capacity in producing children, men can produce a very large number of children based on having sex with as many women as they can find for sexual relationships.

Several research workers such as Starbird et al. [1], Kriel et al. [2] and Gopal et al. [3] have drawn attention to the limited role of men incorporated in various State and Community RH initiatives and the need to incorporate men into RH emerging programs. Men are important actors who influence both positively and negatively, the RH outcomes of society, especially those dealing with children and women. The ongoing challenge to the development and implementation of RH policies and programs is how to incorporate the role of men in family planning initiatives and the influences of men in the areas which impact the health of children and women.

The 1994 Cairo International Conference on Population Development (ICPD) Program of Action called for the inclusion of men in RH programs [4]. An underlying driver of the limited role assigned to males in the development of RH policies is the common equalization of gender with women. The exclusion of men in RH policies does not allow for the analysis and inclusion of the considerable interactions of gender with other important political economy variables such as ethnicity, race, and connections to power structures using both income and non-income measures of human well-being.

#### **1.2 Problem statement**

Ghana is an English-speaking Republic located in the western part of Africa. It gained its political independence from Great Britain on 6 March 1957 after it had been a colony for 113 years with the emergence of colonial rule in 1844 [5]. The country is classified as a lower-middle-income country with recorded per capita income of 2353 United States dollars in 2022 [6]. The population of Ghana was recorded as 30.8 million during the July 2021 national population and housing census [7]. This population is currently growing at the rate of 2.1% annually [7]. The high population growth rate imposes negative socio-economic outcomes on the country including poor sanitation and frequent occurrences of many acute diseases. Given that the population doubles every 33 years [7], there is a need for policy makers to formulate effective RH policies based on scientific evidence.

While Ghana has achieved relatively high growth rate of about five percent per year as indicated by the annual change in the gross domestic product (GDP), over the three decades of constitutional governance [8], the country is bedeviled with serious environmental-related problems which are directly linked to rapid growth of the human population [9]. These problems include extensive destruction of water bodies through illegal mining activities, rapid deforestation, among the highest in the world, and poor environmental sanitation. Another worrisome social issue is the rapidly growing national income inequality, considered to be one of the fastest growing in Africa over the last three decades [9, 10].

This research study is particularly motivated by the need to close the knowledge gaps generated from the widespread omission of men in various RH studies and also the need to ascertain the effects of culture and education on the welfare of men using BC products and contraceptives. Hence, the approach of this researcher is to establish relationships between the acceptance and use of BC products and contraceptives (dependent variable) and independent variables related to social factors such as culture and education. Given that the acceptance and use of BC products and contraceptives is influenced by the various stages of the life cycle of a human being, the Life Cycle Theory originally developed by Professor Modiglani in 1957 [11] is the analytical lens used to develop research questions.

In the reviewed literature, men were not the major focus on RH discussion. Several scholars have described this trend as worrying as males are usually ascribed the

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

responsibilities of ensuring that family planning (FP) and RH concerns are addressed in the family [12]. In addition, national population advisory councils in many countries prioritize women in FP and RH policy formulation [13]. In developing framework for a new reproductive health paradigm, researchers have drawn attention to the absence of men from previous reproductive health initiatives and the need to incorporate men into emerging programs [14].

In light of the previous discussion, the objectives of this study were to ascertain the types of BC products and contraceptives used by adult males and to establish the factors influencing the use of these products by adult males in the Amasaman Area Council of Accra, the capital city of Ghana. Further, the linkage between the ever-use (past or current use) of these products on the welfare of the adult male respondents was analyzed using statistical analysis.

The rest of this paper is organized as follows: the next section is devoted to a summary of the review of the literature on the subject. The next section is reserved for the discussion of the methods and procedures used for the study. These include the survey administration procedures used to randomly select adult male responses and a discussion of the statistical procedures used to analyze the data. The results of the study are presented next followed by the conclusions and the list of cited references.

#### **2. Literature review**

#### **2.1 Introduction to reproductive health and use of birth control products**

Reproductive health care is the provision of basic cost-effective health services. Health services cover health promotion, prevention and maternal core issues such as safe motherhood, adolescent reproductive health. Critical to the attainment of good RH attainment and maintenance is the good quality of health services and systems in a nation state.

Over the past four decades, there has been increasing recognition that good reproductive health care could result in personal economic and social welfare of an individual (for example, refer to [3]). Despite the importance of RH decisions and practices, it is only recently that researchers have started to deeply consider RH as a key tool in advancing economic and social welfare of individuals and reducing poverty. Effective RH policies are important tools for the attainment of the 2030 Sustainable Development Goals of the United Nations for which member countries have agreed upon.

#### **2.2 Factors influencing the use of BC products and contraceptives**

The reviewed literature indicates that there are several socio-economic and cultural factors which are responsible for the use of BC products and contraceptives. These factors include marital status, formal educational attainment, culture and awareness of these products. Marital status influences the use of contraceptives among people.

Sedgh et al. [15] suggested that that the individual marital status was an important factor influencing his/her use of BC products and contraceptives. However, culture, religion and other socio-demographic factors, such as age and educational attainment, were also important drivers of the use of contraceptives.

Education and one's educational level have a relationship with contraceptive use. Women with higher levels of education are able to make better and informed decisions regarding contraceptives [16].

Cultural factors are cited reasons for the low levels of acceptance and use of reproductive health and family planning services in many countries arising from the pro-natural beliefs of adherents of religious faiths such as Islam and Roman Catholic Christianity (for example, refer to [17]). The location of a person and his/her adoption and use of BC products has been reported in the literature (Hawkes and Hart [18]). Persons living in urban localities tend to use BC products more intensively than those in rural localities arising from the relatively higher levels of education and incomes of the latter group of people. Further, access to these products tends to be relatively limited in rural areas.

Awareness of BC products and contraceptives has been shown to be a major factor driving the uptake of these products in parts of the developing world [19]. The important role of the mass media in disseminating information about BC products is weaker in rural areas of many developing countries due to the limited access of rural people to electricity and related infrastructural facilities.

#### **3. Methodology and procedures used in the study**

#### **3.1 Survey methods and administration**

The survey of adult males was undertaken in the Amasaman Area Council in the Greater Accra Region of Ghana. It involved randomly selected males who were 18 years of age and above. The period of the survey was November and December 2019. Random sampling procedures which involved confidential interviews were used to elicit information from adult householders who were male from all 39 communities of the Amasaman Area Council. Using statistical theory and concepts indicated by scholars (e.g., refer to [20–22]), the optimal sample size was determined as 292. The previous pilot survey conducted earlier in June 2019 confirmed that the probability of an adult male being aware of at least one BC product was 0.95. Given that the research allowed for 0.025 maximum standard error (MSE) to be achieved with 95 percent confidence level (that is 1.96 standard errors from a normal distribution), 292 was derived as the optimal sample size. This sample size was increased to 300 leading to an oversampling of eight respondents.

#### **3.2 Model of use of BC products and contraceptives**

A binary logit regression analysis was undertaken to determine socio-economic characteristics of the male respondents that significantly influenced the decision to currently use any of the nine identified BC products and contraceptives. The binary logit model is discussed by Gujarati [23]. The specific model used in this study was as follows:

LOG PROBUSEBCP ð *=*ð Þ 1 � PROBUSEBCP Þ ¼ f MALEAGE, MALEEDU, ð SPOUSEEDU, MALEEDU<sup>∗</sup> SPOUSEEDU, PINCOMEM, BCPAWARENESS, BCPAWARENESS <sup>∗</sup> MALEEDU<sup>Þ</sup> (1) *Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

where PROBUSEBCP was the dependent variable expressing the probability of the male respondent currently using one or more of the nine identified BC products and contraceptives.

MALEAGE was the age of the male householder.

MALEEDU was the level of formal educational attainment of the householder in years.

SPOUSEDU was the level of formal educational attainment of the male householder's spouse.

MALEEDU\*SPOUSEEDU was the interaction variable combining MALEEDU and SPOUSEEDU.

PINCOMEM was the average income of the male householder per month.

BCPAWARENESS was the average degree of awareness indicated by the male householder for each of the nine BC products and contraceptives. The Likert scale was used for the assessment of the degree of awareness with zero indicating total lack of awareness, and 5 for the highest level of awareness.

BCPAWARENESS\*MALEEDU.

Eq. 2 represents the specific model used for the analysis and was based on the dependent variable being the natural logarithm of the odds ratio of the respondent using any one of the nine BC products:

LOG PROBUSEBCP ð Þ*=*ð Þ 1 � PROBUSEBCP .

LOGðPROBUSEBCPÞ*=*ð Þ 1 � PROBUSEBCP

¼ A0 þ A1 MALEAGE þ A2 MALEEDU þ A3 SPOUSEEDU

(2)

<sup>þ</sup> A4 MALEEDU<sup>∗</sup> SPOUSEEDU <sup>þ</sup> A5 PINCOMEM <sup>þ</sup> A6 BCPWARENESS

<sup>þ</sup> A7 BCPAWARENESS <sup>∗</sup> MALEEDU <sup>þ</sup> <sup>U</sup>

Where Ai (i = 0, 1, 2, 3, 4, 5, 6 and 7) are the parameters and U is the equation error term.

#### **3.3 Model linking economic welfare of male respondents and their ever-use of BC products**

A multiple regression model analysis was used to ascertain the relationship between personal empowerment, indicated by personal income adjusted for by household size, and the use of birth control methods and other socio-economic characteristics of the 300 male respondents (household heads). The model used is specified as Eq. (3) below:

LPINCOMEM ¼ E0 þ E1 MALEAGE þ E2 MALEAGESQUARED þ E3 MALEEDUSSS þ E4 CUMARRIED þ E5 ISLAMREL þ E6 HSIZELARGE þ E7 EVERUSEDBCP <sup>þ</sup> E8 HSIZELARGE<sup>∗</sup> EVERUSEDBCP <sup>þ</sup> Zi (3)

where LPINCOMEM was the natural logarithm of the average income earned by the householder per month, adjusted for by the size of his household (HHSIZE), to derive adult-equivalent income. This adjusted household size (*λ* derivation was based on the equation *λ =* (HHSIZE)<sup>σ</sup> with σ being the scale parameter. The scale parameter used was 0.70 similar to the work of Buse & Salathe [24].

AGE is the age of the male respondent in years.

MALEAGESQUARED is the square of MALEAGE. This variable is incorporated in the model to examine the possibility of a curvilinear relationship between economic welfare of the male respondent and his age over time; this specification is driven by the life cycle theory employed for this study. Hence, the linear versions are used for the analysis.

MALEEDUSSS is a dummy variable with the value 1 for male respondents who completed senior secondary school or its equivalent and zero otherwise. Rather than using formal educational attainment (MALEEDU), the use of MALEEDUSSS dummy variable was due to the fact that MALEEDU was directly related to the use of BC products. MALEEDUSSS therefore served as an instrumental variable for MALEEDU to avoid the problem of endogeneity in the regression model.

ISLAMRELIGION is a dummy variable taking the value of 1 if the male respondent is a Muslim and zero if the respondent is not a Muslim.

CUMARRIED is a dummy variable taking the value of 1 if the male respondent was married at the time of the survey in November/December 2019, and zero if the respondent was not married at that time.

HSIZELARGE is a dummy variable with a value of 1 if the nominal household size is three or more, and zero if the nominal household size is less than three (that is single-person family or two-person family). The choice of three as the threshold household size was based on a numerical simulation analysis of household sizes from 1 to 17.

EVERUSEDBCP carried a value of 1 if the male respondent had ever used BC products during his lifetime. It took a value of zero if the respondent had never used any BC products in his lifetime.

HHSIZELARGE\*EVERUSEDBCP is an interaction term between the two variables, HHSIZELARGE and EVERUSEDBCP, that evaluates the effect of the use of BC products in larger-sized households of three or more on the economic welfare of the male respondent. Larger-sized households used in this study indicate that the household has an adult male with a spouse and at least one dependent.

Ei (where i = 0,1,2,3,4,5,6 and 7) are parameters to be estimated; and Z is the equation error term, initially assumed to have zero mean and constant variance.

#### **4. Results**

The socio-economic characteristics of these 300 respondents, based on frequency analysis, are presented in **Table 1**. The age range of the respondents was between 20 and 69. However, the dominant age group of the respondents was the 30 to 49 years group; this group had about three-quarters of all the respondents (77.7%). The vast majority of the respondents has some formal schooling with only 4.6% never attending school. About two-thirds of the respondents were formally married (66.9%) while about one quarter were in various cohabitation arrangements with partners ((26.2%).

In terms of religious affiliation, Christianity was declared as the dominant religion with over three-quarters (76.8%) of the respondents indicating this religion as their preference. Following Christianity, the most popular religious affiliation was traditional African religions, either in their sole forms or mixed with Christianity or Islam;


*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*


#### **Table 1.**

*Characteristics of the male survey respondents based on frequency analysis.*

this mixed preference was indicated by about one in seven of the respondents (14.2%). Ghana has nine broad ethnic groups. The largest ethnic group among the respondents was Ewe. The second largest group was Akan and this was followed by Dangme/Ga groups.

In terms of employment, artisans were the largest group followed by selfemployed people from other categories and then by private sector employees, farmers and government sector employees. With regards to the use of BC products, about one in seven of the respondents (13.9%) had used these products during the 12 months before the start of the survey. This proportion was slightly smaller than the proportion of the respondents who had used these products during past periods (14.9%).

**Table 2** represents the summary socio-economic characteristics in terms of average or mean figures. The average age was 35.6 years, ranging from 22 to 60 years. The number of years of formal schooling acquired was 11.0 years. The average number of people living in a household was 6.0 and the average number of children was 3.8, 2.1 male children and 1.7 female children. The average monthly income received by the adult male was about 499 Ghana cedis during the year, 2019. Given that one United States dollar was worth on average 5.22 Ghana cedis in 2019, the average monthly income translated to about 96 US dollars. The amount of money spent on BC products and contraceptives, over the previous year, was 24 Ghana cedis or about 4.6 United States dollars.

As indicated in the literature, the quality attributes of available and accessible health services and systems influences the use of BC products and contraceptives. **Table 3** contains the scores for the various quality attributes of health services and health systems declared by the respondents. The lowest-ranked service or facility was *Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*


**Table 2.**

*Summary of characteristics of male survey respondents based on averages.*

the sanitary condition of the facility. The average quality score for this attribute was 1.705. On the other hand, the highest ranked attribute was the ease of access to the health centre or clinic with an average score of 4.301 out of the maximum score of 5.0. Services provided by doctors at the health centre or clinic were generally considered to be in the very good to excellent range and further the quality values exceeded those indicated for services provided by nurses and pharmacists (refer to **Table 3**). The quality of services provided by pharmacists and nurses at the health centre and clinic



*The assessment of the quality of services or access to services that you received at the health centre that you last visited based a Likert scale of 0 to 5 denoting excellent quality, 4 very good quality, 3 moderate quality, 2 low quality, 1 very low quality and zero (0) for no quality at all. Source: Data from survey undertaken in November and December 2019.*

#### **Table 3.**

*Quality assessment scores of health services and systems by respondents.*

was generally similar; however the average quality scores were slightly higher for services provided by nurses.

The study identified nine BC products and methods which were known by the male respondents. These are reported in **Table 4**. The traditional method of planned abstinence from the spouse for a period of time, after the delivery of a child was the most familiar BC method or product. Male condom was the second most important BC method or product. Other BC methods and products identified by the male respondents were vasectomy, rhythm or calendar method, traditional herbs, outercourse, drinking of local gin before sex, and taking drugs to prevent pregnancy.

**Table 5** shows the most important single sources of information for the BC methods and products. There were no source of awareness for five BC methods and


*The scoring is based on 5 denoting that item is very high level of awareness, 4 represented high level of awareness, 3 indicated moderate level of awareness, 2 represented low level of awareness, 1 represented very low level of awareness and zero (0) represented total lack of awareness of the particular birth control method. The coefficient of variation is the standard deviation divided by the mean score. Source: Data from survey undertaken in November and December 2019.*

#### **Table 4.**

*Ranking of the level of awareness of birth control methods by respondents.*

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*


#### **Table 5.**

*The most important source of information for various birth control methods as declared by the respondents.*

products. These were rhythm method, traditional herbs, outercourse, drinking of local gin before sex, and taking drugs to prevent pregnancy. Further, peers and friends were the most source of information for the BC methods and products: withdrawal before ejaculation and vasectomy. Television was the major source of information for the male condom. This result on male condom was also established by Anaman and Okai [25], for females.

The intensity of the use of BC methods and products is summarized in **Tables 6** and **7**. **Table 6** provides information on the use intensity during the previous 12 months before the survey, considered to refer to current use. The information in **Table 7** refers to past use intensity of the various BC methods and products. The commonest BC method or product was the male condom. Withdrawal before ejaculation was the second most important BC method or product. The findings of



*The scoring is based on 5 denoting that item is very high level of use, 4 represented high level of use, 3 indicated moderate level of use, 2 represented low level of use, 1 represented very low level of use, and zero (0) represented total lack of use of the particular birth control method. The coefficient of variation is the standard deviation divided by the mean score. Source: Data from survey undertaken in November and December 2019.*

#### **Table 6.**

*Ranking of the level of intensity of current use of birth control methods by respondents.*


*The scoring is based on 5 denoting that item is very high level of use, 4 represented high level of use, 3 indicated moderate level of use, 2 represented low level of use, 1 represented very low level of use, and zero (0) represented total lack of use of the particular birth control method. The coefficient of variation is the standard deviation divided by the mean score. Source: Derived from survey data, November to December 2019.*

#### **Table 7.**

*Ranking of the level of intensity of past use of birth control methods by male respondents.*

this study corroborate the disconnect between the awareness of BC methods and products and their relatively low intensity of use in Ghana established by other studies such as [26, 27].

**Table 8** provides the reasons given by the respondents for *not currently using* BC methods and products. The assertion that BC methods and products were meant for women and not men was the most important reasons given by the male respondents for their non-use of these products during the current period (within 12 months of the survey). The dislike of the BC methods and products was cited as the second most important reason for their non-use by the male respondents. The third most important reason was the perceived harmful side effects from the use of these products.

**Table 9** summarizes the suggested reasons for non-use of BC methods and products during the past periods. The results assembled in **Table 9** are similar to those reported in **Table 8** with very close figures for the percentages of the male respondents expressing similar sentiments with regards to the three most important reasons *Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*


#### **Table 8.**

*Reasons given by the male respondents for not currently using birth control methods and products based on the percentage of respondents.*


#### **Table 9.**

*Reasons given by the male respondents for not using birth control methods and products during the past based on the percentage of respondents.*

for non-use of BC methods and products. Non-use of BC methods and products for religious and cultural reasons were cited by the respondents in both **Tables 8** and **9**. However, this reason was generally regarded as not important given the relatively low percentage of respondents expressing this sentiment.

The results of the analysis of the likelihood of use of BC methods and products are reported in **Table 10**. Out of the seven independent variables, five were statistically significant in influencing the likelihood of the use of these products. The statistically significant variables included the formal educational attainment of the male respondent and also the educational attainment of his spouse. However, highly educated male respondents who were married to highly-educated female partners had decreased likelihood of using BC methods and products. As expected, the level of awareness of BC methods and products led to increased likelihood of the use of these products.


*Number of observations for regression analysis was 300 and % observations correct was 86.7. Dependent Variable is log (PROBUSEBCP/1-PROBUSEBCP) (the natural logarithm of the odds ratio in favor of use of BC products and contraceptives).*

*\*\*\*Statistical significance of the parameter at the 1% level.\*\*Statistical significance of the parameter at the 5% level. \*Statistical significance of the parameter at the 10% level.*

#### **Table 10.**

*Binary logit regression analysis of the current use of birth control products and contraceptives versus selected socioeconomic characteristics of the respondents.*

Further, when the level of awareness was combined with the educational attainment, the likelihood of the use of BC methods and products declined. This particular result would suggest that male respondents who had relatively lower levels of formal educational attainment were more likely to use BC methods and products when they had increasing levels of awareness information about these products. Hence, this result paved the way for more aggressive forms of publicity of information about BC methods and products targeted at relatively lower educated male respondents.

The results of the regression analysis of the linkage between economic welfare of the male respondents, as indicated by his adjusted personal income, acting as the dependent variable, and various independent variables including the ever-use of BC products are reported in **Table 11**. Using the popular Ramsey Reset test of model specification [28], the model reported in **Table 11** was adequately specified with the Ramsey Reset probability (p) value of rejection of the null hypothesis of correct specification being 0.168 above the critical p value of 0.10 used in the study. Based on the Lagrange Multiplier (LM) test of heteroscedasticity [29], the model also had no significant heteroscedasticity. The power of the model as measured by the R<sup>2</sup> was 0.22; this value would be considered to be modest.

The results shown in **Table 11** indicate that the parameters of all the independent variables were statistically significant. The positive enhancing effects on the economic welfare of the male respondent were due to the status of the person being currently married and also being Muslim. The significant parameters related to the two age variables indicated the existence of a curvilinear relationship between age and economic welfare, consistent with the reproductive life cycle hypothesis used in this study. Differentiating the estimated economic welfare equation with respect to age, the age at which economic welfare started to increase was 47.8 years, assuming other things constant.

The result dealing with the MALEEDUSSS variable showed that respondents who completed secondary school education had significantly lower levels of economic

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*


*R2 = 0.240 Adjusted R2 = 0.222. Dependent Variable is the natural logarithm of the average monthly personal income of male respondent adjusted for by household size (LPINCOMEM). Significance level of Ramsey Reset test of correct model specification 0.168. Significance level of Lagrange Multiplier (LM) test of heteroscedasticity 0.140.*

#### **Table 11.**

*Regression analysis results of the relationships between a male respondent's economic welfare indicated by his adjusted personal income versus his use of contraceptives and his other socio-economic characteristics.*

welfare than other respondents with different types of educational attainments, ranging from no schooling to completion of university education. Increasing household size led to declining economic welfare of the male respondent given the burden of larger household sizes. The effect of the use of BC products and contraceptives in larger-sized households was established. There was positive enhancing effect on the economic welfare of the male respondent from the use of these products for households of sizes, three or more. Thus, households that have started producing children benefitted from the use of these products, possibly due to increased levels of choices to earn incomes, arising from more spacing of births.

#### **5. Conclusions and discussion of policy implication of the study**

#### **5.1 Summary of major findings and conclusions**

This paper reports the findings of a survey of 300 adult males in all 39 communities of the Amasaman Area Council, Accra, Ghana that elicited information on the perceptions and use of BC products and contraceptives. Nine different BC methods, products and contraceptives were used by the male respondents. Peers and friends were the major source of information about these products. The educational attainment of the male respondent and that of his spouse were statistically significant in increasing the likelihood of use of BC products and contraceptives by the male respondents.

As expected, the degree of awareness of BC products and contraceptives significantly influenced the likelihood of use of these products. Awareness also acted as a moderating variable with combination of formal educational attainment of the male respondent in influencing the likelihood of current use of birth control methods in a negative fashion. This result suggested that males with lower levels of formal educational attainment, and who had higher awareness of BC products and contraceptives, were more likely to use these products.

Economic welfare was shown to be higher for married male respondents than those who were not married. Muslim respondents had significantly higher average income than non-Muslims. The significant parameters related to the two age variables indicated the existence of a curvilinear relationship between the age of the male respondent and his economic welfare; this result was consistent with the reproductive life cycle hypothesis used in this study. Average income of the male respondents increased from 47 years of age onwards.

As expected, larger household sizes were associated with lower levels of economic welfare. However, the ever-use of BC products and contraceptives, in families with larger household sizes, led to increased economic welfare. Given that larger household sizes were defined in the analysis as a dummy variable to denote household sizes of three or more people, this classification would indicate that large households were those involving a married couple with at least one child or dependent. Hence, the economic welfare enhancement obtained from use of BC products and contraceptives was a benefit accruing to households with children.

#### **5.2 New contributions and policy implications arising from the study**

This paper makes three contributions to the existing literature dealing with the use of BC products and contraceptives by males and the related policy implications arising from the pattern of male behavior identified in this study. The first contribution is that this study indicated the expected result that increasing awareness of BC products and contraceptives led to the increased likelihood of use of these products by the adult males. Further, it was shown that the increasing awareness of these products for less educated respondents led to increased likelihood of their use by these people. This result would suggest that educational and publicity campaigns of State and Community organizations should target more resources and efforts in RH care and delivery to the less educated sections of the adult male population. The current approach of non-targeted informational programmes, based on uniform spread of awareness messages across the general population of men, may not be very productive.

The second contribution of the study is related to the establishment of evidence of increased economic welfare of male household heads due to the use of BC products and contraceptives, and particularly for those adult males with larger household sizes; this result was possibly due to the increased spacing of births achieved through the use of these products. This result would suggest that targeting of awareness campaigns related to these products would also need to put emphasis on men with large household sizes as they would benefit more in terms of economic welfare arising from the use of these products.

The third contribution of this paper, which closes a gap in the literature, is the finding of very high awareness by the respondents of the traditional Ghanaian method of birth control and family planning related to the male partner avoiding sex with his spouse/partner for a period of time, often one year or more. Despite its very high awareness, and its pre-eminent ranking as the most well-known form of birth control method, among the 300 responding adult males in this study, only about four percent of the respondents were using or had used this method of birth control. This would suggest the need of policy makers and State and community organizations involved with RH care and delivery to bring back the emphasis on the traditional method of birth control related to controlled abstinence after the delivery of children by the spouses and partners of males.

*Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

Generally, religious and cultural barriers against the use of birth control methods and products were not considered important by the respondents as they were ranked as reasons for non-use of BC products by less than 10% of the sampled respondents. This result would suggest that the low use of traditional abstinence birth control method was largely related to the information market failure problem; this could be resolved by repeated messaging of its importance by State and Community organizations involved in RH care and delivery to adult males in Ghana.

#### **Acknowledgements**

The author thanks all the 300 male respondents for participating in the study. The study was conducted as part of the author's doctoral research work at the Nobel International Business School, Accra, Ghana. The author completed her doctoral research work in December 2021. She received no external funding for this research study. I acknowledge contribution and effort of my research assistant Dennis Nii-Okai Aryee MBA; and the assistance of Professor Kwabena Asomanin Anaman of the Department of Agricultural Economics and Agribusiness, University of Ghana in the development of the statistical models.

#### **Author details**

Hanny-Sherry Ayittey Integrated Investments, Accra, Ghana

\*Address all correspondence to: sayite@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[2] Kriel Y, Milford C, Cordero J, Suleman F, Beksinska M, Steyn P, et al. Male partner influence on family planning and contraceptive use: Perspectives from community members and health care providers in KwaZulu-Natal. South Africa. Reproductive Health. 2019;**16**:89

[3] Gopal P, Fisher D, Seruwagi G, Taddese HB. Male involvement in reproductive, maternal, newborn, and child health: Evaluating gaps between policy and practice in Uganda. Reproductive Health. 2020;**17**(1):114

[4] Basu AM. ICPD: What about men's rights and women's responsibilities? Health Transition Review. 1996;**6**(2): 225-227

[5] Buah FK. A History of Ghana. London: MacMillan; 1998

[6] Ghana Statistical Service (GSS). Annual 2013 to 2022 GDP. Accra: GSS (April); 2023

[7] Ghana Statistical Service (GSS). 2021 National Population and Housing Census: Analytical Report. Accra: GSS; 2021

[8] Anaman KA, Bukari GA. Voter turnouts in presidential elections in Ghana: A political economy analysis using district-level data. Applied Economics and Finance. 2021;**8**(1):13-31. DOI: 11114/aef.v8i1.5083

[9] Abubakari MM, Anaman KA, Ahene-Codjoe AA. Urbanization and arable land use in northern Ghana: A case study of

the Sagnarigu municipality in the greater tamale area. Applied Economics and Finance. 2022;**9**(1):68-84

[10] Oxfam International. Ghana: Extreme Inequality in Numbers. London: Oxfam; 2023

[11] Modiglani F. The life cycle hypothesis of saving, the demand for wealth and the supply of capital. Social Research. 1966;**33**(2):160-217

[12] Hindin MJ, Christiansen CS, Ferguson BJ. Setting research priorities for adolescent sexual and reproductive health in low-and middle-income countries. Bulletin of the World Health Organization. 2013;**91**:10-18

[13] Stephenson R, Baschieri A, Clements S, Hennink M, Madise N. Contextual influences on modern contraceptive use in sub-Saharan Africa. American Journal of Public Health. 2007;**97**(7):1233-1240

[14] Nair S, Dixit A, Ghule M, Battala M, Gajanan V, Dasgupta A, et al. Health care providers' perspectives on delivering gender equity focused family planning program for young married couples in a cluster randomized controlled trial in rural Maharashtra. India. Gates Open Research. 2019;**3**:1508

[15] Sedgh G, Ashford LS, Hussain R. Unmet Need for Contraception in Developing Countries: Examining Women's Reasons for Not Using a Method. New York: Guttmacher Institute; 2016

[16] Gizaw A, Regassa N. Family planning services utilization in mojo town, Ethiopia: A population-based study. Journal of Geography and Regional Planning. 2011;**4**(6):355-363 *Use of Birth Control Products and Contraceptives by Adult Males: A Case Study… DOI: http://dx.doi.org/10.5772/intechopen.111859*

[17] De Silva T, Tenreyro S. Population control policies and fertility convergence. Journal of Economic Perspectives. 2017;**31**(4):205-228

[18] Hawkes S, Hart G. Men's sexual health matters: Promoting reproductive health in an international context. Tropical Medicine and International Health. 2000;**5**(7):A37-A44

[19] Titaley CR, Wijayanti RU, Damayanti R, Setiawan AD, Dachlia D, Siagian F, et al. Increasing the uptake of long-acting and permanent methods of family planning: A qualitative study with village midwives in East Java and Nusa Tenggara Barat provinces, Indonesia. Midwifery. 2017;**53**:55-62

[20] Anaman KA. Research Methods in Economics and Other Social Sciences. Second ed. Saarbrucken, Germany: LAP Lambert Academic Publishing; 2014

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## **Chapter 10** Family Planning Helps the World

*Richard Grossman*

#### **Abstract**

It is generally recognized that voluntary family planning is essential for the lives and health of individuals in today's world. What is less frequently acknowledged is that family planning has decreased the growth of human population over the past decades. Despite many wonderful advances since the industrial revolution, humans have caused massive deterioration of the natural world. Examples include climate disruption caused by the increase in greenhouse gases and the sixth mass extinction of species. Without modern, voluntary family planning, these negative effects would have been greater. This chapter recommends increased attention to the global public health benefits of family planning by reducing the numbers of unintended births and thus the number of people contributing to our environmental deterioration.

**Keywords:** contraception, abortion, environment, social justice, public health

#### **1. Introduction**

*Family planning is the most humane vehicle for achieving sustainable social and environmental justice.*

*Jensen and Creinin*

We are accustomed to think of the advantages of Family Planning (FP) to individuals and perhaps to families, but not of the global benefits. This chapter mainly focuses on these benefits to society and to our environment. Throughout the chapter I include access to safe abortion services along with FP [1].

First, I would like to mention the need for more methods of FP, especially for men. At present we have a large variety of methods for women. However, no method is acceptable to all women, and no method is failure-free. Hopefully, improved FP methods will continue to be developed, for both women and men.

In addition, I need to admit to the lack of equity. FP is available to most people in rich countries. However, even in one of the richest countries, the USA, there are geographic locations where it is difficult to access FP services. This has been improved by telemedicine and also by the ability to get FP, including birth control pills, by mail. Nevertheless, there are "abortion deserts", where a woman has to travel long distances in order to abort an unwanted pregnancy. With today's political climate in the USA, access to safe abortion services even is more difficult.

One might think that distance should be no problem in countries with good transportation, however, this is not so. A study performed in the USA has shown that when there is a FP clinic is close to a high school, female students are less likely to drop out of school [2].

Access to FP services in developing countries is often difficult if not impossible. The difficulty is because of multiple factors including distance, language differences and "stock outs". Often cultural and religious beliefs are serious barriers to accessing and using FP [3].

It is unfortunate that there is no perfect contraceptive method for women, and there is much less available for men. As I write this (April, 2023), I am pleased to note that new oral contraceptive is available that may be safer than past combination pills. Drospirenone/estrol (Nextstellis®) is available in the USA, but is very expensive for those who do not have adequate insurance coverage. Progestin-only oral contraceptives have been around for decades. The have a record of great safety, although breakthrough bleeding and pregnancy rates may be higher than with combined oral contraceptives. Despite the excellent record of safety, the FDA currently requires a prescription for a woman to purchase progestin-only pills. Thanks to the organization "Free the Pill" in the USA our FDA is looking at making this pill available over-the-counter, which will help reduce its cost and make it more accessible.

#### **2. Benefits to the individual**

Contraception allows women to enjoy sex with little worry about unintended pregnancy. This permits a woman to finish her education and to start a career before parenting, if that is what she chooses to do. The role of women in developed countries has changed markedly in the 60+ years since oral contraceptives first became available. Although there have been many other factors causing these changes, certainly "the pill" has had a major effect.

Family planning has been called one of the top 10 public health achievements of the 20th century by the US Centers for Disease Control [4]. It allows for longer intervals between the births of children and for smaller family size. By decreasing the number of pregnancies a woman has in her lifetime and increasing intervals between pregnancies, FP has also reduced the mortality and morbidity of women. Because of the longer birth interval, and because each child can receive more resources, FP has helped to save children's lives—especially in developing countries. Improved barrier methods, such as female condoms and nonlatex male condoms, have decreased transmission of HIV and other sexually transmitted infections.

We now have LARCs—Long-Acting Reversible Contraceptives, including hormonal implants and several IUDs. LARCs have very low failure rates, partly because they do not require doing something (such as taking a pill) on a regular basis. Most of the IUDs available in the USA are hormonal. These are being evaluated to find out if they are effective for use longer than their original approval [5]. In addition, they may be useful for postcoital (emergency) contraceptive use [6].

Copper containing IUDs, such as the T 380A (Paragard®), are also very effective for emergency contraception, if inserted within 5 days of unprotected intercourse. Other emergency contraceptive methods include levonorgestrel tablets (which are available without a prescription in many countries) and ulipristal. Although supplanted by more effective methods of emergency contraception, in some areas the only available method may be the Yuzpe regimen. This is using oral contraceptive pills containing ethinyl estradiol and norgestrel, although other formulations may also be effective. Current research has found that emergency contraceptive pills do not work by causing an abortion.

There are many good sources for information about birth control. One that is objective and geared to people in the USA is: www.plannedparenthood.org. The World Health Organization (www.who.int) is a good worldwide source for information.

#### **3. Abortion**

There are estimated to be 121 million unintended pregnancies worldwide each year [7]. Some of these are miscarried, some intentionally aborted and some go to term. The World Health Organization states that, globally, about 60% of unintended pregnancies are aborted, and almost half of the abortions are "unsafe". They estimate the total number of global induced abortions at 73 million annually [7].

"Unsafe abortion" is the term that is often used for abortions that are performed outside of the medical system. Usually these abortions are expensive, exploitive and dangerous. Women choose to have an unsafe abortion when they live where abortion is illegal or severely restricted. The risks of an unsafe abortion include serious illness such as hemorrhage or infection, and may result in sterility or death.

It is interesting that abortion is no less common in countries where it is illegal [7]. Perhaps this is because many of these countries also limit access to contraception. Many of the countries where abortion is illegal have high levels of patriarchy and religiosity, with the beliefs that sex should only happen within a marriage. This goes along with limited or no sexuality education, so young women are likely to not be prepared to deal with aggressive males.

#### **4. Global benefits of family planning**

The main thrust of this chapter is the benefits of FP to humans, other species and to the environment. I will look at examples in order to make the point that, in addition to helping us, FP helps us to preserve biodiversity and decrease environmental impact.

Most of the world's environmental problems, including climate disruption and loss of biodiversity, would be improved if there were fewer people on the planet. During the past century we have seen remarkable decreases in the rate of population growth, largely due to the use of voluntary FP. Unfortunately, the importance of FP and its relationship to population growth has been largely overlooked by medical and public health people. Furthermore, some people involved in the social sciences seem to actively deny that the planet is overpopulated [8]. Much of this denial comes from religious beliefs and from the regrettable past history of genocide, forced sterilization and eugenics [9].

The good news is that almost half of the world's countries have a total fertility rate (TFR) of less than 2.1, which is the number for replacement fertility [10]. This means that their population will decrease, if the fertility stays below that number, although it may take several decades for that to happen.

How large can the human population be and still be sustainable? I like to use the Ecological Footprint (EF) to compare how we are using Earth's resources with what is available. In short, the EF breaks down our use of resources to land area—land on which to live, to raise food, to develop resources and to dispose of waste.

Globally, there are about 12.2 billion hectares of bioproductive land and of water. Shared evenly among the current roughly 8 billion people on earth, that would be about 1.5 hectares (3.75 acres) for each person. However, many people use more than that. For instance, the average EF for a person in the USA is about 7 hectares (17.2 acres).

The average Ecological Footprint for everyone on Earth is 2.77 hectares—significantly larger than the 1.5 acres that are available. As a consequence, we are using the earth's resources faster than they can regenerate. Calculations suggest that it would take 1.8 planets Earth to support all the humans at the rate at which we are using resources and generating waste. The excess over what the planet can support sustainably is called "overshoot" [11].

One way to calculate a sustainable human population is to divide our current population by the overshoot fraction—8 billion divided by 1.75, or about 4.5 billion people. Unfortunately, one of the shortcomings of the EF is that it does not allow any resources for nonhuman species. With a small allowance for all other flora and fauna, we might find that 4 billion humans would be a sustainable population. If we want the planet to be really healthy, the human population should be about 3 billion people.

There are other, perhaps more accurate ways of calculating the size of a sustainable human population. Mostly they end up with estimates in the range of 2 to 3 billion people, as stated above. For a readable review of this subject, I suggest the book "A Planet of 3 Billion" by Christopher Tucker for more information about a sustainable human population.

The bottom line is that our current human population is not sustainable. In fact, our current population, with the average consumption, is about 2 or 3 times what could be maintained indefinitely. Without modern FP, our numbers would have been much, much larger than the current 8 billion!

Let me explain why I focus on population rather than on consumption. In the formula that describes human impact on the environment, I = P × A × T (Impact equals Population times Affluence (or Consumption) times Technology), population is just as important as affluence. However, remember that there are more than 120 million unintended pregnancies every year! [12]. That means that there are many, many women who wish to have control over their fertility—but I know very few people who wish to decrease their affluence. Indeed, globally we live in a sea of advertisements and other media that urge us to buy and consume more, not less.

I do not give the T in the above formula much attention. For instance, I've replaced the lightbulbs in our home with compact fluorescent light bulbs, then with LEDs. We have solar panels on our roof that make most of our electricity and also power our plug-in hybrid vehicle. However, my wife's and my Ecological Footprint is still much larger than 1.5 acres, since these technological modifications only reduce our impact slightly.

To sum up, it would be great to have everyone decrease their footprints down to what is available (1.5 hectares) if we all shared equally. Unfortunately, that is very unlikely. For the average person in the USA it would mean shrinking their footprint by almost 80%, from 7 to 1.5 hectares! Imagine what it would take to have such a small footprint. There are so many things you could not do, and so many things you'd have to do without to have such a small footprint. You would probably have to live in a small house, eat primarily beans and rice or other simple foods with very little meat or none at all. You would have to walk, bike or take public transportation; a car would be impossible. You would have no frills, no TV and probably lots of hard work. It is no wonder that people are not enthusiastic about decreasing their consumption!

On the other hand, millions of people already are trying to control their fertility. Over half a million abortions are performed every year in the USA [13]. It is estimated that there are about 121 million unintended pregnancies globally [7]. The number of women who do not have access to effective contraceptive methods is estimated to

#### *Family Planning Helps the World DOI: http://dx.doi.org/10.5772/intechopen.111801*

be 218 million [14]. Access to voluntary contraception and abortion are certainly the "low hanging fruit" when it comes to decreasing human impact.

There are other, more quantitative ways to appraise the role of FP in lowering our impact [15]. In this part of the discussion, I would like to use climate disruption caused by carbon dioxide (and other greenhouse gasses) as a proxy for all anthropogenic environmental problems. This is because climate disruption is in everyone's mind—as well it should be. Furthermore, climate disruption has been studied a great deal, and in more quantitative ways, than other environmental problem.

For various reasons, the potential for FP to help solve the evolving disaster of climate disruption has been given much less attention than it deserves [16]. An article written in 2010 claims: "Using an energy–economic growth model that accounts for a range of demographic dynamics, we show that slowing population growth could provide 16–29% of the emissions reductions suggested to be necessary by 2050 to avoid dangerous climate change" [17]. Although it may be too late to achieve such a benefit by the year 2050, there are still large advantages to supporting FP for further in the future. Another study suggests that not only is FP effective, but it may be the least expensive means to slow climate disruption [18]. Another article gives an overview of CO2 emissions in the past and projections using demographics [15].

However, there are other environmental problems than just climate disruption. Extinction of species, global toxification and other impending tragedies may be as bad as, or even worse, than climate disruption. Working together, all this deterioration of the environment will cause problems that we can only begin to imagine. Do not forget that all of these problems are anthropogenic!

#### **5. What could be worse than climate disruption?**

Most people understand the CO2 that we emit is caused by people using fossil fuels. However, the connection between human endeavor and the extinction of species may not be so obvious. What is the association between humans and extinction of species? There are a half dozen ways that we are accelerating the loss of species. Paleontologists have known that species have always become extinct, and estimate that the baseline rate is in the range of 1 per million living species per year. The current estimated rate is at least 100 times that, and probably 1000 times or more. One estimate is that there are 8.7 million species on earth and in the oceans [19]. Using the most likely rate of extinction, that would suggest that more than 8000 are being driven to extinction each year. This has been called the "sixth mass extinction" [20].

The biggest reason for extinctions is loss of habitat. Many species of plants and animals require specific conditions to thrive. There are also species, called "endemics", that only live in small areas. If their habitat is disturbed, they die. This is the reason for the Endangered Species Act in the USA. Before any significant development is allowed to occur, the Act requires a survey looking for endangered species. It is sad that all other countries do not have similar laws, and that often the laws (where they exist) aren't always enforced. Unfortunately, the press of the growing human population has already caused the extinction of many species. Joni Mitchel sums it up well in her song, Big Yellow Taxi: "They paved paradise and put up a parking lot [21]".

Each human on the planet requires a place to live and food to eat. The species who had lived on the land before us are evicted; unfortunately, those individuals who

survive the bulldozers frequently have no place to go. Often the land used to grow our food is treated with chemicals that are incompatible with the life that had been there [22]. Nonhuman species are being challenged and too often killed off by our civilization in a variety of ways.

Briefly, here are the five other ways that we are causing species to go extinct: (1). The changing climate makes it difficult for some species. For instance, the pika is sensitive to heat. It is a small mammal that lives in cold, mountainous regions. As the climate gets hotter, it can move up in altitude to stay cool. However, they will have no place to go when the mountain tops aren't cold enough. (2). Humans have introduced diseases, such as the fungus that causes white nose syndrome in bats. It is killing susceptible species of bats—which destroy untold numbers of pest insects. (3). We have also introduced exotic species that out-compete vulnerable local species. An example is the salt cedar or tamarisk, which has locally displaced native trees such cottonwoods. (4). In the last century chemists have synthesized thousands of new chemicals. Even though they are given cursory testing for safety before being marketed, some of them have had disastrous unintended consequences. DDT is an example of a chemical with severe unintended consequences [23]. (5). Finally, human greed has killed off some species. Carolina parakeets were numerous at one time, but their colorful plumage became fashionable for ladies' hats. These beautiful birds were hunted to extinction.

We do not know how we will be affected by the mass extinction of other species. We do know that we are a part of the web of life, and that all parts of the web are interdependent. To some extent, all species are important, although some are much more important than others. As our understanding of this web increases, we find out that some species that we thought were of little import are actually essential. Slime molds are an example. They appear unbidden in gardens and woods as unwelcome guests; some of them look like someone vomited on the ground. However, they are helpful because they recycle nutrients [24].

Humans have invested in developing just a few species for our nourishment. Much of our food comes from only a few crops, such as wheat and rice. Likewise, much of the meat we eat comes from just a few species of animals, such as pigs and goats. Although this permits efficient factory farming, it makes us very dependent on just a few species of plants and animals. When there is a disease such as the potato blight in Ireland, this lack of diversity may cause a famine. This is just one way that decreasing biodiversity can affect us. Some experts worry that the mass extinction may be even more problematic to humankind than climate disruption [25].

#### **6. What can we do?**

I have several suggestions. Perhaps my strongest recommendation is to support people and organizations that work in the field of reproductive health. This might mean making donations to organizations and clinics that provide FP services. It could mean lobbying politicians who recognize the importance of FP—and it certainly means remembering the importance of FP when it is time to vote.

For those of us in the field of family planning, here is encouragement:

*"As family planning specialists, we should devote part of our effort to educating policy leaders and the public about the importance of our work from an environmental standpoint" [1].*

#### *Family Planning Helps the World DOI: http://dx.doi.org/10.5772/intechopen.111801*

Although an individual cannot cure the ills of the world single-handedly, supporting access to family planning is one way that each of us can work to help with climate disruption and also with loss of biodiversity.

#### **Summary**

Most of the readers of this chapter are already aware of the advantages of modern family planning—the ability to have sexual intercourse with little fear of an unintended pregnancy. Contraception and abortion have slowed the growth of the human population. Nevertheless, the human numbers are currently 2 or 3 times what would be sustainable. It is important to recognize the important role that family planning plays in helping the non-human portion of the world, in addition to the how it serves people.

#### **Author details**

Richard Grossman Department of Biology, Fort Lewis College, Bayfield, Colorado, USA

\*Address all correspondence to: richard@population-matters.org

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[2] Hicks-Courant K, Schwartz AL. Local access to family planning services and female high school dropout rates. Obstetrics and Gynecology. 2016;**127**(4):699-705. DOI: 10.1097/ aog.0000000000001344

[3] Adongo PB, Phillips JF, Kajihara B, Fayorsey C, Debpuur C, Binka FN. Cultural factors constraining the introduction of family planning among the Kassena-Nankana of northern Ghana. Social Science & Medicine. 1997;**45**(12):1789-1804. DOI: 10.1016/ s0277-9536(97)00110-x

[4] Center for Disease Control and Prevention. Ten great public health achievements--United States, 1900-1999. MMWR. 1999;**48**(12):241-243

[5] Dethier D, Qasba N, Kaneshiro B. Society of Family Planning clinical recommendation: Extended use of long-acting reversible contraception. Contraception. 2022;**113**:13-18. DOI: 10.1016/j.contraception.2022.06.003

[6] Turok DK, Gero A, Simmons RG, Kaiser JE, Stoddard GJ, Sexsmith CD, et al. Levonorgestrel vs. copper intrauterine devices for emergency contraception. New England Journal of Medicine. 2021;**384**:335-344. DOI: 10.1056/NEJMoa2022141

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[14] Sully EA, Biddlecom A, Darroch JE, Riley T, Ashford LS, Lince-Deroche N, et al. Adding it up: Investing in Sexual and Reproductive Health. New York: Guttmacher Institute 2019. 2020. Available from: https://www.guttmacher. org/report/adding-it-up-investingin-sexual-reproductive-health-2019 [Accessed: April 24, 2023]

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### **Chapter 11**

Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive Provision in Southern Ethiopia: An Interpretive Phenomenological Exploration

*Abraham Alano and Lori Hanson*

#### **Abstract**

Albeit the government efforts improving access to contraception through health extension programs in Ethiopia, gaps exhibited on experiences of the stakeholder about the basis on services provision. Therefore, perceptions about the enablers and rationale for contraceptive service were explored. Interpretative phenomenological design was employed to explore the lived experiences of stakeholders. Focus group discussions, individual in-depth interviews, and key informant interviews were employed for data collection. Data were analyzed using interpretive phenomenological analysis. The finding indicated that contraceptive service provision from the socio-economic perspectives was understood adequately, but the human rights-based rationale was shadowed. The contribution of the health extension program for contraceptive use has been remarkable. The improvement is attributed to the alignment of primary health care with the community organizations such as women development armies. The health extension program accelerated contraceptive service and given momentum for PHC. Women revealed encouraging involvement in the process of contraceptive service access and use. However, the bigger picture, and rationale for providing contraceptive services, the human rights approach, remained elusive at lower hierarchy. Hence, the study recommends that the disconnect in the broader premises of providing contraceptive services must be properly communicated across the stakeholders.

**Keywords:** health extension program, human rights, contraception, phenomenology, rationale

#### **1. Introduction**

The provision of modern contraceptive services in developing nations began because of the strong push from developed nations in the 1960s [1–4]. However, the lack of strong governments commitments along with limited resources and the underlying socio-cultural factors remain major impediments to the expansion of the services in many developing nations [5]. Among the notable challenges to be mentioned in the process of service provision is the access to contraceptive services affected by a lack of well-structured institutions in terms of the availability of health professionals and material inputs [6].

To narrow the gap between developed and developing nations toward contraceptive service access and use, the Primary Health Care Declaration (PHC) provides guidance that played a significant role [7, 8]. PHC has clarified a meaningful health strategy for reducing maternal and child morbidities and mortalities in developing nations [9]. Moreover, PHC has bridged the gap between institutional health service delivery and community demands through a community-based service delivery modality [10].

Ethiopia has realized that health issues require the involvement of multiple sectors and collective undertakings. Based on this understanding, the country revitalized the primary healthcare approach by identifying key stakeholders and sectors to involve in the implementation of health-related activities and actions [11, 12]. Guided by the health policy of the transitional government, the Federal Ministry of Health of Ethiopia (FMOH) has taken numerous measures to improve the health status of its population. Among the major steps that have been taken in designing and development of A 24 Health Sector Development Plan (HSDP) with its five successive five-year phases is among the several steps the government actions. After a critical evaluation of the health-based initiatives, the MOH revised its approach and incorporated government-paid community-based health service delivery, the health extension program (HEP) in 2003 [13–15].

The HEP is an innovative approach constituting a paradigm shift in Ethiopia's health service delivery creating strong links between the mainstream institutional health service and community-based health service expansion [16]. The peculiar aspect of the health extension program is that the service providers are all women except in a few pastoral villages and permanent employees of the government. They serve in the rural villages where they grew up, live and, are permanent employees of the government. This was different from the former practice which was based on volunteerism.

The HEP is expected to improve access to health care through increased availability and acceptance as workers largely share similar cultural backgrounds and speak the same language as the community they serve [17–19].

In spite of half a century or more contraceptive services in Ethiopia and encouraging engagements of the government and health workers, there are limited research outputs that reveal the depth of the lived experiences of service users, health workers, and health leaders about how service organizations and extension affect the outcome. This study sought to explore the ways that leaders in the health system, health care providers, and service users attempt to create an enabling environment for contraceptive service provision and its use. The study was conducted by aiming to describe patterns of a provision of contraceptive services and capture the perspectives of health care providers, leaders, and service users' and their lived experiences on enabling conditions of the contraceptive service organization, provision, and use.

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **2. Materials and methods**

#### **2.1 The research context**

This study was conducted in three districts of Sidama Zone designated by Hawassa University as technology villages for research and technology transfer. The three districts were selected for accessibility. Hawassa University is located in the Sidama Zone, one of the 13 zones in the Southern Nations Nationalities and People's Regional state (SNNPRG) of Ethiopia. Sidama Zone is located in the south-eastern part of the region and is bordered by Oromia Regional state on the south, east and north and with Wolaita Zone in the west [20]. Projected from the 2007 national population census, the zone has a total of 3,471,568 people of which 1,753,142 (50.5%) are men and 1,718,426 (49.5%) are women. Close to 24% of the total population of the zone are estimated to be women of reproductive age. Household family size is estimated to be 4.7 and the annual population growth of the zone is estimated to increase 2.9% [21].

#### **2.2 Study design**

The study employed an interpretive (hermeneutic) phenomenological approach which is appropriate for understanding the life world of contraceptive service users women, health care workers (health professionals), and health leaders. It focuses on describing the meanings given by the individuals and how these meanings (the experiences of health care workers, health leaders, and service user women enable contraceptive services provision and use) influence the access to the service and use [22, 23]. The approach further considers the importance of the expert knowledge of the researcher as a valuable guide to the inquiry. The study aims to explore the life experiences related to the enabling conditions for contraceptive services and use by employing this approach. It offered a unique opportunity to establish a rich and in-depth understanding of sustainable and progressive contraceptive services establishment [24].

#### **2.3 Data collection**

To capture in-depth information about the topic of interest: focus group discussions (FGDs), individual in-depth interviews, and key informant interviews were used. Three female research assistants with educational and professional experience were employed to fit the majority of study participants (the rural women). Recruiting the research assistants helped to bridge the gap in both language and gender. Recruitment of research assistants was done in consultation with the Regional Health Bureau, Zonal Health Department and colleagues. After recruitment and training the research assistants, health extension workers, and local women, the community leaders collaborated in the selection of study participants. A purposive sampling method was used to include well-informed participants in the study as key informants, focus group discussants, and in-depth interviewees to explore the depth of their lived experiences [25, 26].

Participants were enrolled in the study based on criteria set to suit the study requirement. These include: the women's experiences of the contraceptive services use for at least a year, their ability to elaborate on the services and factors affecting the service access in their locality, and health leaders at different hierarchies (health institute, district, zonal, regional, and ministerial level) and the health extension workers.

A total of 82 women of reproductive age group were included and participated in the focus group discussions comprised of 7–12 participants in each FGD. For the individual in-depth interview, 19 women of reproductive age from nine kebeles were involved. A total of 18 key informants were involved in the interview based on the designated position they hold in their respective institutions (Appendix A). Semistructured FGDs and interview guides were developed for the interview and the participants were encouraged to speak up about their experiences. This type of interview guide is assumed to be in line with the interpretive phenomenological approach that gives reasonable freedom for the participants to express their experiences of the phenomenon of interest in their ways. It further deepened discussions and reflections on the life experiences of the study participants [27, 28].

Discussions were arranged in consideration of the time and regularity and viability of rural women. All the discussions were conducted outside of market days and from 10:00 A.M. to 11:30 A.M. Data collection schedule was arranged with the study participants through the community health workers (the health extension workers and women development army leader). Consideration was given by the study team on time management as such arriving at the data collection site in time and arranging the setup in a convenient way. The seating arrangement was organized circularly so that everybody could have ample opportunity to properly see one another.

Once the study discussants took their seats, the health extension worker carried out greetings and introduced the research team. Informed consent was obtained to audio-tape and take notes during the discussion. Moderation of the discussion was done primarily by the principal investigator. The research assistant aided by translating to the women and back to the PI and taking the note. A discussion was conducted by giving adequate time that was apportioned for the women to raise issues related to the guiding questions. Care was taken to involve all participants equally so each could discuss their lived experiences. The discussion was managed by considering the standard time for the qualitative data collection and women's busy schedules. Each session lasted 60–90 minutes on average. Discussion sessions concluded with due care about the completeness of the collected data, if there were any queries from the participants and acknowledging their commitment. Participants were informed about the need to attend a subsequent meeting following the preliminary analysis of the first discussion.

The discussion session was recorded using two digital recorders to ensure accuracy and prevent equipment failure. A unique identifier was given to each focus group discussion to differentiate it from subsequent discussions and avoid confusion during transcription. Written notes were taken by a research assistant simultaneously.

Following the focus group discussion, the individual in-depth interviews were conducted with women participants by the research team in the woman's home or at the health post based on the preferences of the interviewee. For those who were interviewed at their home, the research team was guided by the health extension worker or the community leader. A signed consent was obtained from the participants by reading the form out loud to continue the interview. The study team managed the session by providing an even chance to all participants and encouraging all to talk about their life experience in detail without any fear or reservations. In such ways, the interview continued for 40 to 60 minutes until the study team agreed on the emerging ideas as

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

repetitions [29]. Handwritten notes were taken and an audio-tape of the interview was recorded.

Lastly, key informant interviews were conducted in the following manner. Flexible interview dates were arranged as almost all the key informants were busy with their official routines. Once the key informants were identified, an interview schedule was arranged with each interviewer either calling via phone or visiting the office in person. The key informants' interviews were arranged in the informant's office or working unit at a convenient time. The study team managed the interview reaching the site in time to ensure the functionality of materials and give adequate time for the key informants to read the consent form and sign it.

Key informant interviews began by briefly explaining the purpose of the study, the procedures for selecting the informants, and the overall process of the study. Once the research team obtained a final signed consent form from the participant, the interview was conducted. The convenience of the room and the sitting arrangement for the interview was ensured before directly embarking into the interview. By using a semi-structured interview guide, the interview was conducted flexibly and systematically.

The interview process was done by following a qualitative study data collection approach suiting this specific (interpretive phenomenology) design. The interview session was conducted as guided by the study guide questions and opportunities to probe more issues as they emerged. Adequate time was given to capture the necessary information and to ensure the documentation of both handwritten notes and recording the audio-tape. Finally, the research team thanked the informants for their time and information before departing and told them about the possibility of returning for further discussion after the preliminary analysis. All key informant interviews were conducted in similar procedures. Data collection was conducted from September 2013 to May 2014.

#### **2.4 Data analysis**

This study used the guiding principles of interpretive phenomenological methodology. It enables viewing the phenomenon along the way that reflects the significant interaction of both the data sources (participants) and the researchers as part of their "being in the world" rather than only "being' itself [30, 31]. Thus, the interinfluence and connections of the two sources are reflected in the interpretive analysis. An adapted flow diagram from the interpretive phenomenological analysis (IPA) was used to guide the analysis (Appendix B).

Data analysis was conducted in two languages. The following steps describe the process: transcriptions were carried out on all the audio-taped materials verbatim, first in Amharic and then in English (Appendix C). Materials were also translated back to Amharic by a professional linguist. After that, the Amharic translation was given to the principal investigator to check for consistency.

Summary finding in the form of shortened transcripts incorporating the field notes was presented to the key informants for their further input and comments. Data immersion by the researcher immersed into the data several times through repeated reading to find out emerging codes. The analysis process utilized several rounds of indulging in the transcripts, reading and rereading, consultation with the key informants, and soliciting their inputs for the emerging descriptive codes. Inputs from the informants were incorporated into the second round of data analysis with remarks. Side notes and descriptive coding were then completed for all the materials. Data

reduction was done in a step-by-step approach, beginning with the transcripts, followed by descriptive coding, and then distilling this material into themes by bringing similar ideas and concepts together.

The overall analysis process made use of the hermeneutic circle, which means iterative back-and-forth linkage of data from both the researcher's and participants' perspectives. Guided by the study questions, the side notes, linked to the descriptive codes, themes were identified These steps were done by re-visiting the transcripts after major themes had been identified to interpret connections between the initial data and our later refinements [29, 30, 32]. Summarized reports were presented to study participants about the phenomena derived from their shared experiences. Discussions were held with participants based on the study guide questions and core concepts. Their feedback was incorporated in line with the experience of the researcher. This increased the confidence in interpretations and further enriched the understanding of the phenomena.

Data quality was assured using the steps of qualitative data quality assurance approaches generally called trustworthiness. The four closely resembling criteria for ensuring trustworthiness are credibility (truth value), transferability (applicability), dependability (consistency), and conformability (neutrality) suggested in the literature [33]. Actions carried out to ensure the trustworthiness were: (1) presenting the summary of transcripts to the study participants to give them an opportunity for further comment; (2) reviewing of the preliminary findings to ensure the early findings reflect what they know and experience; (3) sharing the preliminary summary findings with the health managers and service providers to check interpretations.

#### **3. Results**

The findings of this study are organized under the respective questions relating to health provider efforts in creating an environment conducive to contraceptive uptake and use. The aim was a better understanding of the issues of service delivery organization, processes, and content related to service availability, accessibility, convenience, trends, and the current status of contraceptive services. Moreover, the pattern of service integration, linkage among the primary health care units and the community organizations, and anticipated challenges related to services sustainability and ensuring quality were also explicated.

#### **3.1 Trends and patterns of contraceptive service provision in connection to the HEP**

#### *3.1.1 Health managers and service providers' perspectives*

Despite more than half a decade of longevity of the contraceptive service provision in Ethiopia and the study area, the progress in reaching all segments of the population was sluggish. Voluntary non-governmental organizations mainly, the Family Guidance Association of Ethiopia, started this service provision at an early age. Integration of the contraceptive services into health systems took place gradually but service expansion and increment in method mix remained low until 2005, where sharp increment took place since then. All study participants in three data collection methods expressed frankly that the current level of contraceptive services expansion and improvement in the availability of method mix was attributed to the health extension program.

#### *Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

As pointed out by study participants that the health extension program has brought contraceptive services closer to residents living and working places. In doing so, it has improved unconditional access to the service.

The extraordinary contribution of the health extension program in enhancing the contraceptive service access unlike the previous approach, is its propensity to extend the services to the household level through home visits and other community-based distribution options using community-based organizations such as women development armies. Another merit of the health extension workers is that they are female and recruited from the same *kebeles* where they offer service. This created a conducive environment for service-seeker women to feel comfortable when visiting the health post to access contraceptive service and when the female HEW visits their home; they express their needs without reservation. Moreover, the service-providing health extension workers share a similar culture and speak the same language and being female creates a favorable environment for women to ask whatever questions they desire. Study participants substantiated these conclusions:

*The health extension program has improved access and utilization to communities and households. Gender parity of the health extension workers with plenty of health service users, the women is another important issue received attention. The program played incredible role that averted several barriers of contraceptive service use. These were evidenced by the convenience the program created for women in terms of time, distance language and cultural harmony. On top of the above, the program also created gender parity between the service providers and users. In the nutshell, the health extension program improved access to the services*

*The health extension program is therefore a reason for the rapid increment in contraceptive prevalence and service coverage in the district as of the last seven years. This is so because the health extension workers provide the service both institutional and outreach models (at health posts but also house to house visitation). The health extension program significantly reduced the former distance of more than 5–10 KM to 2–3 KM walk and stretched it to the household level.*

The finding of the study has justified that the establishment of the health extension program created a strong services link within the primary health care units and the community. This further contributed to the current state of contraceptive use progress. More specifically, community mobilization using women development armies, and a one-to-five network [1] through model households are notable experiences to learn from.

All the study participants consensually remarked that the health extension program and the service organization have functional linkages manifested through collaborative undertakings at the community level. The strong collaborative undertakings between the health extension workers, the women development armies, and a one-to-five community network ensured the expansion of contraceptive service within their catchment area. Such interlinks or collaboration among stakeholders not only improves access to services but also is a clear indication for female empowerment as the service providers, advocators, and community leaders lead contraceptive service programs. This was further substantiated by citations from the study participants and a district-level manager explained the issue as follows:

*Health system organization in the study area is a witness for the observed strong linkage and collaborative undertakings. The health professionals from the health center provide supportive supervision to the health post and in a similar passion the health extension worker do so for the women development army. The supportive supervision is for all the health extension packages including the family planning services.*

#### Similarly, another experienced health extension worker has given her experience in this regard by clearly indicating:

*By its very nature the health extension program is from the 'community to the community', that has strong linkage between the service providers, users and leaders. The relationship is eventually took a shape of strong family and created mutual trust. We, the health extension worker provide service with a sense of serving our fellow women. A woman being the first contact point in the household has been another ease condition for the expansion of services both in the household and the community. On top of the women development army a one-to-five network system, we also use other community organizations such as 'edir' and 'kuteba mehiber [2]'. We work collaboratively with all these organizations, networks and systems. Generally, we have established a strong working relationship starting from an individual woman to the community level.*

#### *3.1.2 Service user women's perspectives*

Experiences of service user women toward contraceptive service availability and accessibility in the era of health extension programs are congruent with the health service manager and service providers' articulations.

Women explained that, unlike the previous high-level health institutions, now they comfortably express their feelings and get services including advice easily through understanding. They never fear or feel ashamed of telling their feelings as the health extension workers are from the same localities. When the health extension workers visit clients' houses, women easily talk to them and even invite them to have coffee or food. Because of such interaction, the extension workers feel at home and well-acquainted with the service users. This was not the case before the inception of the health extension program.

Daname, a woman in the focus group discussion who has used contraceptive services from various sources elaborated on the service access difference and the convenience now and previously:

*I paid 270 ETB for contraceptive service (surgical implant) at Yirgalem hospital before the access to contraceptive service improved. I also waited for five days to get service in addition to paying a service charge as stated above. Now the situation is different. Service accessibility was greatly improved. As the former discussants mentioned, we got service here at our kebele by our children. This is a big change. We share our feelings without hiding anything from the health extension workers. We don't have a problem with waiting for long hours for services, no need to go daily to queue up for services, no one tells us to bring your card from the card room. We receive services at one stop shot.*

#### Similarly, another woman in one of the focus group discussions vented:

*More specifically, the establishment of a health post in our kebele has created a better chance to access health services both for ourselves and our children. We were troubled* 

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

*to access the health services for our children before the establishment of this health post. It was customary to move here and there looking for health services previously. We were forced to take them to medically unproven services and exposed them to unsanitary/unhygienic services. Past years were known for us for the huge deaths of our young children others remained disabled. Appreciation should be paid to the government and our God who brought this time. We got relief and our children are growing well and healthy (Baliessie, a mother of 5 children and 30 years old).*

Loetie, a 25-year-old woman who used contraceptive service for 5 years explained her lived experience as how she has benefited from the service as:

*Remarkable change is seen here when compared to the earlier time. Instead of waking far distance to access contraceptive service, this time I am accessing contraceptive service here in my kebele with a short walk distance. Before the health extension program, one was experienced walking long distances and required to pay for contraceptive service. Thus, the long-distance walk, time and financial barriers hampered from service users in the pre-health extension era. Grace be to the Almighty God and appreciation to the government; we receive health information daily. The health extension workers provide services and information in all the packages, with due focus on how to keep our hygiene, different types of contraceptive methods available in the health posts and elsewhere, inform the benefits of contraceptive use about spacing pregnancies thereby improving the health status of both mothers and children.*

Furthermore, women expressed their views on the contribution of the health extension workers in creating health services demand and access in their respective kebele. They are the first to bring contraceptive information and services; by the way, this remains the reason for the improved prevalence of service use in their kebele. Women further witnessed that their know-how and skills for health service use are improved since the establishment of the health extension program.

This is further supported by the excerpts from other participants:

*Before the health extension program, I knew nothing about what contraceptive service mean and why it exists. We hardly find health services in our locality until the establishment of the health post in our kebele. Mostly we were ignorant about health services such as contraceptive use and vaccination. Immediately following the establishment of the health post in our kebele, the worker started to inform us about various health extension packages including contraceptive use and related benefits. They showed us the difference between unplanned and planned fertility and mechanisms to control fertility, (Dalbe, a 27 years old used contraceptives for 7 years).*

A one-to-five network means a model woman in one of the five neighboring households: act as a team leader (due to her outstanding performance on the health extension program) for all development-related affairs in that team.

#### **4. Discussion**

#### **4.1 Toward an enabling environment for contraceptive use**

The perception of participants in the study regarding the environment in relation to contraceptive service is discussed in this section and includes: (1) the service organization that includes accessibility, availability, acceptability, and convenience (2) the premises of rights approach for service provision and (3) special contributions of health extension program as an innovative primary health care strategy toward contraceptive service.

#### **4.2 Contraceptive service organizations (content and process)**

The study has indicated that until recently, the access and availability of services were weak in the country. The findings confirmed this claim, as, at the early stages of the health extension program, only oral contraceptive pills were available at health posts. Currently, couples of methods are available including short-term methods and long-term methods at the health posts provided through a health extension program. However, the availability of more methods is not uniform across the health institution. It increases when one goes up in the hierarchy of health services delivery institutions.

Agreement is established among stakeholders (services providers, users, and health managers) of the availability, accessibility, convenience, and use of contraceptive services in the study area. One can conclude that there are some improvements in coordination and communication among stakeholders concerning the service processes and contents. Except for a few, all the participants' experiences showed that contraceptive service availability, accessibility, and quality are improving. Some peculiarities were experienced concerning the injectable contraceptive method availability of specifically injectable contraceptives.

The lack of a particular method, an injectable contraceptive (which is more likely accepted by users), may pose a challenge to further expanding and sustaining contraceptive services [34]. Switching from one method to another ought to be due to defined medical reasons or the choice of the client, but the current shortage-related switching is another hindrance that may overshadow service quality and expansion. The shortage of widely acceptable contraceptive methods could hamper service expansion and negatively affect the good feedback toward the HEP. The irregularity in availing of preferred methods may contrast with the established service norms, which state that the service delivery should provide adequate attention to sociocultural and personal experiences [35–37].

The study examined the processes that support the provision of high-quality contraceptive services and revealed that most contraceptive users' access services from health posts. As indicated, the prime source of contraceptive services in the community is the health extension worker with close supervision from the health center. Therefore, maintaining the quality of such service is dependent on regular updating of the competence of the health extension workers through continuous refresher training and supportive supervision. These must be coupled with the provision of materials that help with spot references such as job aid, guidelines, manuals, and standard operating procedures. The availability and use of reference materials are examined in this study from the perspectives of service providers and managers.

The higher-level health service managers argue that they have prepared and distributed standard supportive documents in the form of manuals, flipcharts, and leaflets as requested by the regions. Similarly, most of the health extension workers indicated the availability of reference materials adequately and useful in guiding their service provisions. However, few of the service providers had shared their feelings that the materials are inadequate or incomplete for fulfilling the level of competency

#### *Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

required for service provision. The study revealed that reference materials (and that the materials are comprehensive and easy to understand and use) by the service providers helped to provide contraceptive services efficiently. Service providers' competency is crucial for initial service start-up and subsequent continuation of service provision. The findings from USAID-Deliver [38], argue that proper method choice and sustained use are dependent on the information clients receive from providers.

Government-sponsored health extension program is one of the significant indicators for the established links to the contraceptive uptake. The establishment of the health extension program remained a unique landmark for the rapid services uptake and quality improvement. This is further evidenced that more than half a decade-long service remained sluggish in its progress but has shown tremendous improvement since the establishment of this program. As has been indicated in much empirical evidence [39, 40], the service coverage showed tremendous improvement in contraceptive prevalence.

From the perspectives of the service providers, health services managers and users, the study scrutinized their view of which factors contributed to the remarkable improvement in contraceptive use and any defined connection to the new innovative community-based health extension program. Their lived experiences indicated that the health extension program has made a unique contribution to rapidly improving access to and convenience of these services for women. As indicated in the participants' experiences the health extension program improved services access by bringing them closer to women where they live, and work compared with the former strictly institutionalized approach of service delivery.

The availability of the services in each *community organizations* created the opportunity for women to easily access the services tackling challenges related to distance and requirements of permission from their husbands. In circumstances when women maintain the secrecy of their service use from their husbands, they go to the health post as if they are going to a neighbor's house. Studies support this finding that any service to be promoted and used by the target group should fulfill certain conditions including physical, financial, and socio-cultural aspects. Bringing services closer to the potential users increases the possibility of actual use [41, 42].

Another peculiarity of the health extension program concerning contraceptive service is that the program has removed many obstacles and barriers that hampered women's potential for service use. When the behavior of health professionals welcomes the service users (cultural and linguistic congruence) clients are more likely to use services [43, 44]. Thus, this study finding is in congruence with the above one as the health extension workers are almost all women recruited from the *community* which they serve and share the same culture and language. This has removed the gender, language, and cultural barriers between service providers and service users.

The contextual similarity between the health extension workers and service user women not only created a unique opportunity for the early services adoption but also for the continuous use. Women evidently expressed their experiences in this regard by comparing their pre-health extension program service inquiries. Formerly, the service was far from their residential area and male-dominated. Moreover, they were requested to pay for services and in most cases looked for a translator to explain their feelings to the health professional. As a result, they were highly discouraged from the health institutions to seek services [17–19].

The peculiarity of health extension programs in improving access is their conformity to the local community context. The contraceptive service extension to the household through home visits by female health extension workers is favorably welcomed by the community. Program. This is connected to cultural aspects and the domestic work patterns in which most rural women stay home doing domestic duties, and thus, are easily accessible for a health extension worker to provide services during their home visits.

The study further showed another crucial perspective of the health extension program the participants' life worlds related to contraceptive service, its alignment to the multidimensional aspects of the health systems from the health principles and philosophical ascertainments. The organizational arrangement of the health extension program shows strong links from the community level to the mainstream health institution. This further indicated and assured the need for close collaboration across the wide dimensions of actors to ensure the success of the program. The health system closely works with partners at various levels to fill gaps either technically or materially. Many study findings show that health service delivery approaches that do not leave room for inter-sectorial cooperation and that do not ensure community involvement is never satisfactorily accessible, acceptable, or sustainable [19, 39, 43, 44].

More so is the trust the health extension program builds at the community level. It is at this time that the health system closely functions with the local community in a sustainable manner. This is in line with the assertion that the health system is being affected and affects other systems. This is evidenced by that the health extension program functions in a network at the *kebele* level. The health extension workers participate in the *kebele* affairs and receive support from the *kebele* administration. They are members of the *kebele* command post, which is responsible for overall affairs. Furthermore, the health extension workers closely function with the women development armies, one-to-five networks, and model household women. This has established strong linkages between the health extension program and the community members at a basic level. Thus, it is through such channels that information and services flow until they reach the households and target women.

The trust and strong collaboration established between the health extension workers and the current women users of contraception has created a circular passion for the information dissemination to the current non-user women in the community. The platform of current service-user women in the community through the women development army and the one-to-five network in their neighborhood helped initiation of discussion about contraceptive use and its benefits with the current non-user counterparts by sharing their life experiences. Perry and Roger (2014) argue that if the health service delivery approach offers attention to the multiple dimensions of health determinants and involves all stakeholders, the service uptake increases tremendously. Gulzar and Ali [45] also agree that the client's family planning service use behavior is largely influenced by the relationship between the service provider and the client. This study has proved that female health extension workers have greatly improved contraceptive service uptake by extending service to households through home visitation.

The basic premise of contraceptive service provision was reemphasized that the health extension program packages were designed based on fundamental human and reproductive rights. The human rights dimension for reproductive health received little attention at its earliest time. Through the persistent struggle of the advocacy

#### *Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

groups coupled with a series of UN conferences, meetings, and treaties have produced an agreed-upon approach to ensure the reproductive health rights of service users. The essence that human beings have a right to enjoy the highest level of attainable health, including sexual and reproductive health, received increased attention. Women and men have the right to have means to do so without any discrimination and coercion. Such ascertainments ensure that women have the right to choose a method best suited to their condition and to withdraw from the method when it fails to do so. In the contrary to the human rights principle, failure to provide adequate information and limiting service access is an indication that the contraceptive service is not in line with the ICPD plan of action. Hardee et al. [46] argue that any family planning program must respect the ICPD plan of action and must guarantee freedom of contraceptive choice and respect, protect, and fulfill human rights.

#### **4.3 Strengths and limitations**

The study was conducted in three districts of the Sidama zone and considered only the married women currently using the services may be considered as the limitations of the. Sexual and reproductive matters are usually sensitive and considered as taboo in most rural communities, thus might have limited the depth of response during data collection. Another possible limitation is that the study has not considered current non-users' perceptions of the benefits of contraception. Men are also not considered in this study as the prime purpose of the study is to explore the experiences of women.

The study was carried out to explore the experiences of women contraceptive service users in the Hawassa University research villages, which were established to observe the impact of university-based research in knowledge generation, technology transfer, and the livelihood of the residents. The scope and patterns of this study have taken such shape with the assumption to strengthen the university-community linkage. These are some of the delimitations of this study.

#### **4.4 Conclusion and recommendation**

Based on the findings of this study, it can be concluded that the contraceptive service organizations' process and content, are encouraging and improvements made in service quantity and quality. HEP symbolized the effectiveness of communitybased health services provision as the backbone of primary health care. Moreover, HEP amicably expressed the functionality of intersectoral collaboration and various community-based organizations networks hand-in-hand for the betterment of the most needy segment of the society. Women revealed encouraging involvement in the process of contraceptive service access and use in their organizations such as development armies and the one-to-five network.

#### **4.5 Recommendations**

Identifying successful strategies for the sustainable use of reproductive health services from the human and women's rights perspectives is vital not only to ensure the wellbeing of women and their significant others but also toward ensuring the attainment of sustainable development goals. This study, therefore, has come up with the following recommendations to ensure evidence-based service provision and propel contraceptive service use in a way that consistently respects human rights and sustainable use:


#### **5. Declaration**

#### **5.1 Ethical considerations**

Ethical clearance for this study was obtained from all concerned institutions both abroad and in-land. These are: the University of Saskatchewan, Canada, Hawassa, University, Ethiopia and the SNNPR Health Bureau, Ethiopia. Study participants offered their consent in written form ensuring their voluntariness to be part of the study. The study team explained the purpose of the study; its benefits and any risk in case thoroughly to prove the confidence of the study participant. Study participants were informed about communication of the study finding in various meetings, workshops and publications and verbal consents were obtained.

#### **5.2 Consent for the publication**

This manuscript is an extract from the PhD dissertation with some addition later on. All ethical issues including communication of the finding to various stakeholders were properly communicated and their consents were obtained. Study participants signed consent forms in the local language are attached under the supporting document Section 7.

#### **5.3 Declaration of funding**

The original PhD dissertation was funded by the joint contribution of Hawassa University, Ethiopia and the University of Saskatchewan, Canada. The funding was only covered fieldwork expenses such as travel cost, perdiem, fuel, and related incidentals. Additional data were gathered at the expense of the authors' personal pockets. No fund was allocated for the communication of finding such as publication. There is no interference of the funding entities in all undertakings of the study work except offering the fund for the accomplishment of the study.

#### **Authors' contribution**

The manuscript is a joint effort of all the authors. AA was responsible for conducting data collection, analysis, and the write up. LH was responsible for revising transcription, analysis, editing, and supervising all steps. MM was involved in designing the study, manuscript preparation, editing of the manuscript.

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **Competing interest**

The manuscript is the efforts of both authors primarily dedicated to academic purposes. The financial support from Hawassa and Saskatchewan universities was in support of a PhD study. The manuscript is partially taken from the PhD dissertation with some addition of data after it. Hence, there were no competing interests either from the funding sources or the authors.

#### **List of abbreviation**


#### **A. Profile of study participants**

#### **A. 1 FGD**

#### **Site 1**

See **Tables A1**–**A9**.


**Table A1.** *Profile extracted from the FGD participants' transcription document of the Waycho site.*


#### **Site 2**

#### **Table A2.**

*Profile of the participants extracted from the FGD participants' transcription document of the Ganie site.*

#### **Site 3**


#### **Table A3.**

*Profile of the participants extracted from the FGD participants' transcription document of the Degara site.*


#### **Site 4**

**Table A4.**

*Profile of the participants extracted from the FGD participants' transcription document of the Korangoge site.*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*


#### **Site 5**

#### **Table A5.**

*Profile of the participants extracted from the FGD participants' transcription document of the Dilarife site.*

#### **Site 6**


#### **Table A6.**

*Profile of the participants extracted from the FGD participants' transcription document of the Konsore Fullasa site.*

#### **Site 7**


#### **Table A7.**

*Profile of the participants extracted from the FGD participants' transcription document of the Gassara Kuwie site.*


#### **Site 8**

#### **Table A8.**

*Profile of the participants extracted from the FGD participants' transcription document of the Wotara Gendo site.*

#### **Site 9**


#### **Table A9.**

*Profile of the participants extracted from the FGD participants' transcription document of the Basha site.*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

#### **A. 2 Profile of key informants**



*N.B. The Key informants composed of service providers at community and health institution levels, health service managers at district, regional and federal levels indicating the hierarchy.*

#### **Table A10.**

*Key informant profile extracted from the transcription of the informants' document from the study sites such as health institutions (health post and health center) and the health services administrative offices.*

#### **B. Data analysis flow diagram adapted from IPAThe qualitative data analysis steps adapted from IPA (Smith et al., 2009, pp. 82–100) and customized to fit my study taking the following steps as indicated below in flow diagram (Figure B1).**

#### **Figure B1.**

*It can be cited as Fig. B1. Flow diagram of data analysis adapted from the Interpretive Phenomenological Analysis (IPA).*

#### **C. A flow diagram indicating steps in translation**

This study involved several participants in the overall processes with various languages background. In order to establish a common understanding and create

**Figure C1.**

*This can be cited as a flow diagram developed to indicate a translation of transcription from the local language to the working language in the stepwise (developed by the researcher).*

*Government Sponsored Community-Based Health Extension Program Enhancing Contraceptive… DOI: http://dx.doi.org/10.5772/intechopen.111694*

closeness in the process of the research, use of language translation from one to another has been a necessary condition. Accordingly, the following steps in translation has been taken until the final text took its recent shape (**Figure C1**).

#### **Author details**

Abraham Alano1 \* and Lori Hanson<sup>2</sup>

1 SNNPR Policy Research Institute, Hawassa University, College of Medicine and Health Sciences, School of Public Health, SNNPR, Hawassa, Ethiopia

2 Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Canada

\*Address all correspondence to: alanoabraham@yahoo.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*Edited by Panagiotis Tsikouras, Nikolaos Nikolettos, Werner Rath and Friedrich Von Tempelhoff*

This book provides a comprehensive overview of contraception. It provides the most recent evidence to guide clinical practice and management. The chapter topics include general management of contraception, family planning and more specific issues such as hormonal and non-hormonal barrier methods and emergency contraception.

> *Zouhair O. Amarin, Obstetrics and Gynecology Series Editor*

Published in London, UK © 2024 IntechOpen © Md Saiful Islam Khan / iStock

Conception and Family Planning - New Aspects

IntechOpen Series

Obstetrics and Gynecology, Volume 2

Conception

and Family Planning

New Aspects

*Edited by Panagiotis Tsikouras, Nikolaos Nikolettos,* 

*Werner Rath and Friedrich Von Tempelhoff*