Bombay Hospital Journal EDITOR'S CHOICEContentsHomeArchivesSearchBooksFeedback


Contraceptively Aware -
Nonacceptance Beware!! : A Study of Correlation of Awareness of Family Planning Methods (TL + IUCD) with its Nonacceptance

Punam M Satpute, Vinayak Swati, Rakhee M Gupta, Suchitra N Pandit, RV Badhwar

A prospective cross sectional study of 765 eligible multiparous women with at least one previous living offspring was done at a major referral tertiary set-up at LTMGH, Sion, Mumbai over a period of three months for sterilisation and IUCD options.
The overall contraceptive awareness claimed was 100% but adequacy of awareness was only 22%. Spouse and media were poor source of awareness but refusals were minimum with spouse (36.23%), in laws (47.6%) and hospital (37.2%) as source. Counseling done at two ANC refusals and only postpartum counseling has maximum refusals.
Eligible multigravidae are the focus for family planning methods. The option of sterilization of IUCD in this group sees an arena of
nonacceptance. This focussed our attention to study the correlation of contraceptive awareness (TL and IUCD) and its nonacceptance to ?nd solutions to this ever increasing problem that is retarding the National Progress.
1. To study the incidence of Contraceptive (TL and IUCD) awareness in eligible multiparous
2. To study the adequacy of the awareness.
3. To study the source of awareness.
4. To study the relationship of refusals for contraception (TL and IUCD) with time of awareness.
A prospective cross sectional study was carried out for 765 women over a period of three months from Aug-Oct 2001 at LTMGH Sion, a major teaching institute and 1416 bedded tertiary centre, Mumbai, India.
Recruitment Criteria
Seven hundred sixty ?ve eligible healthy multiparous women with at least two years old living previous offspring who had delivered normally during the study period in the institute and had undergone counseling for sterilisation and IUCD.
Women recruited for study were individually interviewed for the contraceptive option (Sterilisation or IUCD) in one of the three languages
(English, Hindi and Marathi) that they best understood. Their awareness about the two methods were documented. The awareness was adequate when they knew details regarding - The type of method (i.e. permanent/temporary), duration of use, procedure know how, warning signs, major complications/side effects, follow up. The time of awareness of the method were noted and the reasons for refusals were probed into and recorded.
Variables under study
Age, children and education wise distribution,
source, adequacy and timing of contraceptive
Incidence of refusals
Of the 765 women under study, 81% of women refused sterilisation and 67% refused IUCD after counselling.

Table 1 shows a high (95%) refusal for sterilisation in the twenty to twenty ?ve younger age group and a lower IUCD refusal compared to the other two age groups. The more than 30 years age group has high refusals for sterilisation and IUCD and this group is less receptive to changes in contraceptive methods. Hence it is imperative to motivate the women during their formative reproductive years (i.e. less than thirty years of age) for sterilisation - Counsel them when young. After thirty years though the family size is completed, decision to undergo sterilisation is not readily arrived at, and the trend to use IUCD and cannot exercise their independent contraceptive choices. In the four to five years marital span group, sterilisation refusal is seen higher in two living issues than in three living issues which also depicts that the two family norm has not yet seeped in and there is a want of the third child. IUCD refusals are also high in the four to five years marital span group with three living issues
and in ?ve to eight years marital span group with two living issues, though the sterilisation refusals are less in the former than the later group. It is these groups that need focused attention and counseling.

Education wise status and refusals

There were 74% refusals in the illiterate group vs 26% in the literate group (Table 3) in our series as compared to the NFS-2 series which were 57% and 43% respectively.1 However the level of education
studied was only to high school level in the NHFS-2 study. As the level of education increases, the incidence of refusals decreases. Education has a vital role to keep contraceptive refusals at bay, which also supports the Retherford study.2
Contraceptive awareness
All the women under study in our series admitted to be aware of the contraceptive methods available, similar to the NFHS-study 98-99 that showed 98% awareness.3 Of these only 22% had adequate know how of sterilisation and IUCD and 78% had inadequate information.
Source of contraceptive awareness

Tracing the source of awareness as depicted in Table 4 in our series, spouse and media have been poor contributors as a source of contraceptive awareness. Refusals were minimum when the source was spouse, inlaws and hospital. However refusals were maximum when the source was media, neighbours and friends. This can be attributed to the fact that even if the source is neighbours, family and media, the spouse and inlaws have a major role in decision making of contraceptive choices and women cannot exercise their independent choices for family planning method.
Time of contraceptive awareness
Fig. 1 shows that the earlier the awareness is obtained in the reproductive career, i.e. before marriage or the ?rst pregnancy and even before the current pregnancy and even at the ?rst early antenatal visit, the contraceptive refusals are low i.e..33.3%, 28.9%, 41.5% and 58.6%. A dip in graph at 44.24% suggests that counseling for more than two occasions in antenatal visit prepares the women to decide the contraceptive method. Postnatal counseling have the highest refusals. Postnatal period is one where the woman has experienced
freshly the child birth process and even though may have decided not to go through the process again, gives way to family pressures of want of another child. This revolves around the social culture of the Indian women who put everybody else before herself even in the contraceptive decisions. The in?uence of inlaws is so strong that the couple cannot withstand this in?uence even in the postpartum
period. Hence antenatal counseling must include the spouse and/or inlaws in tertiary setups and a change in the antenatal setup is mandatory, where the relatives or spouse accompanying are not kept out of the antenatal clinic doors.

1. Refusals are common in twenty to twenty-?ve and more than thirty year age group. Marital span of > 5 years and illiterate group. Education plays a key role.

2. Contraceptive adequacy is only 22% and it needs improvisation by use of scienti?c content as information through media sources like documentaries shown in TV/Cable/Theatres/ Hoardings at cross roads, bus, railway station, health articles and talks through newspaper, magazines and radio involving the corporate sector.

3. Amongst the various sources. Inlaws, spouse and hospital ensure lesser refusals. Media itself was a poor contributor as a source. Friends and neighbours are not potential sources as they cannot withstand spouse and relatives in?uence.

4. Earlier the awareness in the reproductive career lesser are the refusals hence counsel them when young. Postpartum counseling have maximum refusals hence counsel early in pregnancy and ensure repeat reminders.
We express or gratitude to our Dean Dr ME Yeolekar who has permitted to publish our hospital data. We thank our Head of the Department Dr Mrs VR Badhwar who has been the force behind our efforts and all those women who opened to us freely their minds, constraints and desires, without which the study would have been incomplete.
1. Socio-Economic differentials in current use of FP Methods: NFHS2 1998-99 National Report India: International institute for Population Sciences: 134-5.

2. Retherford and Ramesh et al 1996, Fertility and contraceptive use in Tail Nadu, Andhra Pradesh, Uttar Pradesh National FHS Bulletin No. 3, Mumbai: International institute for population Sciences and Honolulu East-West Center.

3. Knowledge of FP methods: NFHS 2 1998-99 National report India: International institute of population sciences:

Lymphopenia was present in 98%, neutrophilia in 82%, and thrombocytopenia in 87%. Also, low CD4 and CD8 cell counts and a high concentration of lactate dehydrogenase at presentations were associated with adverse outcome. Depletion of lymphocytes, which was found in various lymphoid organs at postmortem examination, may be a good marker of disease activity.

BMJ, 2003; 326 : 1358.

  1. To Section TOC
Sponsor-Dr.Reddy's Lab