Factors influencing decision on contraceptive use among married female youths and their husbands in a rural area of Ayeyarwaddy Division, Myanmar Myo Myo Mon A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Science in Epidemiology Prince of Songkla University 2009 Copyright of Prince of Songkla University i
Thesis title Factors influencing decision on contraceptive use among married female youths and their husbands in a rural area of Ayeyarwaddy Division, Myanmar Author Major Programme Dr Myo Myo Mon Epidemiology Supervising Committee: Examining Committee: The Graduate School, Prince of Songkla University, has approved this thesis as partial fulfillment of the requirements for the Master of Science degree in Epidemiology. Associate Professor Dr Krekchai Thongnoo Dean of Graduate School ii
This is to certify the work here submitted is the result of the candidate s own investigations. Due acknowledgement has been made of any assistance received. Associate Professor Tippawan Liabsuetrakul, M.D., Ph.D. Principal Supervisor Myo Myo Mon, M.B.B.S.,M.P.H. Candidate iii
I hereby certify that this work has not already been accepted in substance for any degree, and is not being concurrently submitted in candidature for any degree. Myo Myo Mon, M.B.B.S.,M.P.H. Candidate iv
Title Factors influencing decision on contraceptive use among married female youths and their husbands in a rural area of Ayeyarwaddy Division, Myanmar Author Programme Myo Myo Mon Epidemiology Abstract Background Half of the world s population are aged under 25 years of whom the majority are adolescents and youths, especially in developing countries. A youth, according to World Health Organization (WHO), is defined as a person between the age of 15-24 years. This target group faces the transitional changes both in biological and psychological aspects as well as economic burden, with many having to cope with unintended pregnancy and induced abortions. Lack of contraceptive use is a major contributor to the high rates of unintended pregnancies and births observed worldwide for youths. Although contraception is the most effective method to overcome this problem, the problem still exists and has not been solved in many countries, especially developing countries. Therefore, this study aimed to identify the factors related to contraceptive use using Health Belief Model (HBM) perceptions and other influencing v
vi factors among married female youths and their husbands as well as the magnitude and importance of the factors and persons related to contraceptive decision making using married youths self determination. In addition, the agreement of perceptions among wives and husbands as well as agreement between willingness and actual use of contraception were also explored. Methodology A community-based cross-sectional survey was conducted in Ayeyarwaddy division of Myanmar where the maternal mortality ratio (MMR) is 300 per 100,000 live births. Of 14 townships in Ayeyarwaddy division under reproductive health projects, Hinthada township was randomly selected as the study setting. Currently married female youths aged between 15-24 years and their husbands were included in the study. According to a 20% difference of knowledge and attitude on contraception, a ratio of contraceptive user and non-user to be 1:1 and an 80% power to detect this difference, at least 98 couples for each group were needed. After obtaining the list of married female youths from the midwives, the first household containing a married female youth and living with their husband was randomly selected. If more than one married female youth lived in the house, only one couple was selected. An information sheet was provided and written informed consent was obtained. Couples were interviewed by using a well-validated, structured questionnaire.
vii The associations between independent variables and contraceptive use were analyzed by univariate analysis using unpaired t test or Wilcoxon Ranksum test for continuous data and chi-square test for categorical data. The effect of HBM constructs and other influencing factors to the use of contraception was explored by multiple logistic regression. Similarly, the effect of influencing factors and persons to the contraceptive decision making was also analyzed by multiple logistic regression. Kappa coefficients were used to determine the agreement of perceptions among wives and husbands and agreement between willingness and actual use of contraception. Results A total of 222 eligible couples were included in the study. The age of the wives ranged from 16 to 24 years (mean ± sd 21±2.1) and that of their husbands was 18 to 40 years (mean ±sd 25 ± 4.3). Almost all were Buddhists (97.7%) with the remaining being Christian (1.8%) and Muslim (0.5%). The distribution of education among wives and husbands was similar and one-third of couples had completed primary school education. One-third of the women were housewives without having their own income. Among employed wives, the median monthly income was 30,000 Kyats ($31) and that of the husbands was 42,500 Kyats ($44). Almost all husbands were employed, of which 49.1% were farmers or running their own business. The mean age at marriage of the women was 19 years (range 14 to 24 years). Of all couples, 39.6% had no children at
viii the time of interview. Wife s and husband s desired family size were similar and ranged from 2 to 7 with a mean size of 4. Of 6 constructs of Health Belief Model, perceived susceptibility of pregnancy (OR 6.31, 95%CI 2.3-17.4) and no barriers to use contraception (OR 2.9, 95%CI 1.5-5.7) were identified as the significant predictors. After adjusting for other factors of wife and husband, having positive perceptions on measured by HBM, wives aged 15-24 years, having own income, having spousal communication on contraception and shorter distance to health center were significant predictors of contraceptive use by logistic regression. Regarding the influential factors on decision making, factors which attained the magnitude of >50% and importance of >5 scores for their decision were couple s attitude, spousal communication, pregnancy susceptibility, couple s knowledge and benefit of contraception. Poor agreement on HBM between wife and husband was noted. Moderate agreement between wives and husbands willingness to use contraception, and fair agreement between willingness to use contraception and actual use were detected. Conclusion Our study highlights the importance of perceptions of young wives measured by HBM, particularly perceived susceptibility of pregnancy and barrier on contraceptive use. In addition, motivation from a provider, involvement of friends, spousal
ix communication and perception on benefits of contraception significantly increased the decision of young wives to use contraception. Couple s attitude, spousal communication, perception on pregnancy susceptibility, couple s knowledge and perception on benefits of contraception were identified as having a higher magnitude and importance than service and provider factors. Couple s attitude was considered as the most important factor for both contraceptive users and non-users. Future programs to scale up the contraceptive use among married youths should address more extensively on the encouragement of their perceptions of pregnancy susceptibility and reduction of the barrier on contraception. Correction of misperceptions and negative attitudes of contraceptive use is essentially needed. Promoting the husband s involvement in communication and role of peers and providers will be an important added value.
x ACKNOWLEDGEMENT I would like to express my sincere thanks to Associate Professor Tippawan Liabsuetrakul, my principal supervisor, for her valuable advice, encouragement and support throughout my study. I also wish to extend my thanks to Professor Virasakdi Chongsuvivatwong for his helpful suggestions and constructive criticism on my study. My sincere thanks are directed to Dr Than Tun Sein, Director, Department of Medical Research (Lower Myanmar), who gave me advice for field survey, Township Medical Officer of Hinthada Township and research assistants from Department of Medical Research (Lower Myanmar) for their kind help and cooperation in data collection. I am also grateful to all couples who participated in the study. I would also extend my heartful gratitude to Mr. Edward McNeil for editing and proof readings of the manuscripts and thesis. I greatly appreciate all the teachers of the Epidemiology Unit, Prince of Songkla University, who gave me knowledge and skill to conduct epidemiological research. I sincerely acknowledge the support of the World Health Organization through Special Programme of Research, Development and Research Training in Human Reproduction for sponsoring my training in Epidemiology.
xi Last but not the least, I wish to express my heartfelt thanks to my family and friends for their support and encouragement during the training period.
xii TABLE OF CONTENTS Abstract... v TABLE OF CONTENTS... xii TABLES... xvii CHAPTER 1... 1 INTRODUCTION... 1 1. Background... 1 1.1 Study background... 1 1.2 Study setting background... 4 2. Literature Review... 9 2.1 Epidemiological pattern of married youth... 9 2.2 Factors influencing contraceptive use and contraceptive behavior... 13 2.3 Health Belief Model... 23 3. Rationale... 25 4. Research questions... 27 5. Objectives... 27
xiii 5.1 General Objectives... 27 5.2 Specific Objectives... 27 CHAPTER 2... 29 METHODS... 29 6. Conceptual framework... 29 7. Research Methodology... 31 7.1 Study design... 31 7.2 Study area... 31 7.3 Study population... 32 7.4 Study sample... 32 7.5 Sample size... 33 7.6 Sampling procedures... 35 7.7 Variables... 36 7.8 Independent variable definitions... 38 7.9 Study instrument... 45 7.10 Data collection... 45 7.11 Data processing and analysis... 47
xiv 8. Ethical consideration... 50 CHAPTER 3... 52 RESULTS... 52 1. Background characteristics of the couples... 52 1.1 Socio-demographic characteristics... 52 1.2 Marital and obstetric characteristics... 53 2. General information regarding contraception... 54 2.1 Awareness of couples on contraceptive methods, place and source... 54 2.2 Accessibility to and availability of contraceptive services... 57 2.3 Contraceptive use... 57 3. Factors influencing contraceptive use... 58 3.1 Health Belief Model Perception... 58 3.2 Agreement of HBM perception between wife and husband... 60 3.3 Knowledge, attitude, spousal communication, accessibility and HBM perceptions... 61 4. Factors influencing the decision to use contraceptives... 65
xv 5. Willingness to use and actual use of contraception... 72 6. Providers information... 72 CHAPTER 4... 73 Discussion... 73 1. General Discussion... 73 1.1 Factors influencing contraceptive use... 73 1.2 Factors influencing the decision to use contraceptives.. 76 1.3 Strengths of study... 79 1.4 Limitations of study... 79 2. Conclusions and recommendations... 80 References... 82 Annexes... 91 Annex 1 Informed Consent Form to interview married female youths and their husbands... 92 Annex 2 Questionnaire for interviewing married female youths... 97 Annex 3 Questionnaire for interviewing husband of married female youth... 108 Annex 4 Question for contraceptive availability index... 116
xvi Annex 5 Informed Consent Form for health care providers... 117 Annex 6 Questionnaire for health care providers... 122 Annex 7 Ethical Approval... 126 Annex 8 Approval from Ministry of Health, Myanmar... 127 Annex 9 Submitted Manuscript 1... 128 Annex 10 Submitted Manuscript 2... 159 Vitae... 182
xvii TABLES Table 1 Epidemiology of youths in Southeast Asia... 10 Table 2 Marital and obstetric characteristics... 54 Table 3 Awareness of places to get contraception and source of contraceptive knowledge... 56 Table 4 Contraceptive use of married female youths... 57 Table 5 Correlations among the constructs of wives HBM perception... 59 Table 6 Prediction of wife s HBM perceptions on contraceptive use by logistic regression... 60 Table 7 Agreement of perceptions in HBM between wife and husband 61 Table 8 Individual characteristics, knowledge, attitude and spousal communication of couples between user and non-user.. 62 Table 9 Predictors of contraceptive use... 64 Table 10 Prediction of contraceptive use by person/factor influenced in decision... 67 Table 11 Ranking scores of influencing persons and factors by wife, husband and provider... 70
xviii Table 12 Association between weighted ranking score of the factors and the decision to use contraception... 71
xix FIGURES Figure 1 Map of States and Divisions in Myanmar... 5 Figure 2 Diagram of reproductive health system in a Township of Myanmar... 6 Figure 3 Maternal mortality ratio in States and Divisions of Myanmar... 9 Figure 4 Proportion of women married by age 18 years... 11 Figure 5 Proportion of women giving birth by age 18 years... 12 Figure 6 Relationship between contraceptive prevalence and availability of methods in 72 developing countries... 20 Figure 7 Contraceptive use among married adolescent girls in selected countries of South Asia and South-East Asia... 22 Figure 8 Conceptual framework of study... 30 Figure 9 Predictors of contraceptive use... 65 Figure 10 Ranking and proportion of influenced factors on wives decision of contraceptive use... 66 Figure 11 Magnitude and importance of factors among users and nonusers... 69
CHAPTER 1 INTRODUCTION 1. Background This background presents the study background and study setting. The study background includes the importance of youths and reproductive health consequences resulting from early marriage and child bearing. 1.1 Study background Half of the world s population are aged under 25 years of whom the majority are youths, especially in developing countries. 1,2 A youth is defined as a person between the age of 15-24 years and further classified as late adolescent (15-19 years) and young adult (20-24 years) according to World Health Organization (WHO). 3 A high proportion of this age group has an enormous impact on global and national developments. 4 Youth period is important because it is the period of life where transitional changes in biological and psychological aspects mostly occur. As a result, these changes lead to deleterious problems and issues, especially concerning reproductive health. 2 In addition to health risks, youths are also in a state of dependence resulting in an economic burden if they are not well responded. 1
2 Early sexual activity and early childbearing have long-term effects not only on the adolescents but also on the young adults. 5 Young mothers have a higher incidence of premature labour, miscarriage and stillbirth. Their infants weigh less at birth and experience higher rates of mortality and morbidity. 2 Although many countries in the Asia-Pacific region have shown a trend towards increasing age at marriage for both sexes, marriage during adolescence is not rare. 6 Many adolescents in Asian countries, such as Nepal, India and Bangladesh, usually marry before the completion of their physical growth and lead to many reproductive health problems in subsequent lives and also affects the survival of their offsprings. 7 Lack of contraceptive use is a major contributor to the high rates of unintended pregnancies and births observed worldwide for young adults. Every year, about 15 million women under age 20 give birth. This accounts for more than 10 percent of all births worldwide. 8 Similarly, in Myanmar, youths cover 20 percent of total population: 9.9% for 15-19 years age group and 9.6% for 20-24 years age group respectively. 9,10 Although the median age of marriage is 26.4 years, 6.6% of those aged 15 to 19 years and 34.8% of those aged 20 to 24 years are married. 11 The tradition of early marriage and consequent childbearing among youths still prevails in rural areas. 12 About 41% of married women in age group 15-19 had already one or more births according to Fertility and Reproductive Health Survey (FRHS 2001). 13
3 In Myanmar, negative health consequences of pregnancy in youths are attributed to a high maternal and perinatal mortality rate. Maternal deaths among youths are not only related to pregnancy but also abortion. 14,15,16 According to the reports from Basic Health Staffs in 2005, the national maternal mortality ratio (MMR) was 210 per 100,000 live births and it varied from 90 to 330 by different States and Divisions. 17 Most common causes of maternal deaths related to pregnancy were septic abortion, pregnancyinduced hypertension and haemorrhage. 18 The most common cause of maternal deaths related to abortion was unsafe abortion which accounted for approximately 50% of maternal deaths, according to an unpublished report in one tertiary hospital (1992-1998). 16 Importantly, 20-30% of maternal deaths involved women aged under 25 years. 14,15 Although contraception for birth spacing is an important factor, it is less likely to be used among married youths. 13 The contraceptive prevalence rate (CPR) in currently married women aged 15-49 years is 37% (modern methods in 33% and traditional methods in 4%). For 15-24 years age group, the rate is 32% (29% for 15-19 years and 35% for 20-24 years). Comparing to neighbouring countries, the CPR in Myanmar is lower than in China, Vietnam, Thailand, Indonesia, Bangladesh, India and Philippines but is relatively higher than in Laos and Cambodia. 13 There have been some studies on possible factors to determine the contraceptive practice of married couples. Some unpublished
4 reports identified knowledge, husband s education, family factors and attitude. 19,20 Other studies found the misconception on contraceptive use 21 and problem of access to contraceptive service 22 ; however, the behavioural theory on care seeking was not investigated. Evidence that factors with respect to Health Belief Model (HBM) influence the decision of health practice exists. HBM consists of six components, namely perceived susceptibility, severity, barrier, benefit, cues to action and self efficacy. 23 There is still limited knowledge of the factors that influence the decision on contraceptive use among married female youths and their husbands in Myanmar. Therefore, this study aims to identify the factors influencing the decision on contraceptive use in married youth couples at the couple, provider and facility levels. The findings of this study will enable stakeholders of reproductive health (RH) to improve the contraception rate of married youths leading to a reduction of maternal deaths and improvements to maternal health. 1.1 Study setting background Myanmar is located between South and Southeast Asia bordered by India, Bangladesh, China, Thailand and Laos. The total population of Myanmar is estimated at 55.4 million with a population growth rate of 2.0%. Administratively, there are 14 states and divisions with a further division into 17 states/divisions for the management of health programmes. These states and divisions are
5 then subdivided into 66 districts, 325 townships, 2,781 wards, 13,714 village tracts and 64,910 villages. Figure 1 depicts the states and divisions in Myanmar. About 70% of the total population lives in rural areas. The lowland delta and central dry zone are highly populated areas. 18 Figure 1 Map of States and Divisions in Myanmar The circled division is the study area.
6 The Department of Health, one of the seven departments in the Ministry of Health, is responsible for providing comprehensive health care throughout the country, according to the National Health Plan. Delivering reproductive health services to both urban and rural population is the responsibility of Township Health Departments and the township medical officers are leaders of these departments. RH services are provided by township hospital and maternal and child health (MCH) clinics in urban and by station hospitals, rural health centres (RHCs) and sub-rural health centres (SRHCs) in rural areas. A rural area of a township comprises one to four station hospitals and four or five RHCs. Reproductive health providers consist of medical doctors, health assistants (HA), lady health visitors (LHV) and midwives (MW) in both urban and rural areas. The diagram of RH services is shown in Figure 2. Township Township MCH 4-5 Station Hospital unit RHC Hospital Urban Rural 5 sub-centers Figure 2 Diagram of reproductive health system in a Township of Myanmar
7 Within the jurisdiction of each of the RHCs, there are four to five SRHCs where a midwife is stationed to provide the services in 5-10 villages. The midwives and LHVs often provide services like antenatal care and treating minor ailments at their own home and at the home of clients. According to the 1992 Bali Declaration and 1994 International Conference on Population and Development (ICPD) commitments, the Government of Myanmar is committed to extend RH services to all regions of the country. One of the objectives of the RH programme is to improve the health of mothers and children by lowering the high fertility rate, morbidity and mortality ratio through provision of quality birth spacing or contraceptive services and reproductive health care. 13 Birth spacing services in all states and divisions in Myanmar are provided through public and private sectors. Contraceptive methods are available both in public and private sectors. Among the public sector, oral and injectable contraceptives, condoms and IUD are available. Female sterilization is available in all township hospitals. For the private sector, the contraceptive services are available through drug shops and private clinics in all townships. In addition, International Non-governmental Organizations (INGO) such as Population Services International (PSI), also takes part in providing contraceptive services with a minimum cost through it s
8 franchise network of private general practitioners in some townships. 24,25,26 In this study, Ayeyarwaddy division is our study setting. It is situated in the delta region and subdivided into 5 districts and 26 townships. The average population in one township is about 150,000. In 2005, MMR of Ayeyarwaddy division was 300 per 100,000 live births, the second highest figure among all states and divisions (Figure 3). 17 Of 26 townships in Ayeyarwaddy division, 14 townships are the target areas for reproductive health projects, especially family planning supported by United Nations Fund for Population Assistance (UNFPA). UNFPA have been providing all contraceptives free of charge to all project townships. However, a woman needs to pay at a subsidized rate according to a cost sharing mechanism. Thus these project townships were the study sampling frames to explore the factors influencing decision on contraceptive use among youth couples.
9 Figure 3 Maternal mortality ratio in States and Divisions of Myanmar 2. Literature Review This section describes the epidemiological patterns of married youths, factors influencing contraceptive use and contraceptive behavior and health belief model. 2.1 Epidemiological pattern of married youth Although the number of young people aged between 10 and 24 years is decreasing, this age group still comprises more than 25% of all population worldwide. The proportion of population in this age group in Southeast Asia varies from 21% in Singapore to 36% in Cambodia (Table 1). 27
10 Table 1 Epidemiology of youths in Southeast Asia Youth Ages 10-24 (2006) Youth Ages 10-24 (2025) Millions % of Total Millions % of Total Population Population Southeast Asia 164 29 159 23 Cambodia 5.2 36 5.7 29 Indonesia 62.9 28 61.5 23 Laos 2 33 2.6 30 Malaysia 7.4 29 8 24 Myanmar 15.4 30 12.8 22 Philippines 26.8 32 28.7 26 Singapore 0.9 21 0.7 13 Thailand 16.1 25 14.5 20 Vietnam 26.6 31 23.5 23 Source: The world s youth 2006 data sheet, Population Reference Bureau According to Demographic and Health Surveys (DHS) conducted in developing countries, more than 60% of sexually active adolescents are married. In most parts of the developing world, early marriage
11 has declined but is still widespread. The proportion of women married by age of 18 years in Southeast Asia is higher than America, Western Asia, Eastern and Southern Africa but less than Western and Middle Africa as shown in Figure 4. 5 Figure 4 Proportion of women married by age 18 years Marriage during adolescence is common among those who are poor, less educated, and those who practice more traditional customs and rituals. 28 Most married youths are often pressured by their family and community to have their first child as soon as possible after marriage. 29 However, they are generally not more knowledgeable about reproductive biology or diseases than unmarried youths.
12 Furthermore, because of their increased exposure to sexual intercourse and their physiological immaturity, married youths face greater reproductive health risks, including unwanted or poorly timed pregnancies, maternal mortality, and morbidity, than do their unmarried peers. They have a higher risk of delivering low birth weight babies and experiencing premature delivery. 8 Figure 5 shows the percentage of women experiencing their first birth before age 18 in developing countries. One in every four young women in Southeast Asia has a child by age 18. 5 In Myanmar, about 41% of married women aged 15-19 had already one or more births. 13 Figure 5 Proportion of women giving birth by age 18 years
13 2.2 Factors influencing contraceptive use and contraceptive behavior The factors influencing contraceptive use includes the possible factors on knowledge, belief/attitude, spousal communication and approval, other influencing factors (socio-demographic factors, accessibility, availability and costs) and contraceptive behavior. 2.2.1 Knowledge concerning contraceptive use There is a wide variation of evidence on knowledge and practice of contraceptive use. 30,31,32 According to a review on the trends in adolescent fertility and contraceptive use in the developing world, there is a positive relationship between modern contraceptive use and knowledge. 30 Awareness of contraception is almost universal among married adolescents according to DHS and other national surveys in Asia (over 90% in all countries, except Pakistan). However, knowledge of specific methods is more limited, and knowledge of sources and actual use vary widely. 32 Data from the 1999 Guatemalan Migration and Reproductive Health Survey, which included 971 married women and men, revealed that lack of knowledge is an important barrier for contraceptive use. 33 Similarly, insufficient knowledge was stated as one of the constraints to the use of family planning methods, according to a study among 1188 married women aged 15-40 years from Nigeria. 34 Knowledge of contraception is associated not only with contraceptive use but also with child spacing among 500 women of
14 reproductive age in Nigeria. 35 In addition, the predictors of contraceptive knowledge and use among postpartum adolescents in El Salvador using the questionnaire-guided interviews with 50 postpartum adolescents revealed that higher levels of education and literacy predicted greater contraceptive knowledge, but could not predict prior or future contraception use. 36 In Myanmar, according to the 2001 Fertility and Reproductive Health Survey among 8288 women aged 15-49 years old, though the knowledge of at least one method of contraception was quite high (97%) among currently married youths, the practice was only 35%, indicating the existence of knowledge and practice gap. 13 It is essential; therefore, to find the determinants and improve the contraceptive use among married youths who are not ready for pregnancy. 2.2.2 Underlying beliefs/attitude and contraceptive use Previous studies have shown an effect of beliefs or attitude in relation to contraceptive use. 37,38,39,35,21,20,40 According to a qualitative study, young women s decision making regarding hormonal contraceptives was depended on their underlying beliefs regarding the effect of hormones on natural menstruation. 37 In addition, a study conducted among women aged 18-45 years in Oxford using both quantitative and qualitative methods identified that many women were more concerned about the adverse health effects associated with hormonal contraceptives such as bleeding irregularities, weight gain and risk of thrombosis than its
15 effectiveness. 38 Regarding knowledge on side effects of medical contraception, 85% of 486 girls who attended pregnancy counseling centers in southern Ontario had heard about the side effects, such as weight gain, nausea, circulatory disorders (e.g-stroke, HT), emotional changes, menstrual problems and cancer. However, 59% of them believed that the advantages outweighed any negative effects, and 12% believed that the side effects outweighed the advantages. Regarding the safety, 85% said that they were safe, 11% were undecided and 4% described as dangerous. 39 Concerns of contraceptive side effects are associated with use. A study in Nigeria identified that the side effect was one of the reasons for non-use of contraception among 500 Nigerian girls in a cross sectional community based study. 35 According to the survey of contraceptive assessments in 7 townships of Myanmar using individual and group interviews, focus group discussions and clinic observations, many women expressed concerns about the continuation of contraception use for more than three years, difficulty of future pregnancy after stopping use or an increased risk of cancer. Perception of the potential health risks associated with contraceptive use, particularly hormonal methods, was of great concern, and is one of the main reasons for the non-use of contraception. Several non-users reported that they were afraid to use contraception because of the possibility of causing congenital malformations. 21 A cross sectional study on attitudes of contraception conducted in one township of Myanmar on
16 attitudes of married couples revealed that more than half thought that contraception affected maternal and child health. Thirty-six percent of wives and 17% of husbands thought contraceptive use was against their religion, culture and nature. About 68% of women did not like methods dependent on medical examination (unpublished report). 20 In contrast, religion was not related to contraceptive use of women, according to the findings from the 1997 Vietnamese Demographic and Health Survey. 40 2.2.3 Spousal communication and approval on contraceptive use Age at marriage of adolescents is related to spousal communication. In Togo, Gage (1995) found that age at marriage affects spousal communication regarding family planning. Women who married after age 18 communicated with their spouse on family planning (59%) and used contraception (53%) more than those who married before age 16. 41 Likewise, data from the 1990 National Family and Fertility Survey and 1997 Southern Region of Ethiopia Community and Family Survey showed that women in southern Ethiopia, who marry at age 18 or higher, are more likely to discuss about the family size and family planning with their spouses and more likely to be contraceptive users. 42 A study on factors affecting contraceptive use in Ghana among 3,156 married women identified that married women who discussed family planning with their partners were three times more likely to be current contraceptive users. 43 Lack of couple agreement and communication were also mentioned as the primary reasons for non-use of
17 contraception from a study in Kenya among 594 married women. 44 Apart from spousal communication and approval, parent-in-law approval was also important among Nigerian women. 45 Findings from a community-based cross-sectional survey on 420 married women of reproductive age in Pakistan showed that husband agreement as a determinant for contraceptive use (OR = 5.4; 95% CI = 2.2-13.2) 46. Similarly, from a study among 291 Latino women in Los Angeles, California, 48% reported that contraceptive responsibility was a women's role. Forty two percent of women reported opposition to use of birth control by their partner. 47 On the other hand, a national representative telephone survey on 1,852 low-income women aged 18-34 years in US reported that 69% of women did not agree on husband s approval for their decision on contraceptive use. 48 Husband s attitude and behavior regarding contraception was revealed in a study of 123 married men in Turkey. In the study group, 26.8% of the men did not want their wives to use IUDs. The reasons they mentioned were harmful side effects (47.8%), risk of cancer (8.2%) and harmful during intercourse (2%). Thirty two percent did not agree with women using the contraceptive pill. The reasons mentioned were side effects (80.6%), chance of unwanted pregnancies in the event of a missed or late pill (11.6%) and risk of cancer (5.6%). Among those unwilling to use a condom (46.3%), 70.1% stated that it might interrupt intercourse. If a contraceptive pill for men could be used, 25.2% would be prepared to use it. 49
18 2.2.4 Other factors influencing contraceptive use Socio-demographic characteristics on contraceptive use An operational research using quasi-experimental design on 1800 married couples was done in Nepal to improve the young couples access to RH information and services. The study identified that socio-demographic characteristics such as age, education and number of living children, influenced contraceptive use. The use increased with a rise in age and educational level. 50 Similarly, a study in Ghana among 3,156 married women found that women with higher education were three times more likely than uneducated women to use contraception. 43 Apart from age and education, place of residence also influenced the use, according to the 1997 Vietnamese Demographic and Health Survey. 40 Likewise, findings from British and German national contraception surveys revealed that oral contraceptive use was greater in urban areas compared to rural areas. 51 Urban women were two times more likely to use contraception than their rural counterparts in Ghanaian women. 43 According to FRHS (2001) in Myanmar, the level of current use varied significantly by women s background characteristics. The association between age and current use was curvilinear (inverted U-shaped pattern). Adolescent women aged 15-19 and women aged 45-49 were less likely to use modern contraception than other age groups. In addition, women in urban areas were more likely to use a contraceptive method than their rural counterparts. Nearly 46% of currently married women are using any modern contraception in
19 urban areas compared with only 28% of rural women. However, the use of traditional methods is almost identical in both urban and rural areas (4-5 %). 13 Accessibility and availability of services on contraceptive use Data from 23 developing countries found that accessibility to modern contraceptives was positively related to contraceptive use. However, its relationship is weaker than the association between knowledge and use. 30 A cross sectional community-based study in Nigeria about the determinants of contraception among 500 women of reproductive age found that distance from the family planning clinic was significantly associated with contraceptive use. 35 Apart from distance, communication and autonomy problems on the services are also affected. This result was supported by an in-depth interview of Indian, Pakistani and Bangladeshi women on their family planning behaviour and use of family planning services. Married non-professional women experienced significant difficulties in using family planning services largely due to communication problems with health providers and their low levels of personal autonomy. 52 A systematic review of contraceptive medicines by Gray, et al. stated that increased availability of a variety of methods can be expected to lead to an increased use of contraceptives. Figure 6 shows a regression of contraceptive prevalence data from 72 developing countries against an index of method availability (Jain-1989). One additional method (about 4 points on the
20 availability index) would be associated with a 12% increase in contraceptive prevalence. 53,54 Figure 6 Relationship between contraceptive prevalence and availability of methods in 72 developing countries There has not been any specific study looking at the accessibility or availability of contraceptive use in Myanmar. The available information shows only that proximity to a birth-spacing service provider was a key determinant of the availability of services for the clients who want to use contraception by contraceptive method mix assessment. 21 Cost of method and contraceptive use A review on the cost and contraceptive use in 41 developing countries among married adolescents noticed that the relationship
21 between the prevalence of contraceptive use and its cost is not linear. This means that the cost is not related to contraceptive use. 30 In contrast, a cross-sectional study done by the Department of Health in 7 townships of Myanmar identified the cost as an important barrier for accessing contraceptives. 21 2.2.5 Contraceptive behaviors of married youth The contraceptive use rate among adolescents is lowest in Pakistan (6%) and highest in Indonesia (45%) according to a Demographic and Health Survey in Asia (Figure 7). The most commonly used modern contraceptive methods varied among countries. Oral contraceptives were popular in Bangladesh, the Philippines, Sri Lanka and Thailand, while condoms were commonly used in Nepal and Pakistan. Injectables and intrauterine devices (IUD) were commonly used in Indonesia and in Viet Nam. 55
22 Figure 7 Contraceptive use among married adolescent girls in selected countries of South Asia and South-East Asia Most studies on contraceptive use have been conducted among reproductive aged women, and not specifically among youths. A study in Nigeria among 500 women of reproductive age revealed that 19% used contraception and IUD was the most common method among users (38.3%), followed by OCP (29.8%), condom (23.4%) and injectables (8.5%). 35 Kumar et al. conducted a study among 600 married or previously married women aged 15-44 years in a rural community of India and it was revealed that among the 351 everusers, the first contraceptive method used was sterilization (41.3%) followed by condom (35.6%), IUD (17.9%) and oral pills (5.1%). 56
23 In Myanmar, the contraception rate among current users of married youth is 32% in which injectables are the most common methods (57%) followed by oral contraceptives (40%), according to Reproductive Health End of Programme Community Survey 2005. 57 However, there has no information on the factors with respect to contraceptive use in this group. 2.3 Health Belief Model The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors. The original HBM, constructed by Rosenstock (1966), was based on four constructs: perceived susceptibility (an individual's assessment of their risk of getting the condition), perceived severity (an individual's assessment of the seriousness of the condition, and its potential consequences), perceived barriers (an individual's assessment of the influences that facilitate or discourage adoption of the promoted behavior) and perceived benefits (an individual's assessment of the positive consequences of adopting the behavior). 23 Two constructs, namely perceived efficacy (an individual's self-assessment of ability to successfully adopt the desired behavior) and cues to action (external influences promoting the desired behavior) were later added by Rosenstock and others in 1988. HBM has been applied to a broad range of health behaviors and subject populations. It can be applied mostly in three main health aspects: 1) preventive health behaviors, including health-
24 promoting and health-risk behaviors, 2) sick role behaviors, which refer to compliance with recommended medical regimens and 3) clinic use, which includes physician visits for a variety of reasons. 58 There have been several studies in health using HBM to predict seeking behavior; however, only some studies used HBM in relation to reproductive health behaviour. 59,60,61,62,63 These studies showed the influence of HBM constructs on different reproductive health behavior in various perspectives. A case-control study on reproductive health beliefs and behaviors in teens with Diabetes applied HBM to identify significant correlates among constructs of the model. All major constructs of the model were found to be significantly correlated with birth control use and seeking preconception counseling among the 80 adolescents. 59 In addition, perceived barriers, cues to action, and self-efficacy were strong predictors when the intention to use birth control was measured. 60 A school-based study focusing on AIDS health beliefs examined whether perceived severity and perceived susceptibility of HBM were associated with abstinence intention among 297 male adolescents. Students with a high level of perceived severity were significantly more likely to have a strong abstinence intention than those with a low level of perceived severity (crude odds ratio 1.86, 95% CI 1.02 3.38). However, a higher level of perceived susceptibility was not related to strong abstinence intention (crude odds ratio 0.70, 95% CI 0.39 1.28). 61 A study on contraceptive use applied another theory including attitude,
25 normative beliefs and self efficacy among adolescents in different school grades and found that attitudes (perceived pregnancy consequences and benefits of sex) and contraceptive self-efficacy were associated with contraceptive use level. 62 Another study in Kenya showed that only perceived barrier was a significant factor to the frequency of condom use. 63 3. Rationale Half of the world s population are aged under 25 years of whom the majority are youths, especially in developing countries. A high proportion of this age group has an enormous impact on global and national development. This target group faces biological and psychological changes with many having to cope with unintended pregnancy and induced abortions. Lack of contraceptive use is a major contributor to the high rates of unintended pregnancies and birth observed worldwide for young adults. Nearly 20% of the total population of Myanmar is composed of youths (15-24 years). Although the median age at marriage is quite high, the tradition of early marriage and child bearing still prevails in rural areas. The national maternal mortality ratio (MMR) is 210 per 100,000 live births. One of the main causes of maternal mortality is abortion related complications and unsafe abortion accounts for approximately 50% of all maternal deaths. In addition, 20-30% of maternal deaths are of women aged less than 25 years.
26 Even though contraceptive use is an important strategy to improve maternal and child health of married youths, CPR is only 32% in this age group, thus the improvement of CPR in married female youths is essential and urgently needed. To achieve this goal, the influencing factors on decision making and behavior of contraceptive use among this group are needed in order to explore future steps of implementation. It is known that the contraceptive use of married women depends on many factors: wife and husband s knowledge and attitude, spousal communication, perception on pregnancy and contraceptive use with respect to HBM and accessibility of services. However, there have been few studies investigating perceptions of both couple on contraception in relation to HBM and the factors influencing contraceptive use among married youths from perspectives of wife, husband and service factors. In addition, there has been no information on the self-determination of the factors and persons related to the decision on contraceptive use, particularly among married female youths. No documentation considering the magnitude and importance of factors using self-ranking is available. Therefore, this study aimed to fill these gaps by studying the factors related to contraceptive use using HBM perceptions and other influencing factors among married female youths and their husbands as well as the magnitude and importance of the factors and persons related to contraceptive decision making using married youths self determination. The findings of this study will provide straightforward information to the stakeholders of
27 Reproductive Health to increase contraceptive use leading to reduction of maternal death and improving maternal health due to unintended pregnancy. 4. Research questions What are the factors influencing contraceptive use and decision making among married female youths and their husbands in a rural area of Myanmar? 5. Objectives 5.1 General Objectives To identify the factors influencing contraceptive use and decision making among married female youths and their husbands in a rural area of Myanmar 5.2 Specific Objectives 1. To predict the contraceptive use of married female youths and their husbands by using HBM perceptions 2. To assess the agreement of perception on contraceptive use with respect to HBM between female youths and their husbands 3. To identify the factors influencing contraceptive use among married female youths considering wife, husband and service factors
28 4. To evaluate the magnitude and importance of factors and persons related to the decision to use contraceptives by married youths self-determination 5. To determine the agreement between willingness to use contraception and actual use
CHAPTER 2 METHODS 6. Conceptual framework We hypothesize that there are three levels of factors, namely service, husband and wife, influencing on a couple s decision to use contraceptives. The accessibility and availability of contraception and providers are one of the components that encourage contraceptive use. However, contraceptive use will be low if couples are not willing to use. Couple s factors, such as couple s characteristics, knowledge, attitude, spouse communication and perception according to HBM, may affect the decision at the wife and husband level. The conceptual framework is shown in Figure 8. 29
30 Service Facility Provider -Accessibility -Characteristics -Availability -Attitude Wife -Characteristics -Knowledge -Attitude -Spousal communication -Health belief model Husband -Characteristics -Knowledge -Attitude -Spousal communication -Health belief model Decision on contraceptive use -Actual use -Willingness to use Figure 8 Conceptual framework of study
31 7. Research Methodology 7.1 Study design A community-based, cross-sectional analytic study was conducted comparing the influencing factors of contraceptive use and decision making among married youth couples. 7.2 Study area Ayeyarwaddy division of Myanmar was selected purposely as a study setting because Ayeyarwaddy division is available for reproductive health services, has a high proportion of youths and has high maternal mortality. Of 14 townships in Ayeyarwaddy division under reproductive health projects, one township was randomly selected to be the study setting using a computer generated sampling number, resulting in Hinthada Township. Hinthda Township is one of six townships situated in the Hinthada district (Figure 9). The total population of the township was 464,456 in 2005, of which 17.4% were 15-24 years. It consists of 21 wards in urban areas and 103 village tracts in rural areas, respectively. Seventy percent of population resides in rural areas and the reproductive health services in rural areas include 4 station hospitals, 9 RHCs and 36 sub-rhcs.
32 7.3 Study population The study population in this study was divided into two groups: couple and provider. For couple Married female youths aged between 15-24 years and their husbands living in Myanmar. For provider All reproductive health care providers who currently work in the rural area of Hinthada Township for at least 6 months. 7.4 Study sample For couple Inclusion criteria (1) Currently married female youths aged between 15-24 years living with their husbands who have resided in the rural area of Hinthada Township for at least 6 months before the survey. Exclusion criteria (1) Those who plan to get pregnant or are currently pregnant (2) Those who are mentally retarded
33 Definition of couple: A man and woman who are legally married or who are living together in a consensual union. Definition of contraceptive use: A couple who has continuously used the modern methods of contraception in the past 6 months. Definition of non-use of contraception: A couple who has not used the modern methods of contraception continuously in the past 6 months. For provider All public reproductive health care providers from the rural area of Hinthada were included in the study. 7.5 Sample size To obtain the sample size for objective 1, the sample size formula for two-group proportion comparison was used. Z α/2 2 * [(1+1/r)* P(1-P)]+ Z β 2 * [P1(1-P1)+ P2(1-P2)] n = n = required sample size (P1-P2) 2 P 1 = exposure rate among youth couple who used contraception P 2 = exposure rate among youth couple who do not used contraception r = ratio of women aged 15-24 years who used and did not use the contraception = 1:1
34 From previous literature, three factors were identified as associated factors to contraceptive use among married women as shown in the following table. Percentage of Factors factors between used (p1) and Sample size per group non-used (p2) Nonused P1 P2 Used Total sample size Female knowledge on contraceptive method 75% 44% 45 45 90 Female perception on side effects of contraceptives 65% 33% 44 44 88 Female education (no schooling vs high school) 49% 18% 42 42 84 From previous studies, there was a 30% difference of proportion of exposure between use and non-use groups. However, we adjusted this difference of exposure to 20% to ensure greater sample size in case that the difference in our study was not as wide as previous studies. According to 20% difference of influencing factors, ratio of use and non-use to be 1:1 ratio and 80% power, at least 98