Abstract

Background: Egypt's population encroach 100 million, the government is trying to change the people's minds. The government launched a family planning campaign two children enough to challenge the traditions of large families in rural Egypt. Family planning is a main point to control growth of population and promoting maternal and child health Aim: to assess attitude and practice of Egyptian married women toward using contraceptive methods to encourage campaign two-children enough. And compare between attitude and practice of women who had <3 children and those who had ≥3 children. Methods: descriptive research design conducted at antenatal outpatient clinic of Woman's Health Hospital, Assiut University. A total number of 500 women recruited for the study which divided into two groups; group1 (250 women who had <3 children) and group2 (250 women who had ≥3 children). An interview questionnaire that divided into three parts was used. Results: it was found that the majority of studied women (82.8%) in group1 and (74.0%) in group2 agreed with the campaign with highly statistical significant difference between both groups p-value 0.001. Conclusion: the majority of the women in both group had a positive attitude toward family planning methods. Recommendations: The need for an educational programme for both the healthcare providers and the nursing women and media awareness campaigns should be tailored to encourage campaign.

1. Introduction

Increasing population growth is a worldwide problem today ¹. Egypt has a population of about 102 million people. According to current projections, Egypt’s population is expected to double by 2078. The population is currently growing at a rate of 1.94%, a rate that adds about 2 million people to the population every year. Egypt’s fertility rate is about 3.3 births per woman, well above the population replacement rate of 2.1 births per woman. The rapidly increasing population poses a threat to the Egyptian economy, where one-third of people live below the poverty line and the unemployment rate is around 10% ².

Family Planning (FP) is a main point to control growth of population and promoting maternal and child health through providing adequate space between children as well as preventing unwanted pregnancy ³.

It is the most influential measure to achieve control on the population leap. It helps in reducing morbidity and mortality of infant. It also aid in protection the health and wellbeing of young women who are at higher risk of pregnancy related complications and deaths ⁴.

Faltered economy make Egypt's authorities to become clear about family planning, one of the most influential part on this matter because of increasing Egyptian population extent beyond the landmark of 100 million, President Abdel-Fattah el-Sissi is releasing a campaign called “Two is Enough.” That was, supported by the United States and the United Nations ⁵.

Egypt faces a two biggest dangers including terrorism and population growth that hinders chances of Egypt to move forward. In addition to a media campaign encouraging fewer births, the “Two is Enough” campaign provides maternal and child health care, plus cash support to 1.15 million women in the country’s poorest families. In rural Upper Egypt, the ideal number of children is still four, but it is expected that this program will succeed because actually, economic conditions are forcing us to have smaller families ⁵.

Egypt is encouraging to educate people in rural areas on family planning methods in a trial to slow a population growth rate that President Abdel Fattah al-Sisi said poses a threat to national development. The country is already the most populous in the Arab world with 93 million citizens and is set to grow to 128 million by 2030 if fertility rates of 4.0 births per thousand women continue, according to government figures ⁶.

To support the money-bundle government in Cairo, the U.S. Agency for International Development will provide Egypt with $19 million over the next five years to assist country-hold clinics and enhance the use of family planning methods and improve women’s health. The U.N. Population Fund allocated about $6 million this year for reproductive health services in Egypt ⁵.

Different family planning methods are available, which are highly safe than complications result from pregnancy and childbirth. Not all family planning methods are appropriate for all women. Extending the number of family planning options available to women is a vital matter to increase contraceptive coverage and decrease unwanted pregnancies and reducing morbidity and mortality of mothers around the world ¹.

Last month health minister of Egypt initiated a process of Lifeline, a planning to reduce the birth rate to 2.4 and economize the government up to 200 billion Egyptian pounds ($11.3 billion) by 2030. Al-Azhar university of Egypt, a 1,000-year-old place of Islamic learning, agrees with the ministry's plan and said family planning is not forbidden. Its objective is rural areas where many view large families as a source of economic power and there is opposition to family planning because of a belief that it is illegal under Islam to intend to conceive a certain number of children ⁶.

The role of nurses is particularly important, given that up to 30 percent of women may stop using birth control because they cannot access advice when it is needed .The nurse has the responsibility to give education about different contraceptive methods to the clients; she is being a client counselor and educator ^{5, 7}.

There should be interaction between nurse and clients, the nurse should deal respectfully with all clients, assist them to choose suitable FP method, and give sufficient information to use the chosen method safely and effectively. It is important to help the client to understand the chosen method. Explain to them all information regarding side effects to help them both with method selection and method continuation. Also, making follow-up visits may help patients switch between methods or using emergency contraception to protect them against pregnancy ^{8, 9}.

On the demographic front, Egypt has passed the peak of the demographic bulge due to the decline in fertility of two decades ago. However, more needs to be done to further reduce the pace of fertility decline which has leveled at about 3.1 for almost a decade. In rural areas, the fertility rate is 3.2 births, around 20 percent higher than the rate in urban areas (2.7 births). Fertility levels are highest in Upper Egypt (3.4 births) In Egypt ².

Egypt's population is growing by 2.6 million a year, a high rate for a country where water and jobs are scarce. Moreover the schools and hospitals are overcrowded. President Abdel Fattah al-Sisi says the two biggest threats to Egypt are terrorism and population growth. Decades ago, Egypt had a family-planning program, supported by the United States. The fertility rate fell from 5.6 children per woman in 1976 to 3.0 in 2008 while the use of contraceptives went up from 18.8 percent to 60.3 percent ⁶. So, the researchers interested to identify the women's attitude and practice regarding the campaign.

Ÿ To assess attitude and practice of Egyptian married women toward using contraceptive methods to encourage campaign "two-children enough".

Ÿ Compare between attitude and practice of Egyptian married women who had less than 3 children and those who had more than 3 children.

2. Methods

Research design: descriptive research design was used in this study.

The study setting: the study conducted at antenatal outpatient clinic of Woman's Health Hospital, Assiut University, Egypt.

Systematic random sampling technique was used with sampling interval of three. Sample size was calculated using Open Epi, (ver. 3) using prevalence of family planning 41.5 % according to DHS 2015 and 97% confidence interval. The minimum required sample was 500. A total number of 500 women recruited for the study which divided into two groups each group included 250 married women. The two groups involved group1 (women who had less than 3 children) and group2 (women who had 3 children or more).

Inclusion criteria: all married women in child-bearing period attending outpatient clinics at Woman's Health Hospital.

An interview questionnaire that divided into three parts which included:

Part (I): it contained three sections:

Ÿ Personal characteristics like name, age, occupation, education, religious, family income, age at marriage, and years of marriage.

Ÿ Obstetric history as no. of pregnancy, labour, abortion, and living children.

Ÿ History of family planning as previous using, type of methods used, and priority for chosen of contraceptive method……ect.

Part II: Attitude toward using contraceptive methods to encourage the campaign as: with the campaign or against it, responsible for decide to take contraceptive methods, spacing between children allow healthier child, and contraceptive methods are harmful because their side effects....ect.

Scoring System for Attitude

Each question was scored as (1) for a positive attitude and (zero) for negative attitude. While the total attitude score was calculated as the following: positive if 60% and more was and negative if less than 60%.

Part III: Reported practices toward using contraceptive methods to encourage the campaign: it includes intention to use contraceptive methods in the future, methods prefer to use, causes of not using, and intention to encourage friends or relatives to use contraceptive methods in order to encourage the Campaign …ect.

The internal consistency of the tool scale was calculated by using Cronbach's Alpha; and it was 0.722.

Questionnaire was examined and reappraised by a group of specialists in the field of Obstetrics & Gynecological nursing and was assessed in a pilot study. The panel reviewed the instruments for clarity, relevance, comprehensiveness, understanding and applicability.

This design involves the description of the preparatory phase, the pilot study, and then the procedure.

The researcher reviewed related literature of current study local & international, using text books, articles, and scientific magazines. The tools were then prepared.

Pilot study was carried out before starting of data collection on 10 % (50) of women 25 from each group. Women who attended outpatient clinics, Woman’s Health Hospital, Assiut University to test the applicability of the tools and test the clarity of the designated questionnaire as well as to estimate the time needed to answer it. Data obtained from the pilot were analyzed and included to number of study sample because no essential modifications were done.

An official letter approval was obtained from the Dean of the Faculty of Nursing, Assiut University and directed to the manager of Woman's Health Hospital to complete the study. The letter involved a permission to carry out the study.

Study suggestion was approved from ethical committee in the Faculty of Nursing, Assiut University. No danger found during implementation of the study. The researcher introduced herself to the eligible women, and briefly explained the nature of the study. Then oral consent was obtained from them. Research participant had the choice to reject to join or dropped out from the research at any time they want and in the absence of any reason.

Data were collected from the participant women through interviewed the women attending to outpatient clinics individually after explanation the nature of the study and obtained their consent to be included in the study. The researcher informed the participant that their participation is voluntary. Confidentiality and anonymity of subjects were assured by the researcher.

The researchers met all married women attending to outpatient clinics through three days in a week from 9 am to 12,30 pm, great women, introduce self and explain purpose and important of the study. The data collection took about 45 minutes for each participant in average five patients a day regarding their personal, obstetrics, family planning data, attitude and practice of women toward campaign. After that every woman was given a bourchore about important of campaign family planning methods, how to use each method, advantages, and dis advantages of each methods.

The whole duration of data collection took about eight months, started from May to December 2019.

Data entry and analysis were done using SPSS version 18 Program statistical software package for social sciences. Data were presented using descriptive statistics in the form of frequencies and percentages. Correlation between variables were done. Statistical significance was considered at P-value ≤0.05 and high statistical considered at P-value ≤0.01.

3. Results

Table 1 shows personal data of studied women in group1 (who have less than 3 children) and group 2(who have 3 children or more), it was obvious that less than three quarter (72%) of group1 while less than half (45.6%) of group2 between 20-30 years old. The majority of them (81.2 in group1 and 83.2 in group2) had no work. The table presents that about one fifth (21.6%) of group 1 and more than one quarter (27.6%) of group 2 were illiterate. Regarding to year of marriage, it was observed that more than two thirds (66.8%) in group1and (2.8%) in group2 married from less than 5 years.

Table 2 illustrates obstetric history of studied women, it is found that women who had one or two gravity and parity were (70.4 % ، 72.4%) respectively in group1and only (1.2%) in group2. Around one quarter (24.0% in group1 and 29.6% in group2) have a history of abortion. As regard to number of male children, only 12% of group1 and more than two fifths (42.4%) of group2 had more than one male child.

Table 3 reports distribution of studied sample according to their family planning history, it was observed that less than two fifth (38.4%) of studied women in group1 and four fifth (80%) in group2 used family planning methods. Regarding women used family planning methods, the most common used method was pills in both group (54.2 and 30.5) in group1 and 2 respectively. Less than one quarter (23.9) in group1and near to one third (28%) of women in group2, their first priority to choose family planning methods was safety of the method. More than one half of studied women (69.8 in group1 and 54.0 in group2) terminated their family planning method because they want to get pregnant. About 10% in group1 and 16% in group2 pregnancy occurred to them during using family planning methods, and pills considered the majority method that women get pregnant while using it (80.0% in group1 and 84.4 in group2).

Table 4 shows distribution of studied sample according to their attitude toward using contraceptive methods to encourage the campaign; it was found that the majority of studied women (82.8%) in group1 and around two thirds (65.2%) in group2 of women agreed with the campaign with highly statistical significant difference between both groups p-value 0.001. Also, sharing in decision to use the method by women occupied more than two thirds (79.6% in group1 and 70.4% in group2). In addition, the vast majority of both groups (96.4% in group1 and 99.2% in group2) agreed on spacing between children allow healthier child. Furthermore, more than half (70.8% in group1 and 63.2% in group2) of studied women in both groups their husband encouraged them to use contraceptive methods with no statistical significant difference between both groups p-value 0.071.

Figure 1 illustrates total attitude toward using contraceptive methods to encourage the campaign, it was found that around two thirds (79.6% in group1 and 65.2% in group 2) had a positive attitude toward using contraceptive methods to encourage the campaign, with statistically significant difference between them (P-value = 0.023).

Table 5 demostrates statistical significant difference between both groups according to women reported practice toward using contraceptive methods, it was found that the majority of studied women (68.8% in group1 and 85.2% in group 2) intend to use contraceptive methods in the future. Around one half (45.3% in group1 and 52.6% in group 2) of women (who will use family planning method) intend to use IUD in the future. Regarding visiting family planning health services, 22.8% of group1 and about half (49.6) of group2 had always visits to the family planning services. Moreover, the majority (84%) of studied women in group1 and (72.0%) in group2 had intention to encourage others to use contraceptive methods with highly statistical significant difference between both groups p-value 0.001.

Table 6 illustrates distribution of studied women according to provision of family planning services, according to accessibility and sufficiently of family planning services; it was observed that the vast majority of women in group1 and group2 (95.6% and 96.4% respectively) had access to family planning services. In addition, it was found that the majority (82.8% in group1 and 86.4% in group2) of women considered family planning sufficient. Furthermore, availability of family planning methods reported by more than two thirds (69.6% in group1 and 72% in group2) with highly statistical significant difference between both groups p-value 0.004.

Table 7 views relation between personal characteristics of studied women and their total attitude toward using contraceptive methods, it was found that there was a relation between studied women’s age, employment status, residence and education with their total attitude toward using contraceptive methods (P-value = 0.003, 0.002, 0.002 &0.001 respectively).

Figure 2 illustrates the relation between studied women’s intention to encourage campaign and total attitude toward using contraceptive methods. It was observed that there was a relation between women’s intention to encourage campaign and total attitude toward using contraceptive methods (P-value = 0.001).

4. Discussion

Family planning services were the instruments that used by people and nation to achieve some objectives as reduce poverty, enhance citizens' income for a better life, reduce maternal and infant mortality, and assess exposition of population ¹⁰.

Using of contraceptives is not to limit the size of the family and regulate the spaces between births only, but it can be used as indicator for health and women's liberation. Increasing program coverage and access of family planning will not be enough unless all eligible women have adequate awareness for favorable attitude and correctly and consistently practicing as per their need. Increasing awareness and favorable attitude for practicing FP activities at all levels of eligible women are strongly recommended ^{11, 12}.

Regarding women’s attitude toward contraceptive methods use, the results of the present study revealed that the majority of the women had a positive attitude toward family planning methods. In addition, more than three quarters of women intend to use contraceptive methods in the future. In addition, the vast majority of them supported that spacing between children allow healthier child.

These finding near to ¹³ who performed their study in a resource limited settings of Northwest Ethiopia to identify knowledge, attitude and practice towards family planning among reproductive age women, and illustrated that near to three fifths (58.8%) of the participants had favorable attitude towards family planning, the majority (88.5%) of them discussed FP issues with their partners and wants to use it in the future. The vast majority (93.6%) of the participants encouraged having appropriate gap between child birth.

These results agreed with ¹⁴ who applied their study in an urban area of Rohtak district, Haryana among currently married women to identify their family planning knowledge, attitude, and practices, and reported that the majority (83.1%) of women had a positive attitude regarding family planning methods. Moreover, ¹⁵ who implemented their study in Central Tanzania on married women of reproductive age to evaluate their knowledge, attitude and practice (KAP) towards modern family planning methods, and reported that half (50%) of women had a positive attitude towards modern contraceptives.

In contrast, ¹⁶ who performed their study among eligible couples in Manipur to clarify community perceptions on family planning, and illustrated that the majority (80%) of respondents had negative attitude towards family planning methods.

Actual study found that around two thirds of the studied women their husband encourages them to use contraceptive methods, more than half of studied women agreed on contraceptive methods are harmful because of their side effect.

On the other side, ¹⁷ who applied their study in Zambia to assess the effect of joint contraceptive decisions on the use of long-acting and permanent methods among married female (15-49) contraceptive users, and revealed that around two thirds (68%) of women reported discussing family planning with their partner/husband. But less than one quarter (22.5%) of participants agreed on the fact that contraceptive methods have more benefits than side effects.

According to women practice toward family planning methods current study revealed that the majority of women intend to use family planning in the future.

This was on the same line with ¹⁸ who applied their study in Nigeria to identify the knowledge, attitude, and practice of married couple about family planning methods and reported that the majority (69%) of married women intend to use family planning method.

Near to previous results ¹¹ who conducted their study in Saudia Arabia to evaluate knowledge, attitude, and practice toward family planning methods and illustrated that around two thirds (64%) of women want to apply family planning method in the future.

On the other side ¹⁹ who implemented their study in India to assess the level of awareness, attitude, and practice of toward different family planning methods and clarified that less than one third (27%) of women intended to use family planning method in the future. This dissimilarity can be explained by caused by culture, tradition, and education difference between these women and current study.

Also ²⁰ who executed their study in Addis Ababa, Ethiopia to assess knowledge, attitude, and practice of permanent family planning methods, and reported that less than one quarter (23%) of women intended to use family planning method in the future. this variation returns to performing Wallance M.`s study on permanent family planning methods, but current study works on all types of family planning methods.

Concerning the type of family planning method, the women intend to use in the future, near to half of studied women prefer to use intra uterine device (IUD) as a contraceptive method.

This is similar to ¹⁹ and ¹⁸ who cleared that around to one half (43.4%) and (63%) respectively of studied women want to use IUD as a contraceptive method in the future.

Also, near to previous results, ²¹ who performed his study in Osogbo Local government, Osun state to identify health care providers' knowledge, attitude, and practice toward family planning, and clarified that more than one third (34.3%) of them intend to use IUD as a contraceptive method in the future.

Previous result was not accordance with ²² who carried out their study on current married women in an urban area of Rohtak Disfrict, Haryana to assess their knowledge, attitude, and practice toward family planning methods, and reported that near to half (45.6%) of studied women prefer to perform tubal ligation as a contraceptive method. This difference comes back to the difference between ages of women as almost of studied women of ²² in age above 30 years old and they completed their family member, so they intend to use a method that probability of pregnancy not occur during using it.

According to cause of intention to not use family planning method in the future, existing study stated that more than one quarter will not use due to travel of their husband.

This was disagreed with ¹⁸ who lighted that more than one half (60%) of studied women not intend to use family planning method in the future for no reason. This disagreement return to variation in tradition, believes, and level of living. And more than one quarter (30.6%) of studied women for the same reason in ¹⁹ study.

Also ²³ who implemented their study in Ethiopia among women with unmet need for family planning to clarify their attitude toward family planning methods and reason for not use, they showed that more than one quarter (27.0%) of studied women will not use contraceptive method related to opposition to use family planning methods. This may come back to variation in time that the study performed in.

As regard visiting the family planning clinics the present study reported that more than one third of studied women had always visit to family planning clinics and about one fifth of them had a usual visit. And near to one quarter of them used a different family planning methods.

This was in agreement with ²⁴ who carried out their study in Suva to identify the level of knowledge, attitude, and practice of family planning among women of reproductive age, and illustrated that more than one third (37.5%) of studied women had always visit to family planning clinics and about one fifth (19.7%) had a usual visit. And more than one third (44.4%) of them used a different family planning methods.

Actual study state that the majority of studied women intended to encourage their friends and relatives to use contraceptive methods.

This was near to ²⁵ who carried out their study in Ghana to clarify knowledge, attitude, and practice of family planning among women attending Amix Government Hospital, and found that the great majority (96%) of studied women intended to recommend family planning services to others.

Current study illustrated that the majority of studied women easy access to family planning and the service is sufficient and all family planning methods are available.

This was on the same line with ²⁵ who found that the majority of studied women report accessibility of family planning service and the service was available when needed (92%) and described this service as good.

Knowledge and practice regarding family planning methods was influenced by many factors and educational level play an important role to adapt family planning methods ²⁶. This study showed that there is relationship between total attitude toward using contraceptive methods and women's age, occupation, residence, and educational level, but there are no relation between total attitude toward using contraceptive methods and women's religion, and average income.

Congruent with previous result ²⁷ who applied their study in Cameroon to assess knowledge, attitude, and practice of family planning among women living in the Mbouda health District, and reported that there was relation between educational level and practice toward family planning p value 0.05.

Also ²⁸ who implemented their study in Pakistan to identify the relationship between contraceptive and unintended pregnancies among married women, and cleared that there was relation between women's age and practice toward family planning p value 0.001.

Family planning usage is a baseline for health of the family with many benefits for women’s health, mood and the sense of autonomy ²⁹.

A noteworthy finding of this study reports that about three fifth of studied women used contraceptive methods and the most frequent methods used were pills (38.2%) followed by IUD (27%). In addition, only 12.5 % of studied women terminated methods for their side effects. These finding supported by ¹¹ who performed their study in Saudi Arabia to assess knowledge, attitude and practice towards FP, and reported that 58.6% of the subjects currently used contraceptives for family planning and they in contrasted with the study finding on 77.3% of the subjects suffered from side effects of contraceptive pill.

Moreover, ³⁰ who implemented their study in selected wards of Dharan Sub-Metropolitan city to identify knowledge, attitude and practices of contraception among the married women of reproductive age groups, and showed that 70.8% of the respondents had ever practiced contraception. In addition, the current study supported by ¹³ who reported that three fourth (75.3%) of study participants ever used contraceptive methods. The main types were pills.

³¹ who applied their study in Rwanda to assess knowledge, attitudes, and practice on contraceptive use among women attended FP services, disagreed with the current finding and reported that almost all respondents (96.9%) use one or other of the family planning methods. Pills and injections are the most practiced methods (43.5% and 42.5% respectively).

These finding in contrasted with ²⁸ who performed their study in Thatta District, Pakistan to evaluate the relationship between contraceptive use and unintended pregnancies among married women, and reported that the most frequently used method of contraception was injections (47.9%) and IUD (3.5%) were rarely used. Also, disagreed with ²² who revealed that female sterilization (45.6%) was the most common chosen methods. The factors contributing to discontinuation of contraceptive use are inappropriate treatment, incomplete follow-up, and limited choice of these methods. Therefore, the respective services should prioritize the issue of improving women’s ability to achieve their desired reproductive goals.

The current study revealed that half of studied women had more than two children this may be related to slightly more than fifth of studied women married early less than 18 years’ old and less than two fifth of them married from 5 to 10 years. This results were in the same line with ¹¹ who reported that 42.1% of studied subject had three or more children.

As regard studied women’s age, the present study revealed that about three fifth of studied women were between 20-30 years, about one quarter of studied women were illiterate and hadn’t certification degree this may be related to 64.6% of women from rural areas. Concerning women’s working, the present study viewed that the majority of studied women were housewives, this may be explained by one fifth of the studied women had high education.

On the same line ¹⁹ illustrated that around three fifths (60.1%) of studied women their age ranged from 21-34 years, and less than one quarter (24.8%) had a graduate level of education, and the majority (79.04%) of them were housewives.

These finding disagreed with ¹³ who reported that more than half (53.5%) of studied women their age ranged from 20-45. Near to half (47%) of women were illiterate. And more than three fifths (64.6%) of women were housewives.

Moreover ³¹ reported that more than one quarter (29.5%) of studied women their age between 31-48 years. And only 1.8% of respondents hadn’t any education

5. Conclusion

Level of family planning utilization was quite low in comparison with many studies and the majority of the women in both group had a positive attitude toward family planning methods

6. Recommendation

Ÿ Provision of counseling about family planning methods for both couples of family planning.

Ÿ Information should be provided through conferences and seminars that encourage people to plan their families.

Ÿ Provision of different types of contraceptives in the units and hospitals.

Ÿ Change the perceptions towards family planning methods.

Ÿ Brochures and booklets about family planning methods should be written in nice colorful way to attract people.

Ÿ Schools and universities should support discussions about family planning issues.

Ÿ Fund raising should be carried out on different levels, in both the public and nongovernmental sector, in order to enhance the family planning services provided.

Ÿ Family planning programs should be modified according to the target groups. The family planning awareness programs should be tailored for husbands, wives, and young adolescents. Moreover, the information should be tailored for different audiences (i.e. educated vs. non educated groups).

Acknowledgments

Authors would like to thank all childbearing women included in the study, and all medical staff who facilitate collecting data and performing educational program.

References