Barriers to Modern Contraceptive Practices among Selected Married Women in a Public University in Malaysia

In Malaysia, only 30% of the married women use modern contraceptive methods. Low usage of contraceptive methods, results in high rates of unwanted pregnancies and its consequence which includes; psychological problems physical health and unsafe abortion. The main purpose of this study is to understand the barriers of modern contraceptive practices among women in University Putra Malaysia. This study was carried out through two main research questions: 1.What is the women’s perceptions of modern contraceptive methods? 2. Why women do not use modern contraceptive methods? A qualitative research method was used for exploring misconceptions and barriers to contraceptive use among married female staff in University Putra Malaysia (UPM). The data was collected using the non probability, purposive sampling method, from 6 women by face to face interviews, which was also audio-recorded. The records were then transcribed verbatim and analyzed consecutively. This study finding showed there were personal, cultural, and health system barriers to modern contraceptive use. The women have been surrounded by fears, and misconceptions which serve as obstacles to initiation and continuation of contraceptive use. Strong socio-cultural norms and health services barriers including negative response of service providers, and low male family planning activities influence contraceptive use negatively. This study suggests that the promotion of modern contraceptive methods should be considered in women and men educational programs. Further studies should examine health providers’ views and quality of family planning services.


Introduction
The World Health Organization estimates that; 210 million women get pregnant each year and that about two-thirds, or approximately 135 million, deliver live infants globally.The remaining one-third of pregnancies ends in still births, miscarriages and induced abortions (World Health Organization, 2011).From the estimated 42 million induced abortions each year, nearly 20 million are performed under unsafe conditions, which results in the deaths of an estimated 68,000 girls and women.This represents about 13 percent of all pregnancy-related deaths (World Health Organization, 2011).Five million women are hospitalized each year, for treatment of abortion complications such as hemorrhage and sepsis (Singh, 2006).It is also estimated that among the total pregnancies each year in South and South-East Asia, about one-third are unplanned or unintended (Hossain,et al., 2005).The reasons for such huge number of unplanned pregnancies in South and South-East Asia, include low contraceptive use, methods failure (both users' and technological faults), and high unmet need for contraceptives."Unmet need" means that, women want to limit or space future pregnancies, but are not using a contraceptive method, or have no access to the method (Hossain, et al., 2005).Sixty six percent of women with unintended pregnancies in developing countries do not use contraceptives, 14% use traditional methods, and only 20% use the modern methods (Singh, et al., 2003).
Previous researchers have identified several obstacles to the use of modern contraceptives including; husbands' opposition to the use, fear of side effects, health concerns, and dissatisfaction with sexual sensation when using them (Bongaarts & Bruce, 1995;Casterline, et al., 1997;Nagase, et al., 2003).Another factor that influences usage of contraception is ambivalence about pregnancy.Women who are ambivalent about avoiding pregnancy are less likely to use contraception and more likely to have gaps in contraceptive use thus placing themselves at risk for unintended pregnancy (Frost, et al., 2007).A study conducted in rural Peru, showed that contraceptive choice is strongly related to a couple's life experiences, their contact with urban centers, their economic status, and their emphasis on cultural values.Majority of the couples practice natural and traditional family planning methods, which are not reliable.Villagers do not use modern contraceptives, as a result of cultural barriers, created by family planning services that do not take into account the lifestyle of these people, insufficient knowledge of human physiology, and message from users who are dissatisfied with their contraceptive methods, and women's reliance on their reproductive role for self-esteem (Tucker,1986).Another study among young people in Uganda, explored misconceptions and fears related to contraceptives, gender power relations, socio-cultural expectations and contradictions, short term planning, and health service barriers were the main obstacles to the use of contraceptives (Nalwadda, et al., 2010).A study in Ethiopia showed that, disturbance of the menstrual cycle is one of the most common reasons for discontinuation of hormonal methods of contraception (Weldegerima & Denekew, 2008).
In Malaysia, modern contraceptive practice is low, with only 30% of married women aged between 15-49 years old, making use of modern contraceptives (United Nations Population Fund, 2004).Low use of contraceptive methods, results in high rate of unwanted pregnancies among Malaysian women (Asian Pacific Resource & Research Center, 2006).The importance of understanding barriers to the use of contraceptives will contribute to the health maintenance of women in reproductive ages by avoiding unplanned pregnancy, and induced abortions.The purpose of this study therefore was to understand the misconceptions and perceived barriers to the use of contraceptives, among married female staff in a public university in Malaysia.The two main research questions for this study were: 1. What are the women's perceptions of contraceptive methods? 2. Why is it that many women do not use modern contraceptive methods?

Research design
Data from the qualitative interviews are used to elucidate perceived issues around the use of contraceptives in this population.Specifically, the analysis focuses on women who make use of traditional methods, or do not use a modern method of contraception.In this study modern contraceptive is defined as types of contraceptives such as condoms, pills, injectable, intra uterine devices (IUDs), implants and female / male sterilization.A qualitative research approach is well suited for exploring the intricate issue of misconceptions, and barriers to the use of contraceptives.Qualitative methods allow for a free form of investigation into topical areas, for which there is little prior knowledge.They are also useful for examining sensitive issues, such as; sexual behaviors, and contraceptive preference.This approach is particularly useful in the context of Malaysian society, where open discussion of sexuality is unacceptable and research related to sex can be difficult.

Participant and setting
The set criteria for the study were married female staff in University Putra Malaysia.A non probability, purposive sample of the target women was taken.
The interviewees were selected from Faculty of Medicine and Faculty of Education of the University Putra Malaysia

Ethical issues
Before obtaining the participants consent, the researcher explained to them the purpose of the interview, the content of the interview, and the confidentially of the recorded information.In addition, they were informed that they could quit the interview at any stage.A written informed consent was obtained from the participant, and the interview was recorded after obtaining the written consent.

Data collection procedure and analysis
Data was collected, processed, and analyzed by the researchers.Data collection included a series of open-ended, semi-structured interviews.A set of questions was designed to get the required information for addressing the research questions such as: How would you describe modern contraceptive methods?

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What is your opinion about using contraceptive methods?
• What are your experience regarding using contraceptive methods?
• Which factors play an important role in contraceptive use and decision making?
The goal of the study was explained to the potential participants by the researchers, then, with their consent, an appointment was made for the interview.The duration of interviews was between 50-80 minutes.The interview was audio-taped.The recorded data were transcribed verbatim within one day after the interview.The verbatim data were read through in order to get an overall sense of the interview.Next, the data were read line by line in order to identify related statements.During the interviews, notes were made about the situation of the interviews and non verbal signals from participants.These helped the researcher to develop the interview guide over time.
Data collection was carried out by the same interviewer and audio taped.Then the records were transcribed verbatim and analyzed consecutively.
These interview statements were marked, and tentative codes were written in the margin for the detection of emerging patterns.Differences and similarities between codes were compared, and codes that were similar in contents were subsequently grouped and classified into various categories.The codes were repeatedly reviewed to ensure consistency of the coding.

Rigor
Rigor in qualitative designs can be measured in terms of credibility, dependability, transferability, and conformability (Denzin & Lincoln, 1994).In this study, credibility was established through the participants' review of transcripts, and peer check.The participants were contacted after the analysis, and were given a full transcript of their coded interviews, with a summary of the emergent themes to determine whether the codes and themes were true to their point of view, (member check).The researchers also documented precisely, the steps in the research for other researchers to confirm the findings in future studies.The results were checked with some individuals who did not participate in the research to confirm their fitness (peer check) (Denzin & Lincoln, 1994).

Results
Three of the respondents were from Faculty of Medicine and Health Sciences and the other three from Faculty of Education.A total of 25 codes were extracted from transcribed data and four main themes emerged from the data analysis as barriers to using contraceptive methods.

Personal barriers
Women's baseline knowledge of contraceptive methods was assessed at the outset of the interviews.
When the interviewees were asked about their awareness of specific contraceptive methods, most of the respondents were able to spontaneously identify numerous modern contraceptive methods, but one of respondents was not able to differentiate traditional methods, from modern contraceptive methods.
They lack specific knowledge regarding these methods, and how the methods work, particularly IUD.For example respondent Number 1 said: "I know several methods like pills, condom, IUD.About IUD I just know the short name".

Cultural barriers
Fear of side effects created a substantial barrier to continuing the method, and women rely on ineffective contraceptive methods such as herbs and natural methods which can lead to unintended pregnancy.All the interviewees abandoned their contraceptive method because it caused symptoms such as headache, dizziness, nausea, vomiting and weight gain.
"I prefer the herbs.Pill reduces my milk and I feel nausea, headache I don't like pill at all.I tried to use it but all symptoms like vomiting, nausea and body weight increased".(Respondent Number 2) Respondent Number 1 described her friends' experience about using IUD that, it causes irregular bleeding.She said: "Not all people can take the IUD because, like my friends, they got side effect.They had irregular menstruation and got infection".
There were several misconceptions about the consequences of using contraceptive methods such as; fear of infertility, cancer and tumors.In fact, misconceptions surrounding contraception and fertility were reported in all interviewees.The fear came from their own and their peers' experiences.The women perceived that contraceptives interfered with fertility, and they were scared to use something that could harm their ability to reproduce.
"I have heard that some women, who used contraceptives, will be infertile and they can't have a baby forever".
(Respondent Number 4) Most respondents believed that many forms of contraceptive methods are harmful and cause illness.They perceived oral contraceptive pills and IUDs are unacceptable, because they change the body weight and menstrual cycle, and thus would cause diseases.
"Using contraceptives for a long time causes cancer and abdominal tumor".(Respondent Number 4)

Health system barriers
Health providers' attitude regarding family planning plays an important role, either in choosing or continuing contraception.It seemed there were health system barriers for young women who were seeking contraceptives.
Negative attitude of health providers towards the young women's contraceptive use, inhibit them from practicing contraception.
"After 3 years I went to the clinic to the female doctor to take out the IUD.I asked to replace a new one but she said: you shouldn't use contraception again because you are still young you can bear children……..until now I didn't use anything".(Respondent number 5)

Low family planning activities of males
Low involvement of husbands in contraceptive decision making, and using male's contraceptive methods was explored in this study.All respondents mentioned that their husbands disapproved of male's contraceptive methods, and would not like to use condoms."My husband doesn't like to use condom because, he is not satisfied when he uses it".(Respondent Number 6) Friends and peer group also influence the family planning decision making.
Respondent number 2 reflected that her decision making for using traditional herbs was based on her friend's suggestion.Her friends are the first choice for obtaining information regarding contraceptive methods.
She said: "My friend suggested to me herbs for family planning.I bought traditional herb from my friend's mother.She had traditional medicine home business".

Discussion
This study revealed personal barriers and lack of information about modern contraceptive methods.Although all respondents were able to indentify numerous modern methods, they had a vague understanding of contraceptive methods.Cultural attitude influence women to believe they must bear children to prove their ability in reproduction.Findings from this study revealed that women are still limited by cultural norms that equate marriage and motherhood with female status and value.
Another factor that prevented the use of contraceptives was people's concerns for their health and fear of the side effects.Perceived longer-term effects such as cancer or infertility can lead to the discontinuation of use.(Inaoka, et al., 1999).Health providers should be responsive to their patients' culture, and provide factual information that addresses individual beliefs and concerns without judgment.All respondents in this study had negative attitudes toward oral contraceptive pills due to experiences of side effects.When discussing why they would not use oral contraceptives, the most common side effects mentioned were nausea, vomiting, and weight gain.In this study one of respondents used herbs as a contraceptive method.Reliance on ineffective and unreliable methods can lead to unintended pregnancy and unsafe abortion.Health providers should address negative information given to the women about contraceptive methods and provide factual information about risks, potential side effects, and incorporate it into a family planning strategy that meets each client's particular needs.
This study showed that negative views of health providers, in family planning services create barriers for young women to seek, and use contraceptives.Getting negative messages from health providers discourages women from using contraceptives.Every couple who wants family planning needs good quality and effective consultation.Health-care providers who offer these consultations should provide them in accordance with international norms and ethics (Sevil, et al., 2006).Educational and enlightenment programs should focus on providing specific knowledge, with special attention to correcting common misconceptions about the methods.
Health care providers should be encouraged to inform all potential users about the methods, and to prescribe it to clients who require it (Yam, et al., 2007).

Conclusion
This study set out to explore barriers to modern contraceptive practices, among women in a public university in Malaysia.The participants' perceptions indicate personal barriers, and knowledge gaps on contraceptive information.There were also cultural barriers towards modern contraceptive practices.Most of the women had misconceptions, and fears about modern contraceptive use.Strong socio-cultural norms, and health services barriers including negative response of service providers, low males family planning practice influences the use of contraceptives negatively.Improving the counseling service program can help women choose appropriate contraceptive methods, and use them consistently and correctly.There should be strategies to increase male participation in family planning activities.Distributions of reproductive health information to women would help them to realize the potential effect of modern contraceptive methods in preventing unintended pregnancy and unsafe abortion.There is an urgent need to educate women, about effective contraceptive methods with emphasis on availability, benefits, mechanism of action of modern contraceptive methods, side effects and how to manage them.

Limitation of study
The purpose of the study was to explore, married women's perceptions and experiences regarding modern contraceptive methods.The study relied heavily on married staff in a public university as the primary source of data.The data comprises some items such as individuals' experience, beliefs, and understanding regarding contraceptive methods and family planning.It is quite difficult to determine and ascertain the experiences of individuals as many factors come into play and individual perceptions could be biased due to diverse backgrounds.
We cannot conclude all Malaysian women feel the same way about any contraceptive approach discussed in this article.This study was limited to only six respondents, and further in depth study need to be conducted, to examine women's view in other settings as well as health providers' views, and quality of family planning services in order for the health system to be able to provide good contraceptive services to women of reproductive age.