Indian Journal of Public Health

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 65  |  Issue : 2  |  Page : 159--165

Contraceptive behavior and unmet need among the tribal married women aged 15–49 years: A cross-sectional study in a community development block of paschim Bardhaman District, West Bengal


Ananya Mukherjee1, Niladri Banerjee2, Somnath Naskar3, Sima Roy3, Dilip Kumar Das4, Sutapa Mandal5,  
1 Post Graduate Trainee (PGT), Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India
2 Senior Resident, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India
3 Associate Professor, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India
4 Professor and Head, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India
5 Assistant Professor, Department of Community Medicine, Burdwan Medical College, Burdwan, West Bengal, India

Correspondence Address:
Sima Roy
P 50, New Parnashree, Kolkata - 700 060, West Bengal
India

Abstract

Background: Contraceptive behavior and unmet need for family planning, particularly among the tribal women of reproductive age in India, still remains a public health concern. This needs to be explored in different geographical regions. Objectives: This study aimed to ascertain the contraceptive behavior of tribal married women of 15–49 years and to assess the unmet need for family planning and its determinants. Methods: A descriptive, cross-sectional study was conducted during May 2019 to April 2020 in Barabani Block of Paschim Bardhaman District, West Bengal. A calculated sample of 530 study participants was selected from the study area by the simple random sampling. Required data on contraceptive behavior characteristics, unmet need, and correlates were collected by interviewing them with a predesigned schedule. Bivariate analysis and multivariable logistic regression were done. Data were analyzed using the SPSS software v. 20. Results: All study participants were Hindu and belonged to Santhal ethnicity; 53.4% were illiterate; 51.7% had early marriage, and 52.4% had adolescent pregnancy. Only 41.1% women were found currently using any contraceptives, another 14.5% ever used and 44.4% never used any methods. Apprehension of side effects and spouse disapproval were reported as two common reasons for never using contraceptives. The age of the women appeared as a significant predictor of current contraceptive use. Overall, unmet need for family planning was 19.4% and age of the women, socioeconomic status, and type of the family were found as significant predictors. Conclusion: Issues contributing to unsatisfactory contraceptive behavior and high unmet need for family planning need to be addressed appropriately.



How to cite this article:
Mukherjee A, Banerjee N, Naskar S, Roy S, Das DK, Mandal S. Contraceptive behavior and unmet need among the tribal married women aged 15–49 years: A cross-sectional study in a community development block of paschim Bardhaman District, West Bengal.Indian J Public Health 2021;65:159-165


How to cite this URL:
Mukherjee A, Banerjee N, Naskar S, Roy S, Das DK, Mandal S. Contraceptive behavior and unmet need among the tribal married women aged 15–49 years: A cross-sectional study in a community development block of paschim Bardhaman District, West Bengal. Indian J Public Health [serial online] 2021 [cited 2021 Sep 21 ];65:159-165
Available from: https://www.ijph.in/text.asp?2021/65/2/159/318351


Full Text



 Introduction



Reproductive health of the women has emerged as a basic right globally. However, various components of reproductive health such as contraceptive behavior and unmet need of family planning remain unsatisfactory and varies across the world including India[1],[2] This is further influenced by traditional customs, religious beliefs, and social prejudices. In India, the overall contraceptive prevalence rate is 54% among currently married women aged 15–49 years, 48% of them using a modern method.[3] In general, 13% of currently married women have an unmet need for family planning during 2015–2016, almost the same as in 2005–2006 (14%).[3],[4]

However, as evident from various studies across the world[1],[5],[6],[7],[8] as well as in the different regions of our country,[2],[3],[9],[10],[11] there is substantial lacunae in the knowledge toward contraceptive behavior among various population groups in India, particularly among the weak and the socioeconomically deprived section of the society, like the tribal women of India. Due to the lack of knowledge, economical issues, fear of side effects, religious reasons, the tribes have more unmet need for family planning than other population groups.[12] A contraceptive prevalence of 45% was reported among the currently married tribal women of India, which is much lower than the currently married women of general caste (57%).[3] Unmet need was 6.4% among the tribal women during 2005–2006, 19.8% during 2007–2008, and 13% in 2015–2016.[3],[4],[13] In West Bengal,[3] unmet need was found in general as 7.4% during 2015–2016.

The status and determinants of contraceptive behavior and unmet need pertaining to their different dimensions have always been required to be assessed for comprehensive understanding and developing flexible and need based strategies and interventions. Adequate evidence in this regard is lacking in India and particularly among different population groups of West Bengal. Contraceptive behavior and unmet need of family planning, especially among tribal women in different districts of West Bengal remained less explored. In this overall perspective, the present study was conducted at Barabani block of Paschim Bardhaman district to ascertain the contraceptive behavior of tribal married women of 15–49 years and to assess the unmet need of family planning and its determinants.

 Materials and Methods



Study type/design, study area, and subjects

This community-based descriptive, cross-sectional study was conducted during May 2019 to April 2020 in Barabani Block of Paschim Bardhaman District, West Bengal. Out of 8 community development blocks of the district, Barabani block had been selected as the study area for this research work, where 14% of total population belonged to scheduled tribe.[14],[15],[16]

Of 52 census villages in the block, ten villages had more than 90% tribal population (persons belonging to scheduled tribes) and tribal population of these villages constituted the target population.

Tribal married women within the reproductive age group (15–49 years), residing for at least 1 year in the identified ten tribal villages of the Barabani block was considered as the study population. Seriously ill and those who attained menopause were excluded.

Sample size and sampling

The sample size was calculated using the formula, n = ([Z1-α/2]2 P [1 − P])/d2 where contraceptive prevalence (p) among the currently married tribal women (modern methods) was taken as 45%, based on National Family Health Survey-4 (2015–2016),[3] with 95% confidence interval and a relative precision of 10%. With further addition of an anticipated nonresponse of 10%, the final sample size came to be 523.

An equal number of study participants (523/10 = 52.3~53)were selected from each of the 10 tribal villages of the study area. Sampling frame of eligible study subjects was prepared for each of the ten villages with the help of peripheral health workers and required number of subjects (53) was selected by simple random sampling. Thus, finally, a total of 530 study participants were included in the study.

Tools and techniques/data collection

Data were collected at the household level of selected eligible study participants, interviewing them with a predesigned, pretested schedule. Review of available relevant records such as Maternal Child Protection Card, discharge certificates, treatment and other documents, like Voter's card, Adhaar card, as appropriate, were also checked during the data collection. Prior to data collection, purpose and procedure of the study was briefed to the study participants. In addition, permission from the district health authorities was also obtained.

Study variables and operational definitions/descriptions

Background and sociodemographic variables included age, age at marriage, age at first pregnancy, number of children, religion, ethnicity, occupation, literacy status, type of family, family income, number of family members, and socioeconomic status.

Variables related to contraceptive behavior and unmet need included currently using any contraceptive methods-modern and traditional method (if any), ever using and never using any contraceptive methods, types of methods used, source of knowledge about contraceptives, source from where the contraceptives were obtained, decision maker of any method of contraceptives, reason for discontinuation and for never using any contraceptive methods, unplanned pregnancies (if any), unmet need (willing but not using method) and reasons for unmet need, etc. Unmet need for family planning has been defined[17] as the percentage of women of reproductive age, either married or in a union, who wanted to stop or delay child bearing but not using any method of contraception. The unmet need had been calculated by taking numerator as the number of study participants who were not currently using any modern method of contraceptive but were willing to use such to delay or limit the next pregnancy. Those who had unintended pregnancies and were willing to use contraceptive were also considered eligible for unmet need.

Ethical considerations

Ethical approval was obtained from the Institutional Ethics Committee of Burdwan Medical College and Hospital, Purba Bardhaman, West Bengal (No. 83. dated 08.01.2019). Prior to data collection, informed consent/assent (for subjects below 18 years) was obtained from each study subject. Confidentiality and anonymity of information were maintained.

Data management and analysis

Collected data were checked for completeness and consistency and entered in Excel data sheets. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Released 2011. was used for the analysis. The results of categorical variables were expressed in frequency and percentage. Current contraceptive use and presence of unmet need among the study participants were considered as dependent variables. Both bivariate and multivariable logistic regression analysis were done to find the associations. Independent variables which were significantly associated with the outcome variables in the bivariate analysis were considered for the multivariable model. All these models were found to be fit based on Hosmer Lemeshow test. P ≤ 0.05 was considered to be statistically significant for all inferential statistics.

 Results



Out of total of 530 study participants, all were Hindus and belonged to Santal ethnic origin. Majority of the study participants (55.3%) belonged to the age group of 20–29 years, were illiterate (53.4%), homemakers (91.1%), and belonged to lower socioeconomic class (67.6%). More than half (51.7%) were married before 18 years and had their first pregnancy (52.4%) before 19 years of their age.

Contraceptive behavior characteristics

Out of 530 study participants, 218 (41.1%) were found currently using any contraceptives, another 14.5% ever used and 44.4% never used any methods [Table 1].{Table 1}

Intrauterine device (37.2%) and ligation (28%) were the two common methods used by the participants. Decision for adoption of any contraceptive method was taken jointly by wife and husband in majority cases (61.9%), and in 24.3% cases, it was by woman herself [Table 1].

Most commonly cited reason for discontinuing contraceptives by the ever users was experiencing side effects (63.6%) followed by planned pregnancy (28.6%). Apprehension about side effects (28.1%) and spouse disapproval (27.7%) were the two commonly reported reasons for never using contraceptives [Table 1].

Among the various sociodemographic factors, age of the women and the number of living children they had were found to be significantly associated with the current contraceptive use on bivariate analysis. However, on adjusting for all the independent variables by multivariable logistic regression, only age of the participants remained a significant predictor of current contraceptive use. None of the other factors were found to be significant predictors. However, only 8.4% of the variance in dependent variable (current contraceptive use) can be explained by this model [Table 2].{Table 2}

Unmet need for family planning

[Figure 1] shows the flow chart depicting the process of identifying subjects whose felt need for family planning was not met. Thus, overall unmet need among 530 tribal women of reproductive age, i.e., proportion of women willing to use any contraceptive method but not currently using any method was 19.4% (103/530).{Figure 1}

Further enquiry revealed that apprehension about side effects among the women (42.7%) was the most common reason for unmet need. The other reported reasons were unaware about availability (37.9%), nonaccessibility (19.4%), spouse disapproval for any method (16.5%), discourage by other family members (8.7%), and nonavailability of methods (3.9%).

On bivariate analysis, age of the study participants and the type of family were found to be significantly associated with the unmet need for family planning. However, on adjusting for all the independent variables, age of the study participants (20–29 years), socioeconomic status, and type of family of the participants remained significant predictors of unmet need. However, only 8% of the variance in dependent variable (unmet need) can be explained by this model [Table 3].{Table 3}

 Discussion



The present study focused on the contraceptive usage and unmet need for family planning among the tribal married women in a rural area. Existing evidence[3],[18],[19],[20] indicate that tribal women are less likely to use any contraceptive method than the nontribal women. Studies specifically among tribal women in the different parts of India reported varied proportion of contraceptive use. Earlier studies by Sharma and Rani[21] reported that 42% of tribal women in Central India were using any contraceptive method and Prusty in his study[12] reported contraceptive use among the currently married tribal women to be 39.5% in India, 40.2% in Chhattisgarh, 17.2% in Jharkhand, and 48% in Madhya Pradesh. Bharadwaj and Tungdim[20] found 24.6% current contraceptive use among the tribal married women of Rajasthan during 2010; Battala et al.[13] reported the proportion of contraceptive use as 27.7% in rural Maharashtra during 2012. However, Gogoi[22] reported a contraceptive prevalence of 58.3% among the tribal women of Assam in 2016, which is much higher than the contemporary findings in the other parts of the country.[21] According to NFHS 3, the use of any modern contraceptive method among the tribal women was only 39%[4] which increased to 45% during 2015–2016 as reported in NFHS-4.[3]

In West Bengal, an earlier study[12] reported 41% current contraceptive use among the tribal women and a comparatively recent study in 2015 in Purulia district[23] found current contraceptive prevalence of 32.1%.

As compared to all these studies, current contraceptive use was found to be 41.1% by the present study in a block of Paschim Bardhaman district. The present observation was higher than few above-mentioned studies, which might be due to the differences in the study period as well as other methodological issues. Over the years, interventions might have also influenced the adoption of methods. However, the present findings almost corroborate with the national proportion (45%) according to the NFHS–4 reports. In West Bengal, according to NFHS–4, current contraceptive use of modern methods among married tribal women was 57% and 60.7% according to NFHS-5,[3],[24] which is higher than the present study, but no data were available at the district level for comparison.

Among the various sociodemographic characteristics, significant association was noted between the age of women and number of living children with the current contraceptive use. This may be otherwise explained by the fact that the women with more than two children were belonging to the higher age group. However, after adjusting the different independent factors, the subject's age was found to be actually related and a predictor of the contraceptive use among the tribal married women in the studied area.

Age of the women was significant predictors by few other studies in the country.[12],[13],[21] However, in contrary to the present study, few studies[12],[20],[21] also reported significant association with some other factors such as literacy, number of children, and socioeconomic status.

Almost similar to current users (41.1%), in the studied area 44.4% of the tribal women never used any method. In general evidence is lacking regarding never user of contraceptives, but studies among the Dhur Gond tribal community in Chhattisgarh (37.4%)[12] and among the tribal women in Maharashtra (32.2%) reported almost similar proportion of never users.[13]

Various reasons for never using contraceptives as elicited in the present study were apprehension about side effects, spouse disapproval for any method, unaware about availability, forbidden by other family members, etc. Experiencing side effects was also the most common reported cause for discontinuation of methods by the ever-users. The very nature of reasons indicates certain issues still persisting both from providers and beneficiaries sides requiring measures to address the issues.

In the present study, IUD (37.2%) and ligation (28%) were the two preferred methods. However, according to NFHS-4, female sterilization (36.5%) had been the most common contraceptive choice among the currently married tribal women in India.[3] A study in Purulia district of West Bengal also reported female sterilization as the most commonly adopted method.[23]

Decision-making for the adoption of contraceptives has always been an important determinant for success of family planning and the process itself is related to some other aspects, particularly intra-spouse communication, women empowerment, etc. In the present study, decision for adopting contraceptives was taken jointly in a substantial proportion of cases (61.9%); in 24.3% cases by the women her-self; favorably 86.2% of tribal women participated in decision-making. No such comparable data among the tribal women could be retrieved; however, in general, the decision-making power of women was found to vary across states from as low as 40% in Lakshadweep, 52% each in Bihar and Dadra and Nagar Haveli to as high as 89% in Sikkim, and 91% in Nagaland. Somewhat smaller increase in proportions of women in decision-making has been observed from NFHS-3 (62%) to NFHS-4 (75%).[3],[4] Prakash et al. in their study also found that decision-making power of the women belonging to the reproductive period was associated with lower levels of schooling, poor socioeconomic status, and limited exposure to mass media.[9]

Unmet need of family planning is one of the major priority concerns in the present day family welfare programme in India. According to NFHS-3 and NFHS-4 report, 6.4% and 13% had been the unmet need for family planning among the tribal married women in India, respectively.[3],[4] Although the contraceptive use of modern method by the tribal married women increased from NFHS-3 to NFHS – 4, the increase of unmet need highlights that 13% of the couples with unmet need did not receive the contraceptive services they desired. Although there are notable interstate differences from high unmet need in Uttar Pradesh, Bihar, Nagaland, and Meghalaya to lower unmet need in Andhra Pradesh, Punjab, and West Bengal,[3] the tribal population appears to remain vulnerable to high unmet need throughout the country. Few studies among the tribal women in West Bengal showed higher unmet need[13],[25] than the national average of 13% as per NFHS-4. Prusty in 2014, revealed from the DLHS. RCH III: 2007–2008 data that overall unmet need among the married tribal women was 19.8%, while 38% in Jharkhand, 21.3% in Chhattisgarh and 20.1% in MP.[12] According to NFHS-4, the unmet need for family planning was 18.4% in Jharkhand.[3]

In the present study, the unmet need for family planning among the tribal married women was found to be 19.4%. However, the unmet need in general was only 7.5% in West Bengal according to NFHS-4 and 7.0% according to NFHS-5, with 7.8% being the prevalence in rural areas.[3],[24] On the other hand, a study in Purulia[23] reported a much higher level of 50.7%. This wide variation might due to methodological variations in estimation.

Strikingly, 7.8% of the married tribal women belonging to the adolescent age group were found to have unmet need for family planning. On multivariable analysis, the age of the women, socioeconomic status, and type of family they belonged appeared to be significant predictors of unmet need for family planning. Other studies conducted in Purulia district found that women having more than two children were significant predictors of unmet need for family planning.[23]

There had always been some reasons for unmet need. The two common reasons for unmet need as was reported in the present study were apprehension about side effects which were not addressed (42.7%) and unaware about availability (37.9%). A study in a tribal area of Maharashtra also revealed fear of side effects (36.3%) and lack of awareness (24.4%) as the common reasons.[26] However, a study in Purulia district of West Bengal reported lack of awareness followed by fear of side effects as the two common reasons.[23]

Although addressing the unmet need for family planning was one of the major objectives of India's National Population Policy, evidence shows that there has been rise of unmet need for family planning among the married tribal women. The current data reinforce national trends and indicate more emphasis on addressing the apprehension of side effects of contraceptive methods, so as to ensure each girl and woman is able to access the reproductive health services she needs. Since reproductive health and reproductive right are intertwined, trends in contraceptive behavior and the assessed unmet need among the tribal married women not only reveal the gap toward the national target of reducing the unmet need for family planning but also the call for gender equality.

The present study had some limitations too. Response bias and recall bias cannot be ruled out in relation to few variables. However, sincere effort was taken to minimize the error.

 Conclusion



General vulnerability issues including the disadvantaged conditions are still being faced by the tribal women. Early marriage and adolescent pregnancy are persistent concern among tribal women in the area. Acceptance of family planning methods among the tribal women is yet to reach the satisfactory level. Unmet need for family planning is still unexpectedly high among them and age of the women, socioeconomic status, and the type of family appeared to be significant predictors. Public health-care delivery system though seems to be responsive in providing the family planning methods, but more appropriate IEC/BCC activities need to be emphasized.

Financial support and sponsorship

This study was financially supported by Indian Council of Medical Research financial grant for Post Graduate Thesis vide Memo no. 3/2/July-2019/PG-Thesis-HRD (33) dated 30/07/2019.

Conflicts of interest

There are no conflicts of interest.

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