Awareness , Prevalence and Determinants of Birth Control Methods Use among Women in Saudi Arabia

Results: Of the 287 survey participants, 40 (13.9%) women were not used contraception. Among the 247 women who used contraception, the most frequently used current methods were oral contraceptive (49.1%) condom (17.1%) and intrauterine device (16%). There was a significant increase in contraceptive used among working women, 30 years and older, with high level of education, and those having a large number of children.


Introduction
The use of contraceptive methods has become an essential factor in the life of the most reproductive age group of women, although it varies at different points of their life course.In order to promote women's reproductive health and prevent the risk of unwanted pregnancies, the use of effective contraceptive methods is paramount important.[1] Every year, approximately 350,000 women die while pregnant or giving birth.Of these women, 99% die in developing countries.An estimated 8 million more women suffer serious illnesses and lifelong disability as a result of complication during childbirth.[1] There is a paucity of data regarding contraceptive use in Saudi Arabia, and data from studies conducted abroad cannot reflect the tendencies in the Saudi population.Some women do not use oral contraceptive pills (OCPs) because of their incorrect perceptions regarding their utilization.[2] Secondly, the medications that are used for emergency contraception are available through Gynecologist prescription in Saudi Arabia.[3] In Saudi Arabia, OCPs are available over-the-counter without prescription, and a pharmacist's advice might sometimes be a user's only source of information.[4,5] Self-medication may result in inappropriate use of pills and consequently poor efficacy.However, women tend to start contraception on their own because of high fertility rates, less accessibility to health care for women, and large families.In one report, [6] it was found that 28.7% of Saudi women used an OCP for contraception.Most of the women lacked knowledge about OCPs and had a negative attitude toward their use.Although over three quarters of the women had some knowledge about what to do if they missed a pill, less than 10% knew exactly what to do.Thus, in Saudi Arabia there are gaps in the knowledge and practices of women using OCPs for birth control.If large gaps in knowledge about OCP use are identified among users, recommendations can be made for health care providers to provide contraceptive counseling to all women.
Studies conducted in Saudi Arabia showed low levels of use of contraceptives with only (27%) of women in Abha and (44%) of women in Qassim region.The national data of the Kingdom shows (31.8%) contraceptive use rate in 1996.This percentage has fallen down in 2007 to be (23.8%).[7] In contrast, a study that was conducted in Al-Khobar showed high use of contraceptives among the Saudi Arabian females with (74.8%).[8] It is well documented that effective family planning programs can minimize unintended pregnancies, reduce maternal mortality, and improve child survival.[9] Research may be used to explore patients' knowledge, attitudes and information requirements; one method of doing this is through the use of focus groups [10].Results can be utilized to provide patients with the quality evidence they require in a format that they find acceptable.The provision of information to patients enhances patient choice.[11] Among women who use reversible contraception, most choose less-effective methods such as condoms (26%) and oral contraceptive pills (45%) [11].Recently published data from the National Survey of Family Growth show an increase in the use of long-acting reversible contraceptives (LARC) that include intrauterine devices (IUDs) and implants.[12,13] LARC are not only the most effective methods, but also appear to provide the highest satisfaction and rate of continuation among users.[14] Contraceptive choice is in part dependent on the effectiveness of the contraceptive method in preventing unplanned pregnancy, which, in turn, is dependent for some methods not only on the protection afforded by the method itself, but also on how consistently and correctly it is used.Both consistent and correct use can vary greatly with such characteristics as age, income, users' desire to prevent or delay pregnancy, and culture.Methods that depend on consistent and correct use by clients have a wide range of effectiveness.Most men and women tend to be more effective users as they become more experienced with a method.However, programmatic aspects also have a profound effect on how effectively the method will be used.[15] This study in Qassim region would help to understand the scenario of contraception use.

Aim of the work
The aim of this study was to characterize Saudi women's current contraceptive choices and adherence to contraceptive regimens and to determine the knowledge, attitude and practice of contraception and the associated socio-demographic factors among a representative sample of Saudi married women in Al Qassim region, KSA.

Study design
A national cross-sectional survey was conducted on Saudi married women aged 18-49 years old who had not reached menopause in March-April 2015.A standardized, confidential, Internet questionnaire was administered to female members.

Questionnaire
The questionnaire was designed in English and later translated to Arabic by a professional translator and reviewed for consistency by the investigators.The questionnaire includes socio-demographic characteristics of the participants followed by items related to socio-economic status, pregnancy history, knowledge of contraception, attitude towards contraception and current use of contraception.Also, the questionnaire includes some items to determine the causes for use and reasons for avoiding contraception.
The questionnaire was pre-tested for validity and reliability.It was tested to check if it was easy for the interviewers to understand the instructions and flow of questions.Prior to pre-testing in the field, the interviewers were undergoing training and were provided with instructions about the survey.

Data analysis
The Student t-test was used to ascertain the significance of differences between mean values of two continuous variables.Chi squared analysis was performed to test for differences in proportions of categorical variables between 2 or more groups.P < 0.05 considered as the cutoff value for statistical significance.Logistic regression analyses to determine the impact of the main sociodemographic and lifestyle factors of birth control methods.The SPSS Version 22.0 (SPSS Inc., Chicago, IL) and EpiInfo TM Version 7 (Centers for Disease Control and Prevention, Atlanta, GA, USA) were used for statistical analyses.

Results
A total of 300 Saudi women were approached and 287 consented to participate in this study, giving a response rate of 95.7%.Of these, 13 women were excluded, either due to incomplete questionnaires or they excused themselves before completing the questionnaire due to lack of time.

Sociodemographic and lifestyle characteristics
The sociodemographicand lifestyle characteristics of the 287 participants in the survey are shown in Table 1.Of these participants, 3.83%were under 20 years old, 36.24% were aged between20to 29, 38.68%were aged between 30 to 39 and21.25%aged 40 or over.More than 95℅ of the participants lived in urban areas.Education was also associated with attitude to contraception, (76.31%) had some college or university education and (11.15%) had completed a degree.Only 41.11% of the participants were unemployed.Nearly 87% of the participants were married and living with husband.Only 1.05℅ of the participants were smoking cigarettes.Over (65%) have more than three children.Thirteen percent of qualified participants had experienced an unintended pregnancy (data not shown).
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Knowledge about the birth control methods
Table 2 shows that about 20% of participants did not read about birth control methods before using them and 18% of participants did not have any idea about birth control methods side effects.Most of the participants read about oral contraceptive (pills) before using it (39.01%),followed by women who use intrauterine devices (13.6%), then participants who use condoms (13.2%) and transdermal patch (3.8%).Most of the participants have an idea about oral contraceptive effects before using it (38.6%),then participants who use condoms (15.1%), followed by women who use intrauterine devices (13.6%), and transdermal patch (0.7%).

Attitudes towards fertility and contraceptives
Table 5 shows the attitudes of the participants towards fertility as indicated by the number of children.Most of the participants preferred to have three children or more (65.9%),and (19.9%) preferred to have two children.Only, 10.1% of women desired to have one child, and 4.2% of women desired no children.Non use of contraceptives was explained by several reasons: The first reason, women try to be pregnant (36.93℅), during lactation period (24.74℅).Some women did not use con-traceptive methods without any reasons (22.65℅) or because using of contraceptive method make them feel bad (18.47℅).
However, few women who did not use contraceptives because they considered it to be against their religious beliefs (8.36℅) (figure 1).

Usage of contraceptive methods, sociodemographic and lifestyle characteristics
Table 7 shows that women used birth control methods and belonging to age groups 20-29 and 30-39 were significantly more (28.6 and 34.8%, respectively) compared to the younger and older age groups (2.8 and 19.9%, respectively).Women lived in urban areas (82.2%) are much used birth control methods than those lived in rural areas.Birth control methods use by women living with the husband was significantly more (78%) compared to the married separated women (8%) (OR=0.51;P < 0.000).Utilization of contraception also increased significantly with the increasing level of education (complete college, 64.8%).Women who complete college used birth control methods more than the other levels of education.On comparing the women who were at work and those who were not working, the working  women showed significantly more use of birth control methods compared to non-working women.On comparing the women who not smoking and those who were smoking, the not smoking women showed significantly more use of contraceptives (85.7%) compared to smoking women (0.3%) (OR=0.08;P <0.008).Women with higher parity (3 and more) were using birth control methods more than twice as much as those with 1-2 children.Table 7 showed the results of multivariate logistic regression analyses of all studied socioeconomic variables.It showed that there no variable was significantly associated with the birth control method.

Side effects of contraceptive methods
Of the participants, 247 were used contraceptive methods reportedone or more side effects of the method.The most common complications identified by women were headache (27.12℅), emotional change (27.12℅), depression (16.5℅), and nausea (11.33℅) regardless the method of contraceptive use (Table 8).

Time interval between stopping the common birth control methods and getting pregnant again
On analyzing data which present in table 9, according to type of contraception, it was found that the longest mean time was for oral contraceptive (8.3 months) followed by IUD (5.4 months) and the least for condom (1.5 months).

Discussion
Contraception is an important aspect of reproductive health care for women and health care providers.Contraceptive choices are important in that they not only provide birth control but may also affect the sexual desire and function, have different side-effect profiles, and provide non-contraceptive benefits [16].The use of contraception can have an impact on better child spacing, better child care, improvement of children's health, and is regarded as an important preventive measure against maternal and child morbidity.[17] There was a strong association between the participant's age and the use of contraceptive methods.This could be satisfied with the number of children she has had and feels that she needs more spacing for preserving her health.
The present study illustrated that use of contraceptive methods, increasing with increasing age.In agreement with our results Farheen [7] found that the use of contraceptives increases with the increasing age of the mother.Maximum use is found in females between 30-39 years age group, which is 46.39% of the total users.In a study conducted among Jordanian women in 2001 revealed that the percentage of use was increasing with increasing age in women aged less than 40 years.[15]    Good knowledge of contraceptive methods among Saudi women was shown in the present study, since 86.06% of women used contraceptive methods.Al-Sheeha [2] showed that 27.1% of women in Al-Qassim Region, Saudi Arabia had excellent and good knowledge regarding contraception.Also a study in India mentioned that 11.2% of the study-population was aware of contraception.[18] Other studies in Pakistan and in rural southern Nigeria revealed a higher value of awareness of contraception (81% and 92.2%, respectively).[19] There are wide variations in the reported use of contraceptives in Saudi Arabia.Alsheeha [2] conducted a research in 2010 in the Qassim region revealed that (44.8%) were using or had used a contraceptive method.In another study in Abha, those who used contraceptives represented approximately (23.8%) of women.[7] This study showed that the preferable type of contraception was oral contraceptive (49.1%), then condom (17.1%), and intrauterine device (16%).A study in Saudi Arabia, which showed that (78.3%) of women preferred pills and (20.2%) used an intrauterine device.[20] A study in Abha in 2013 showed that 62.9% of women used pills and 37.1% used Intra Uterine Device (IUD).[7] Another study in Canada in 2009 showed that (54.3%) of women preferred condom and (43.7%) used pills [16].In developing countries, four modern contraceptive methods, oral contraceptives, IUDs, injectables, and female sterilization are the most widely used methods among married women.[21] However, the recent United Nation's report (2007) about contraceptive use worldwide showed more use of condoms among the Saudi population and to be the second most common used method after pills, which matches the trend of developed countries.[22] Use of different types of contraception increase among working women, 30 years and older, with a higher level of education, and those having large number of children which is in agreement with the study reported in Saudi Arabia.[2] The study in Abha, showed that women who preferred IUD were mostly working women.As for women with obstetric/medical history preferred pills.The study concluded that different methods of contraception and their benefits for both mother and children must be emphasized.[7] As regards the use of contraceptive methods, illiterate women were the least likely to practice any contraceptive method and women with university or college education constituted the majority of the sample that were currently using any contraceptive method.The same finding is similar to that done among Qatari women.[23] The present study also showed that (20.9%) had positive attitudes compared to (13.9%) had a negative attitude toward contraception.In general, negative attitudes still prevail across countries and positive attitudes are prevalent in Europe.[24] More than half of participants in this study preferred to three children or more (65.85%).Alsheeha [2] found that the majority of women preferred to have at least 5 and up to 10 children, which means that the women would not stop having children throughout her reproductive life.In Nigeria, there was a desire for large families resulting from positive values attached to family life, marriage and procreation.The desire for a large family was deeply rooted in the fundamental belief that children are a gift from God. [25] Arab women tended to avoid the use of contraception unless they had decided they had had a sufficient number of children, particularly at a certain age, and to let God decide on the ideal number of children.In addition, men play a significant role in determining childbearing.[26] Good knowledge of contraceptive methods among Saudi women was (79.4%) compared to (20.5%) with poor knowledge in this study.This is inconsistent with the result reported by Al-Sheeha [2] in 2010 that 27.1% of women in Al-Qassim Region, Saudi Arabia had excellent and good knowledge regarding contraception.Also a study in India mentioned that 11.2% of the study-population was aware of contraception.[18] In the present study age, marital status, and smoking were a significant factor associated with attitude toward contraception methods.However, Alsheeha [2] study mentioned that higher education, better knowledge, and those working are a significant factor associated with attitude toward contraception.
This study showed that the most common complications identified by women were headache (37.63℅), emotional change (37.63℅).A survey of United Kingdom healthcare professionals found that 87% believed that the contraceptive pills cause mood changes [27].

Conclusion
The results of the present study demonstrated reasonable knowledge and attitude of Saudi women regarding birth control methods.Socio-demographic status and lifestyle are significantly associated with knowledge of contraceptive methods, and attitude toward both contraception and OCP for child spacing.Future public health initiatives in Saudi Arabia should focus on raising awareness of all options for contraception, promoting dual protection, increasing access to a variety of contraceptive methods, and assisting Saudi women in maximizing their contraceptive adherence.

Figure 3 :
Figure 3: Side effects of intrauterine device.

Figure 4 :
Figure 4: Side effects of contraceptive patches.

Table 6
demonstrates attitude of the studied sample towards contraception.About one fifth (20.9%) of them had a positive attitude.

Table 6 .
Attitude of studied sample towards contraception.

Table 7 .
Distribution of female victims of rape as a category of gestational age and sociodemographic characteristics, São Paulo, 1994-2013.

Table 9 .
Time interval between stopping the Common Birth control methods and getting pregnant again