Family Planning Use Among Women Attending a Health Care Facility in Rural Ghana

Demand for and the use of family planning is fundamental in ensuring access to sexual and reproductive health care. Family planning in Ghana remains a delicate issue that is reluctantly accepted. This study was carried out to assess the use of family planning among women attending a health facility in Ghana. A descriptivecross-sectional study design was used involving 344 respondents, randomly selected for the study. A questionnairewas used in data collection and was analyzed using SPSS version 21.0. Majority of the respondents were between the ages of 25-35. Again, the majority was married; again, the majority was non-salaried workers. The majority had good knowledge of family planning, and many had used family planning services for up to 2 years. Almost 50% believed that the ideal time to use family planning services after childbirth is 1-3 months. Many claimed family planning worked effectively for them. Again, the majority received husbands support and approval for family planning services. Barriers to family planning were affordability, religion, and health worker attitude. The study concludes that family planning usage in the study area could be improved. The study recommends awareness creation on the relevance of family planning among women within the study community.


Background
Demand for and the use of family planning is fundamental in ensuring access to sexual and reproductive health care services [1]. Minimizing the increasing incidence of unwanted pregnancies and promoting child spacing hinges on the timely utilization of family planning service [2]. The United Nation Sustainable Development Goals' targets 3.7 and 5.6, stipulates that by the year 2030, access to reproductive health services should be universal [1]. The role family planning plays in decision making with regard to population growth and development has drawn the attention of the global community to its utilization [3]. Family planning essentially is meant to enable couples or individuals to attain the desired number of children, how and when they need them through the use of contraceptive methods [4][5][6]. In Ghana, however, family planning has remained a delicate issue that is still reluctantly accepted on account of religious beliefs and the misconception that family planning is synonymous with population control [7]. It must be emphasized that timely utilization of family planning intervention can contribute to healthy timing and spacing of pregnancy. Again, it plays an important role in decreasing maternal mortality [8]. The realization of the important role of family planning methods and the speed with which this knowledge was put to practice worldwide is perhaps the most remarkable achievements [9]. This notwithstanding, people in lower income economies are still battling with the rapid and uncontrolled increase in population [10]. Research shows that most unintended pregnancies result because many people in the population do not still appraciate the role of family planning in the prevention of these unwanted pregnancies [11][12].
Traditionally, women were the focus of family planning regardless of the important role played by male partners [2]. In the lower income economies, male's general knowledge and attitudes concerning the ideal family size, gender preference of children, ideal child spacing and contraceptive use greatly influence women's preferences and opinions on family planning [13][14][15]. Male partners in these economies are the primary decision-makers regarding family size and the type of family planning method to use if any [16][17]. This area of research has not been given the needed attention within the Upper East region of Ghana. The existing knowledge is information within mass media outlets and is health facility based. The total fertility rate is 4.8 births per woman and is considerably higher in the rural than the urban areas and its country-specific within the sub-Saharan region [18]. The limited use of family planning services among married women in lower income economies is attributed to inadequate knowledge, socio-economic problem, fear of side effects; religious, insufficient family planning information and services, uncooperative husbands and limited supply of family planning services and high cost of services sometimes affect the utilization [19][20]. The main objective of the study was to assess the knowledge and practice of women aged15-49yearsattending the Bawku Presbyterian Hospital on family planning.

Methods and Design
Thestudy was a facility based descriptive cross-sectional design. The study was conducted between June and October 2017. The study examined the experiences of a cross-section of women attending the Bawku Presbyterian Hospital in the Upper East Region of Ghana. The study design was deemed appropriate for this study because of its potential to allow for a section of the population to be selected [21]. The study population was all women in their fertile age in the study area who attended the Bawku Presbyterian Hospital.

Sampling
A total of 344 respondents were sampled. The sample size was calculated using the formula, n= z 2 pq/d 2 . A simple random sampling technique was employed to select respondents. At the site, a number of women were asked to pick pieces of papers from a container after they had consented to take part in the study. These pieces of papers contained "Yes" or "No." All those who picked 'Yes' were used as respondents. This exercise was undertaken at the time the women were waiting to be attended to by health care providers.

Data Collection and Analysis
A structured questionnaire with both closed and openended questions was used in the data collection. An interview-administered questionnaire was used to elicit the desired information from the respondents. Due to the number of respondents involved in the study, two research assistants were engaged and given the requisite training to read and administer the questionnaire to the respondents especially those who could not read or write. The completed questionnaires were crossed checked for completeness and accuracy. The data was entered on to statistical software (SPSS, version 22.0) and then analyzed.

Ethical Considerations
The head of the institution where the study took place granted the researchers permission to conduct the study. Written consent was obtained from each participating woman after the purpose of study was explained to them. All the respondents were assured of anonymity and confidentiality. They were also assured of harm free and infliction free interaction. The final opportunity was given to them to decide to participate or not to participate.

Demographic Characteristics of Respondents
Age is an important factor in maternal health. Results from the study showed that 55.9% of the respondents were between ages 25 to 34 years; 36.3% were between ages 15 to 25 years, and 7.6% were between ages 35 to 45 years (Table 1). Again, the mean age of the respondents was 22.2 (SD 2.9). Regardings their marital status, 78.2% were married whilst 18.9% were single.About2.9% of the respondents were divorcees. The average age of marriage among the respondents was 21.1 years and the average age of first pregnancy was 22.81 years. On educational qualification, 18% had at least Senior High School education, 34.9% had at least tertiary education, 21.8% had at least Junior High School education and 13.4% had no formal educational training. Again on religious affiliation, 61.3% were Muslims whilst 36% and 2.7% were Christians and indigenous religious believers respectively. Again, 58.7% of the respondents worked in the informal sector while 41.3% were employed in the formal sector. The educational level of respondents' husbands was also assessed. About 31.1% had secondary education whilst 25.6% had no formal education. With regard to the number of children they had, 55% had 1-4 children; 25% had 1-2 children; 10% were evenly distributed at having 4 or more children and primigravida.

Knowledge on Family Planning Services
Results from the study showed that93% had ever heard about family planning before at the time of the study. Interestingly, 7% had never heard of family planning at the time of the study. Among those who have heard of family planning, their sources of information included; schools, media, health centres, markets, relatives and friends ( Figure  1). Asregards their understanding of the meaning of family planning, 83% explained family planning is used to control pregnancy whereas 14% indicated family planning is used for spacing birth. Again, 3% were of the opinion that family planning is for preventing sexually transmitted infections (STIs) and pregnancy. Again, 32%of the respondents had used family planning before at the time of the study whilst 68% indicated they had never used family planning services.
Source: Field data, 2017  From the study, it was revealed that 44.3% of the respondents who had used contraceptives before at the time of the study had used it between 1-2 years; 40% used it for less than a year (Table 2). Again, 26.5% of the respondents said contraceptives could be used immediately after birth whilst 23.8% respondents said contraceptives could be used 4-5 months after birth.

Effectiveness of Family Planning Services
The results showed that 47% of those who had used family planning service before indicated that it was effective. Again, 13% said it was moderate ( Figure 2). Again, 46.8% said they ever heard of emergency contraceptives whereas 53.2% never heard about emergency contraceptives. Among those who had ever heard of it, they said it as any contraceptive taken immediately after having unprotected sexual intercourse to prevent pregnancy.  From the results, 93% of the respondents indicated the existence of various types of family planning methods to choose from whilst 7% said they had no idea. The family planning methods mentioned include; Pills, Intrauterine device (IUCD), Injectable (depo-provera), Norplant (buried under the skin), Condom, Spermicidal, Tubal ligation/female, Sterilization, Vasectomy/male sterilization and periodic abstinence/calendar (Table 3). From the results, 34.6% ever used pills before whilst 65.4% said they never used it. Again, 1.2% ever used spermicidal before whilst 98.8% responded to the contrary. Additionally, 29.1% claimed they had used injectable before. Again, 56.4% said they were aware of the calendar method, 39.8% said they were aware of the withdrawal method whilst 22.7% said they were aware of lactational amenorrhea.

Barriers to the Use of Family Planning Services
Results from the study showed that 39% of the respondents considered socio-cultural factors as a hindrance to family planning services utilization ( Table 4). The results further showed that 74.4% considered the affordability of family planning services as a barrier to its uptake. Again, 89.5% did not consider interpersonal relations of significant others' influence them in accessing family planning services. Additionally, 89.5% considered the competence of service providers as a major barrier to family planning services utilization. From the study, 50.6% said religion was a barrier to family planning practice. Despite the divergent religious views of respondents particularly with respect to Islam and Christianity, there was still a misconception that family planning adoption among believers of both sects is a violation of their own religious beliefs and practices. The research findings revealed that the majority of the Muslim and Christian sects mentioned emphatically that their practices abhor family planning in any form and therefore do not see any reason for either supporting or practising it.

Male Involvement in Family Planning Services Among Women Aged (15-49) Years
From the analyses, 65.7% said their husbands approved family planning services for them whilst 34.3% said their husbands don't approve family planning services ( Figure 3). Again, 27% said their husbands were not supportive towards family planning, 56% respondents said their husbands were supportive towards family planning whilst 17% respondents said their husbands were partially supportive of family planning. Some of the respondents indicated that some of them used family planning methods secretly without the knowledge of their spouses.

Discussion
Knowledge of family planning services is an important factor for an individual to consider in the use or disuse of family planning methods. In this regard, the level of knowledge has the paramount importance for policymakers and programs. It is therefore a sign of hope with 93% of respondents ever hearing of family planning before [22][23][24][25]. This is however contrary to other studies where knowledge of women about family planning was very low [26].These differences could be attributed to education. As regards the source of knowledge on family planning, the majority of the respondents identified friends, health centres, and the media among others as their main sources of information [27][28].
This may be a sign of progress with regard to information dissemination concerning family planning. It also emerged that 47% of the respondents who had ever used family planning services before indicated that it is very effective [6]. In other studies, however, results points to the contrary and respondents had to terminate usage of planning because it was not effective [29]. This difference could be attributed to the methods used, the timing of the usage and the approach.
Knowledge about the various types of family planning methods available to respondents was good, except that usage of the available methods was not encouraging. About 34.6% had ever used the pills before [30]. The study also found that 98.8% had never used spermicidal before [4]. This is however at variance with other findings where many women reportedly used spermicidal before [29]. Natural methods of family planning among respondents were also assessed and results indicated that 39.8% had ever used the withdrawal method as a natural family planning method [5]. This is however not consistent with a study where women indicated their husbands did not like withdrawal method [31]. It is said that some men are knowledgeable about family planning. This assertion is based on the high knowledge of men on vasectomy, injectables, pills, and IUDs as effective birth control methods [31]. The study, however, blamed men's low approval of family planning method in the matrimonial homes. Neoclassical theory suggests that an investment in human capital increases and as more women participate in the labour market, the fertility behaviour of households is bound to change, in favour of fewer children [32]. From the finding, 56.4% of respondents had ever used the calendar method as a natural family planning method [9]. It is, however, inconsistent with findings where women did not know of the calendar method as a natural family planning method [4].
The findings again showed that 65.7%of respondent's husbands approved family planning services for them [33]. In other instance where women are not being supported, some women have fled for their lives, chased away by hostile men for using family planning. Women always wanted to use a family planning method which their husbands would not so easily notice. Such methods include injectables so that their husbands would not detect. Many women reportedly achieve this by hiding behind taking their babies for a check-up at the health facility, and then use that opportunity to get the injection. Community health workers who seek to provide family planning education and distribute contraceptives have faced hostility from men who accuse them of ruining families [34][35].
The results further revealed that 54.6% of the respondent's husbands decided everything including the number of children they should have [36]. Although both men and women have responsibilities and interest in reproductive health and family planning, demographic studies on fertility and family planning have overwhelmingly focused on women. From the results, 33.7% of the respondents had never discussed with their husbands concerning family planning methods before [37]. This may be due to the fear of been met with the hostileresponse since many husbands do not want to hear anything about family planning [38]. Women considerably have a lower social status and autonomy and this seems to be associated with their lower control over fertility.
In lower income economies, the number of people wishing to use family planning supplies and services but do not have access to modern family planning information and services still remain high [39]. Research suggests that most husbands were the only persons who could determine whether a woman should go to do family planning or not whilst a relatively smaller number said it was the decision of both the man and the woman to agree before the woman could practice family planning [22]. Lack of reproductive health services is one of the reasons for unmet needs and therefore the prevalence of unmet needs gives a clear picture of the family planning program in place.

Conclusion
The study revealed a good knowledge of respondents with regard to family planning services. The study also showed that men are supportive and also approves family planning for their wives. To sustain the use of the family planning among women, issues of affordability, religious related issues and attitude of healthcare staff may have to be addressed. The decision to use or not is primarily influenced by others from within the social network, whose views and perceptions are often more important than an individual's own. Therefore, family planning campaigns should look beyond the individual woman to include other significant social networks in order to drive demand and remove barriers affecting the uptake of family planning among women.

Conflict of Interest
All the authors do not have any possible conflict of interest.