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Indian Journal of Community Medicine

Limiting Factors in Contraceptive Acceptance in Urban Slum With or Without ICDS

Author(s): T. Chattopadhyay, M. Mundle, P. Shrivastava, D. Chattopadhyay, S.P. Mitra

Vol. 29, No. 3 (2004-07 - 2004-09)

Abstract

Objective: To find out the difference in contraceptive acceptance in ICDS and non-ICDS areas with reference to age of wife, religion and caste, wife's educational status, family size and socio-economic status.

Study design: Community-based, cross-sectional, study using pre-designed semi structured proforma.

Setting: North Kolkata-Belgatchia and Dum Dum.

Participants: All eligible couples living in slums in both areas who were fertile and were present at the time of interview.

Sample Size: 398 using CPR of Kolkata (52.5%).

Study variables: Contraceptive acceptance in ICDS and non-ICDS areas.

Statistical analysis: Z test, difference of proportions.

Results: CPR and total contraceptive acceptances are higher in ICDS area than non-ICDS area. Terminal method was more acceptable in ICDS area while OC Pill more in non-ICDS areas. In couples where age of wives is between 30-34 years contraceptive acceptance is significantly more in ICDS area. Contraceptive acceptance among Hindus in ICDS area was more while it is more among the Muslims in non-ICDS area. In couples with illiterate wives contraceptive acceptance is significantly higher in ICDS area. In couple with 4 or more children contraceptive acceptance is significantly higher in ICDS area, but in couples with less than 2 children it is more in non-ICDS area. The contraceptive acceptance in ICDS areas is significantly more in lower middle socio-economic group.

Conclusion: Differences between ICDS and non-ICDS areas may not always reflect direct and consistent 'child welfare scheme'-related benefits so far acceptance of contraception is concerned, except in case of promotion and acceptance of terminal methods.

Introduction

Though family welfare services are better available in urban than rural areas, studies have shown inadequate utilization of such services, especially by slum dwellers1. Studies to identify determinants for family planning acceptance in the general population have shown that religion2, age at marriage, female education6 and economic status are the main limiting factors3,4,5,6. It has been shown that women, who have married whitecollar workers, accept contraception more than others7.

The Integrated Child Development Services (ICDS) Scheme undertaken from 1975 has been remarkably successful in improving immunization coverage and bringing down the Infant Mortality Rate (IMR) and malnutrition8,9. The scheme has offered services for women of reproductive age, including pregnant and nursing mothers, thus leading to better utilization of health care facilities, including family welfare packages.

Vasundhara and Srinivasan showed better family planning acceptance after 5 years of implementation of ICDS scheme as compared to non-ICDS area10. But the comparison was made with available PHC records. No population based study for such comparison was made. Hence the present study attempted a community based comparison between ICDS served and non-ICDS served areas.

Material and Methods

This was a community based, cross-sectional study undertaken in North Kolkata between 1996 and 1997. Taking Couple Protection Rate of Kolkata to be 52.5%, sample size calculated was 362. Allowing for 10% attrition, requisite sample size worked out to be 398. Study area chosen was Belgatchia, since ICDS was in operation there from 1978 as a Central sector project with 100 Anganwadi centres under 4 sectors. By simple random sampling, 3 such centers were chosen. Expected number of eligible couples was 411 to 493. As comparison area, the adjacent township of Dum Dum having 3 municipalities under Calcutta Metropolitan Development Authority (CMDA) was chosen. It had 21 wards out of which 3 were selected by simple random sampling.

All eligible couples of both areas were contacted by house-to-house survey. Couples were rejected unless both partners were present at the time interview or were fertile. Infertility was defined as inability to conceive after 1 year of sexual life without using any contraceptive method. 398 couples in Belgatchia and 402 in Dum Dum were interviewed. Pre-designed and pretested semi structured proforma was used for data collection. For socioeconomic status, modified Kuppuswamy scale was used. Husband's literacy was matched between ICDS and non-ICDS areas by frequency. Number of husbands in each stratum in each area was same as in the other area.

Results

The distribution of various contraceptive methods among acceptors in ICDS and non ICDS areas is shown in Table-I. The age wise prevalence of contraceptive usage in ICDS and non ICDS areas in shown in table II. In all major religious and caste groups, the differences in contraceptive acceptance in ICDS and non-ICDS areas were statistically significant. A notable feature of this difference is that for Muslims, contraceptive acceptance was higher in non-ICDS areas than in ICDS areas and this difference is statistically significant (x2 = 4.11, P<0.05) This may have been due to the small number of Muslim couples in the study sample. The same is true for 'Others' group, where sample size being small, no statistical parametric test is appropriate.

Table I : Distribution Of Contraceptive Methods Used By Acceptors In ICDS And Non-ICDS Areas

Contraceptive
Methods
ICDS Areas (N=398) Non-ICDS Areas (N=402)
a. Terminal * 140 (35.2%) 44 (16.4%)
b. Oral Contraceptives * 29 (7.3%) 61 (15.2%)
c. Intrauterine Devices 12 (3.0%) 19 (4.7%)
d. Condoms 9 (2.3%) 16 (4.0%)
e. Safe Period 30 (7.5%) 31 (7.7%)
f. Withdrawal 18 (4.5%) 11 (2.7%)
g. Total Contraceptive * Acceptors 238 (59.8%) 204 (50.7%)
h. Total of a,b,c & d * (Couple Protection rate) 190 (47.7) 162 (40.3)
* p value < 0.05

Among illiterate couples, the difference in contraceptive acceptance in ICDS (63.0%) to that in non-ICDS (40.8%) area was statistically significant (Z=3.95, P<0.05). In other levels of literacy, the difference were not statistically significant. The highest % of acceptance in both areas was the group having primary level of literacy (67.9% and 62.0% respectively). The lowest acceptance was among higher secondary and above in ICDS area and illiterate among non-ICDS area.

The pattern of contraceptive usage in relation to family size is shown in table III. The difference in contraceptive acceptance among lower socioeconomic status group in ICDS (76.2%) and non-ICDS areas (55.6%) was statistically significant (Z=3.58, P<0.05). In other levels of socioeconomic status, the differences in contraceptive acceptance were statistically not significant.

Discussion

Contraceptive acceptance and Couple Protection Rates were significantly higher in ICDS than in non-ICDS areas. Moreover, terminal method acceptance was also significantly higher in ICDS areas while oral contraceptive pill use was significantly more in non-ICDS areas. Hazari et al found only 2.9% acceptance of spacing methods in a slum of Central Mumbai in 1992. There were 39.9% permanent method acceptors but most of them had three living children already1.

Increasing age of wife as a favorable factor, though may be influenced by other confounders like family size, is evident as contraceptive use increased with age in both areas. But there is no significant difference between ICDS and non-ICDS areas except in the age group of 30-34, likely to be due to increased acceptance of terminal methods in ICDS areas. The highest acceptance of contraceptives was in the age group of 25-29 years. Audinarayana (1986) showed that 4.37 children were born if marriage was before 13 years of age and it became 3.35 if age at marriage was raised to 18 years3.

Table II : Distribution Of Eligible Couples According To The Age Of The Wives In ICDS And Non-ICDS Areas

Age of Wives (years) No. of Couples No. of Acceptors (%) No. of Couples No of Acceptors (%)
15-19 33 9 (27.3) 39 16 (41.0)
20-24 115 48 (41.7) 126 48 (38.1)
25-29 124 74 (59.7) 136 73 (53.7)
30-34 78 67 (85.9) 60 39 (65.0)
>35 48 40 (83.3) 41 28 (68.3)
Total 398 238   402 204  
* p value < 0.05

Table III : Distribution Of Eligible Couples According To Their Family Size In ICDS And Non-ICDS Areas

ICDS Areas Non- ICDS Areas
Family Size No. of couples No. of acceptors (%) No. of couples No. of acceptors (%)
<1* 121 34 (28.1) 139 68 (48.9)
2 110 72 (65.5) 127 73 (57.5)
3 94 67 (71.3) 62 40 (64.5)
4 * 45 40 (88.9) 35 17 (48.6)
>5* 28 25 (89.3) 39 6 (15.4)
Total * 398 238 (59.8) 402 204 (50.7)

Among Hindus, scheduled castes and scheduled tribes the contraceptive acceptance is significantly more in ICDS areas than that in non-ICDS areas. But amongst Muslims, the situation is just the opposite, the reason for which is not at all clear. Biswas (1989) showed that 49.1% of Hindus, 28% of scheduled caste and scheduled tribe and 19% of Muslims accepted any form of contraception2.

Literacy as an important determinant in family planning acceptance has been shown in many studies but here the findings are mixed. In non-ICDS areas there is almost a steady increase in percentage of acceptance with literacy level but in ICDS areas this is true only upto the primary school level. This may have been due to other confounders like family pressure and absence of sufficient privacy to use contraceptives. The contraceptive acceptance in ICDS areas was significantly higher than that in non-ICDS area amongst couples with illiterate wives. Bhende showed that literate women had higher age at marriage. Mean age at marriage ranged from 13-14 years in Maharashtra11.

Couples with less than two children accepted contraception more in non- ICDS areas. But the reason for this is not very clear. In other groups contraception was more in ICDS area than in non-ICDS area though, only in couples with four or more children the difference is statistically significant, possibly due to more acceptance of terminal methods in ICDS area. Vasundhara in 1983 showed that in Mysore, taluks covered by ICDS project for 5 years showed much improvement in contraceptive acceptance. The difference in contraceptive practice between ICDS and non-ICDS areas was also statistically significant. So much so that she considered ICDS to be a model for health care delivery including family planning services9.

As regards socioeconomic status the contraceptive acceptance more or less increases with increase in socioeconomic status and the difference between two areas is only significant in the lower middle SE status group. Rodriguez showed in 1992 that women living in cities in developing countries were the first to reduce their fertility if they completed at least primary education and were married to white-collar workers7.

References

  1. Hazari K, Contraceptive acceptance and immunization status in an urban slum, Report of 10th Annual Conference on Health Care for the villages and urban slums, Indian Society of Health Administration, January 1990.
  2. Biswas B, A comparative study of fertility pattern among two religions in a rural area in West Bengal, MD Dissertation, Calcutta University, 1989.
  3. Audinarayana N, The influence of age of marriage on fertility and family planning behaviour-a cross-cultural study. The Journal of Family Welfare, Sept. 1986; 33(1) : 56.
  4. Agarwala SN, India's population problems, 1965, 3rd edition : 215.
  5. Poddar AK, Barman UN, Impact of the age at marriage on fertility and family planning in rural area, IJPH, July-Sept. 1987; 31(3) : 170.
  6. Bulley M, Traditional practices affecting the health of women and children in Africa, World Medical Journal, Nov.-Dec. 1992; 38(6): 211-214.
  7. Rodriguez G, Ricardo A, Report on Demographic Health Survey and World Family Planning Survey, World Medical Journal, Nov.-Dec. 1993; 39(6) : 76.
  8. Bhende A, Mukherjee A, Summary of the findings of the evaluation study of ICDS and Family Welfare Programmes in Jamshedpur, IIPS, Newsletter 1986; 27(1):11.
  9. Vasundhara MK, Srinivasan BS, Impact of ICDS on fertility regulation. The Journal of Family Welfare, Sept. 1983; 30(4):3-6.
  10. Mahajan BK, Gupta MC, Textbook of Preventive and Social Medicine, Jaypee Brothers Medical Publishers, 2nd edition: 1995:134-5.
  11. Bhende AA, Thyagarajan BP, Kokatary S. Baseline survey on fertility mortality and related factors in Maharashtra, IIPS Newsletter: 1986 April, 27(2) : 18-23.

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