Knowledge, attitudes and practice survey of family planning among South Asian immigrant women in Oslo, Norway



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Clarification of terms and abbreviation
Knowledge, attitude and practices (KAP): A KAP survey is a representative study of a specific population to collect information on what is known, believed and done in relation to a particular topic.

Unmet need: The concept of unmet need points to the gap between women's reproductive intentions and their contraceptive behavior. Women with unmet need for family planning for limiting births are those who are fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of the next child.

Contraceptive prevalence rate is the proportion of women of reproductive age who are using (or whose partner is using) a contraceptive method at a given point in time.

Contraceptive methods include clinic and supply (modern) methods and non-supply (traditional) methods. Clinic and supply methods include female and male sterilization, intrauterine devices (IUDs), hormonal methods (oral pills, injectable and hormone-releasing implants, skin patches and vaginal rings), condoms and vaginal barrier methods (diaphragm, cervical cap and spermicidal foams, jellies, creams and sponges). Traditional methods include rhythm, withdrawal, abstinence and lactational amenorrhea.

Emergency contraception, or emergency post-coital contraception, refers to birth control measures that, if taken after sexual intercourse, may prevent pregnancy.

Sex education is a broad term used to describe education about human sexual anatomy, sexual reproduction, sexual intercourse, reproductive health, emotional relations, reproductive rights and responsibilities, abstinence, contraception, and other aspects of human sexual behavior. Common avenues for sex education are parents or caregivers, school programs, and public health campaigns

Immigrants are defined as being born abroad by two foreign-born parents, and registered as residents in Norway. (“First-generation immigrants” or “migrants”)

Norwegian-born to immigrant parents is defined as those born in Norway with two immigrant parents. (“Second-generation immigrants”)

http://www.nakmi.no/opplastede_filer/Public_Health%20 (2).pdf

South Asian Countries consists of Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka.

(http://en.wikipedia.org/wiki/South_Asia)



Ethnic minority: A group that has different national or cultural traditions from the majority of the population.

Chlamydia infection is one of the most common sexually transmitted infections (STI) in humans caused by the bacterium Chlamydia trachomatis.

IUD

Intrauterine device

ECP

Emergency contraceptive pill

STI’s

Sexually transmitted infections

FP

Family planning

CM

Contraceptive method

ESCAP

Economic and social commission for Asia and Pacific


Abstract

‘Every man and woman has the right to be informed of, and to have access to, safe, effective, affordable and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth as well as provide couples with the best chance of having a healthy infant.’1



Objective: The aim of the study was to investigate the family planning knowledge, attitudes, and practices among the South Asian immigrant women (13-45 years) in Oslo, Norway.

Methodology: A cross-sectional study using a quantitative approach was carried out from August 2010 to December 2010 among 309 women - of which 23.3% were recruited from health centers, and 76.3% from South Asian immigrant’s native communities.

Result: One third participants originated from Pakistan, 72.5% were 1st generation immigrant women. Among 309 respondents, 73.8% married; 66% unemployed; 62.1% had less than 12 years education and 41% were between 20-30 years. More than half, South Asian immigrants 181 (58.6%) showed they have lack of family planning knowledge while 128 women (41.4%) have average knowledge. The majority (62.5%) received family planning information from their family members and friends. Only 33% women had received sex education at the school. The majority of the women (79.6%) never heard of STI’s like Chlamydia and among them 94.4% 13 to 19 years old. 84.2% women stated to discuss family planning information with unmarried women is shame or embarrass in their society. Contraceptive use among the immigrant women was 68.9%. Education is one of the most important predictors for FP knowledge and practices. Conclusion: Nearly fifty percent women have average family planning knowledge. FP knowledge before marriage is significantly associated with country of origin. Therefore, there is need culturally sensitive initiatives to encourage immigrant women for their positive attitude towards discussion on family planning with unmarried women.
Chapter 1. Introduction

1. Introduction:

Family planning allows individuals and couples to anticipate and attain their desired number of children in addition to the spacing and timing of their births. It is achieved through the use of contraceptive methods (1). Family planning is not only focused on the planning of when to have children and use of birth control. Rather, in a broad view, it includes sex education, prevention and management of sexually transmitted infections (STIs), preconception counseling and management, and infertility management (2). Family planning offers a positive view of reproductive life and enables people to make informed choices about their reproduction and well-being (3).


    1. Background:

The practice of family planning methods has increased since the 1960’s - both in developed and developing countries. According to the United Nations in 2009, the use of any contraceptive methods among women is at 62.9% worldwide, 81% in Northern Europe and 54.2% in South Asia (4). On the other hand, the rate of induced abortion has also reduced in both developed and developing countries. The induced abortion rates are 29% in worldwide, 17% in Northern Europe, and 29% in Asia (4). Though the decline in induced abortion rate reduced from 34% to 29% in Asia, more than half of abortions in developing countries were illegal and unsafe (4). In addition to induced, illegal and unsafe abortion, unmet need for family planning is another consideration in developing countries, especially in South Asia. Studies from South and Southeast Asian countries indicate that the unmet need for contraception in Bangladesh is 18.7%; in Pakistan, it is 23 %, while in India, it is 27.1% (5). Thus, the South Asian countries presented a different picture (6) in contraceptive prevalence rate, induced abortion rate and unmet needs of sexual and reproductive health services. The combination of high unmet need of family planning with contraceptive unawareness among the South Asian adolescents and youth will increase the risk considerably (6).

Of the present, worldwide there were estimated 200 million immigrants, with 70.6 million immigrants living in Europe (7). In Norway 2011, 600 900 persons or estimated 12.2% of the total population has an immigrant background (including Norwegian born with two immigrant parents) (8)



    1. Literature review:

A KAP study was done at Manipur India, to assess the knowledge, attitude and practice of family planning (KAP) among the Meitei women. The knowledge of condom and IUD was higher in the age groups of 31-35 years (34.9%) and 20-25 years (32.0%) compared to the respondents in the age group of (24.0%) 36-40 years and (20.0%) 26-30 years. The main source of knowledge was friends at 44 percent. (9)

In Karachi, Pakistan, a study was done to find out the level of awareness, attitude and practice of family planning among rural women. The study revealed that non-supportive attitudes towards family planning exist among the people due to the low level of education, desire for male children and misinterpretation of religion. (10)

Another study at the urban health care center, Azizabad Sukkur, in Pakistan investigated the awareness and pattern of utilization of family planning services among women. The study shows that, before 18 years of age, 69.5% were married, some desiring 4-5 children (37.5%) or more than five children (36%); 40% participants had never used any contraceptive method. Health care providers were the main source of family planning information among 48.5% of women. (11)

In Sri-Lanka, a study was done to investigate the induced abortion and family planning knowledge, behavior and attitude among Sri-Lankan women. The study revealed that 78% women have knowledge of at least one contraceptive method, while only 16.3% were contraceptive users, 80% respondents in age group of 20-40 years were seeking induced abortion. The common reason for termination of pregnancy was too little birth space, followed by three or more children (38.6%), unmarried (13%), unplanned pregnancy (10%) and economic reasons. (12)

In Bangladesh, a study was done to investigate the unmet needs in family planning among rural women. The study found that 72.1% of respondents were using contraceptive methods, of which 61.7% were using oral contraceptive pills. Fear of side effects (46.1%) was related to not using any contraceptives among the remaining (28%) respondents. (13)

There is no coordinated sex education at school in Bangladesh, Pakistan, Nepal, and Myanmar (14). In India, state governments faced criticism for introducing sex education in curriculum. Political parties argued that ‘sex education "is against Indian culture" and would mislead children’. However, in Sri-Lanka when children are 17-19 years, they get information about sex through reading the reproduction section of biology textbooks. Therefore, the family planning knowledge among adolescents appears to be limited. (14) In these developing countries, cultural, social and religious aspects of a community have influenced on family planning knowledge, attitude and practice (15). In such a restrictive society, ‘even health care providers are hesitate to provide contraceptive services and information to unmarried adolescents, and in some instances, before providing such care, health providers are insisting on parents' consent.2 Lack of trust and confidentiality between adolescents and health care providers is a significant barrier to adolescents seeking care (15). As a result, existence of unmet needs is increasing and especially in Bangladesh (18.7%), India (27.1%) and Pakistan (23 %) (5).



Lower educational attainment and larger ideal family size with more children have an association with early marriage. The practice of family planning has relation with social and educational empowerment. Lack of educational empowerment has an association with lack of family planning knowledge, non-supportive attitude and low prevalence of contraceptive use. These facts were found from the analysis of the data from demographic and health surveys among Muslim women in Pakistan, Egypt, Jordan and Indonesia (16). In such countries, when women get married at an early age, they are usually bound by the responsibility to either extended or nuclear family or restricted by social barriers which often prevent further educational attainment. The presence of a mother-in-law in the household is also influential in determining family size (15, 16). The early married women are bound to start an early reproductive life, to have less articulated ideas about family size, and to being non-contraceptive users (16). Another study in Pakistan was done on spousal communication for family planning, which revealed that ‘Contraceptive use is strongly associated with women's discussions with their husbands. It is accepted by the above-mentioned studies that practice of contraceptives is related to having good contraceptive knowledge and a positive attitude towards family planning discussions (17).

    1. Rationale for the study

There are considerable variations between immigrants and non-migrants in use of family planning and contraceptive methods (18). Studies in the UK showed that sexually active women from Pakistan, Asia, the Caribbean and Africa were less likely to use reliable methods of contraception than British women (19, 20). According to a study in Finland, in spite of immigrant women’s “age-adjusted abortion rate”, abortion rates were lower among immigrants than women of Finnish origin, but abortion rates were significantly higher among Russian, Southeast Asian and Chinese immigrant women than other ethnic groups in Finland (18). According to Wilson and McQuiston (2006), Mexican immigrant women in North Carolina, USA were reluctant to use family planning methods and more than half of their pregnancies were accidental (20). Another study among former Soviet new immigrants in Israel also shows that the contraceptive use and prevalence of contraceptives was lower among immigrants than native women (21). Somalian women in the UK were attending the family planning clinic, but they were unwilling to use contraceptive methods because of religious convictions (22). Another study in the UK in 1998 shows a 3 to 4 fold increase in the likelihood of abortion if the women were of Asian or African ethnicity (19, 22). Increase in migrant populations in Western Europe has led to specific dilemmas in the area of sexual and reproductive health (23). Despite growing awareness and available health services in host countries, the minority group does not utilize these services.

Many multi-ethnic European societies now face the challenges of termination of pregnancy among immigrant women (18). The Scandinavian countries are not an exception. In many multi-ethnic Western societies, differences exist across ethnic sexual cultures since requesting induced abortion is relatively common among women of immigrant background women (18,19,20,21,22,24) compared to native women and studies found in Sweden (24,28), Norway (23,25,29), the Netherlands (31), and Denmark found this to be case(27). A landmark study in Sweden shows that 36% of young women, who were attending Swedish abortion clinics and requesting induced abortions in 2003 among them, were of immigrant backgrounds (24). In Norway, of women who were requesting induced abortion in 1999, 25% were from a non-Western, immigrant background (23). “Literature shows that the most probable reasons for the less frequent use of effective contraceptive and higher abortion rates among women of immigrant origin were lower education, weaker social networks, poverty, unemployment and a lack of properly informed access to health care” (18, 24, 27). This landmark Finnish study in 2008 shows that half of immigrant women didn’t use contraceptives prior to abortion (18). The study also reveals that nonprofessional Asian women experienced significant difficulties in using family planning services because of communication barriers with the health professionals while professional and married or unmarried immigrant women were able to meet their family planning needs by utilizing existing family planning services in the host country. (18). A yearlong study in Denmark also found that lack of contraceptive knowledge and a partner’s negative attitudes and experiences of contraceptive failure were associated with the choice of abortion more among the immigrant women than Danish-born women (27). Another yearlong study in Sweden on the abortion rate and contraceptive practices among immigrant and Swedish adolescents in 2006 shows that first and second generation immigrants had more pregnancies and less experience of contraceptive use than Swedish adolescents. This study also reveals that Swedish adolescents had more experience with contraceptive counseling than immigrant’s adolescents (28). Simultaneously, abortion rates and contraceptive practices among immigrant women and native women study in 2003 in Sweden shows that (24) immigrant’s women had less experience with contraceptive use, more previous pregnancies and more induced abortion. This study also reveals that immigration status, weak social networks, unemployment and low education are associated with requesting induced abortion among immigrant women (24). A study in Canada of Chinese immigrant women who gave their reasons for not using oral contraceptives found that their negative attitudes were related to the fear of contraceptive’s side-effects, fear of weight gain and permanent infertility (18, 30).

According to Statistics Norway 2011, Oslo has the largest proportion with 28.4% or 170 200 Immigrants of which 109 959 or 65% are from in Asia, Africa, South-and Central America, Turkey (8). The highest proportions of immigrants are living in Søndre Nordstrand, Stovner and Alna (8). A study on “Induced abortion among women with foreign cultural background in Oslo” shows most of the child deliveries were more prominent among the women less than 25 years of age. This study also shows that requesting induced abortions was more prominent among women who were more than 35 years old (25). Another study on “childbearing or induced abortion: the impact of education and ethnic background” shows that induced abortion requests were more associated with higher education among Pakistani women, while low education was associated with requesting induced abortion among Norwegian women (23). A recent study on “Termination of pregnancy according to immigration status” shows that termination of pregnancy rates (TOP) was significantly higher among Sri-Lankan (36.0, 95% CI=31.8–40.2), Indian (27.9, 95% CI=22.8–33.2) and Pakistani (18.4, 95% CI=16.6–20.2) women than non-immigrants (16.7, 95% CI= 16.3–17.1). The TOP study also reported that a high number of women (36-57%) were not using any contraceptive methods at the time of conception and requesting TOP (29).

‘It is acknowledged that the psychological and cultural aspects of the sexual health dilemmas among immigrant women is related to socials norms and individual and/or community’s attitudes towards family formation, sexuality, and gender. These norms and attitudes affect women’s opinion and influence their sexual and reproductive life’ (18, 32). In addition, sexual health is said to be affected by communication problems in the health care centers. It may be due to the fact that many immigrant women from developing countries have a low level of education in their countries of origin as well as their new host society (32, 18) and therefore, they have poor employment opportunities. All of these problems inevitably lead to a lower quality of care in sexual health (18).

Two studies on induced abortion among immigrant women have been published (25) (29) in Norway. However, to my knowledge, no one has studied the family planning knowledge, attitudes and practices among immigrant women in Norway. Therefore, the purpose of the study was to investigate the family planning knowledge and attitudes towards family planning discussions among South Asian immigrant unmarried young girl and explore the FP knowledge, attitudes towards modern contraceptives and practices of contraceptive methods among South Asian immigrant married women.



Chapter 2. Objective of the study

Research questions:

  • How many immigrant women are familiar with modern contraceptives method?

  • What are the attitude towards family planning discussion and modern contraceptives among the immigrant women?

  • What is family planning practice among immigrant women?

  • What types of reproductive health services do immigrant women prefer?

  • What are the important predictors for family planning knowledge and practice?



  1. Objective of the study



    1. General Objective: To investigate family planning knowledge, attitudes and practices among South Asian immigrant women in reproductive age in Oslo, Norway.



2.2 Specific Objectives:

    • To describe the family planning knowledge

    • To identify the attitudes towards family planning

    • To learn about the attitudes towards discussions and information about sexual health and family planning methods among unmarried women themselves

    • To explore contraceptive practices



Chapter 3. Research methodology

“Research is defined as systematic collection, analysis and interpretation of data in order to shed light on unanswered questions (33, 35). “For each particular photograph the investigator must decide what kind of camera to use what scene on which to focus, through which filter and with what intent (35, 36, and 37)”. The choice of methods depends on the research questions (34)”. Keeping in mind the objectives of the study, it is vital to have a quantitative design in order to find the contraceptives usage rate among married South Asian immigrant women and to investigate the knowledge and attitude towards contraceptives among immigrant married women and unmarried youth.

    1. Study design:

This study was a cross -sectional study among South Asian immigrant women of fertile age during August 2010 to December 2010 in Oslo.

    1. Study population

The study population was immigrant women from Pakistan, India, Sri-Lanka and Bangladesh of reproductive age (13-49 years). They were recruited from the South Asian immigrant’s communities, meeting places and different health centre’s in Oslo, especially Bjørndal, Prinsdal, Klemetsrud, Holmlia and Gamle Oslo.

    1. Sample size

      1. Married women

According to the United Nations, contraceptive prevalence rate is 67% among women in developing countries4. To estimate the sample size, we calculate with following formula:

N= P (1-P) (1.96)2/d2

N= sample size, P=Prevalence of contraceptive rate 67%,

d=0.05 (allowable error of known prevalence),

N= (1.96*1.96*0.67*0.23)/ (0.05*0.05), N= 236.

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