Primary Researchers and Authors: John Bollinger and Catherine Yang

DGHI Faculty Mentor: Dr. Sumedha Ariely

Project Mentors and Coordinators: Dr. Christopher Kigongo, Robinah Jevelah

February 26, 2018

Introduction

Background

Maternal and child health poses unique challenges to the global health community and has received much attention in terms of policy. As such, the Millennium Development Goals specifically target these health challenges. Goal 4 simply states, “Reduce child mortality” (“United Nations Millennium Development Goals” 2017). In 2016 the infant, child, and overall under-5 mortality rates in Uganda were 43, 22, and 64 per 1,000, respectively (Uganda Bureau of Statistics 2016).  These mortality rates are driven by global health factors, including anemia, malaria, soil-transmitted helminth infection, and malnutrition. Anemia is a condition that results from a lack of red blood cells, such that the number of red blood cells cannot support the needs of the individual’s body (WHO 2011). Malaria is a prominent disease caused by plasmodium parasites spread by mosquito vectors. The African Region has a disproportionately high burden of malaria cases and deaths, 90% and 91%, respectively(“WHO | Malaria” 2017). Soil-transmitted helminth infection is one of the most common infections globally, particularly in sub-Saharan Africa, the Americas, and East Asia. These infections can lead to adverse nutritional and developmental effects as well as anemia (“WHO | Soil-Transmitted Helminth Infections” 2017). Malnutrition often compounds susceptibility to other illnesses, resulting in situations of comorbidity. In developing regions such as Uganda, malnutrition poses a severe threat to maternal and child health, especially in the presence of other disease burdens such as anemia, malaria, and helminth infection (Uganda Bureau of Statistics 2016). Naturally child health is closely related to maternal health, and MDG goal 5 reads, “Improve maternal health.” This goal is broken down into subcategories and includes universal access to reproductive health, including meeting the unmet need for family planning products and services (“United Nations Millennium Development Goals” 2017). In the North Central Region of Uganda, 24.1% of women have an unmet need for family planning (Uganda Bureau of Statistics 2016). With the presence of comorbidity between diseases and the strong connection between maternal and child health, future research that incorporates the connection between these areas should be pursued moving forward.

Family Planning

Family planning includes any and all conscious efforts by a couple towards limiting or spacing the number of children they have through modern or traditional contraceptive methods. The modern and traditional classifications for contraceptive methods refer to the manner in which couples pursue family planning. Modern methods include female or male sterilization, birth control pills, implants, injections, condoms, etc. Traditional contraceptive methods include rhythm, withdrawal and other techniques considered folk methods. In the North Central Region of Uganda, 47.4% of women use family planning methods, including modern and traditional methods (Uganda Bureau of Statistics 2016). Of this group, 39% of currently married women are using a method of family planning, with 35% employing a modern method and 4% choosing a traditional method. Among modern methods, injections and implants are the two most common choices due to convenience and their long-lasting effects. However, 24.1% of women still have an unmet need for family planning methods. Having an unmet need includes women who wish to postpone their next birth for two or more years or want to stop childbearing altogether but are not using family planning methods. If a woman’s previous pregnancy was unplanned or unwanted, that is also considered to be an unmet need (Uganda Bureau of Statistics 2016). Currently, family planning employs a facilities-based approach, requiring women to go to a clinic or hospital to obtain or continue using most family planning methods (Schecter, Ciraldo, and Paccione 2016). Moving forward, VHTs may be able to play a practical and vital role in helping overcome the gap between interest and unmet need for family planning methods.

2017 General Aims

1. Describe family planning knowledge and interest in a sample of current mothers.
2. Investigate the effect of side effects and social factors on attitudes towards family planning and reproductive outcomes.

Methodology

Both the Duke University Institutional Review Board and Uganda’s Mityana District Health Officer, Dr. Fred Lwasampijja, approved this study and the following methodology.  Participants were consented and ethical procedures were followed as specified both by Duke IRB and DGHI faculty mentors.

Study Setting

Data collection began in June 2017 and concluded in August 2017. The location was a rural parish of fourteen villages located about 50 miles from the capital city, Kampala, in Mityana District, Central Region 2, Uganda. The number of households in each village ranges from 54 to 247, with an average of 105 households per village.

Participants

In the summer of 2013, 69 women who were either pregnant or had recently delivered were recruited to participate in this now 5-year study. The women were either recruited through a village register or through an annual community health fair. Every year since, as many of these women have been re-recruited, as well as new participant mothers. The new mothers were women who had recently delivered and were recruited by their village health workers to be interviewed. In 2017, 59 mothers who had previously participated in this study were recruited, as well as 17 new mothers for a total sample of n=76.

In the summer of 2017, the mothers answered questions on their use of family planning and cell phones. No blood or stool samples were collected from the mothers in 2017.

Procedures

Consent

A trained translator read and explained the approved consent form in Luganda, the local language, to participating mothers. Written consent was obtained from the mother at the place of survey, either her home or common space selected by their village health worker.

Survey Tool

A trained translator administered the survey by asking the questions in Luganda, the local language, and translating the mother’s response directly to English after every utterance. The responses were recorded in a notebook and later coded. The surveys were administered at either the mother’s home or at a central location in the village. Each survey took approximately 30 minutes per participant.

Measures

The survey contained demographic questions, various questions about family planning use, experience, attitudes, and reproductive outcomes, and questions regarding the mothers’ use of cell phones. The researchers developed the survey questions after reviewing relevant literature and consulting with research mentors, including a Ugandan physician. The translators were consulted regarding the wording of questions prior to finalizing and administering the survey. The survey was printed in English but administered in Luganda, the local language.

Results

Of the 76 women surveyed in 2017 (ages 18-45 years), 81.6% (62/76) were married, and 18.4% (14/76) were single at the time of the survey. The median age at first pregnancy was 18 years, whereas the average age at first pregnancy was 18.49 years. This average age of first pregnancy is comparable but slightly higher than the Central 2 region average of 18.3 years (DHS, 2011).

The average number of pregnancies for women in our sample was 4.12. Of the women in our sample with 2 or more children, 91.2% (62/68) felt that they had waited long enough between the births of any of their children, whereas 18.8% (6/68) felt that they had not waited long enough between births. However, when asked about the intentionality of their previous or current pregnancy, 78.9% (60/76) of women wanted to be pregnant then, 19.7% (15/76) wanted to be pregnant later, and 1.3% (1/76) did not want to be pregnant at all. This can be seen in Figure 4 below.

All 76 women who participated in the survey were asked questions on family planning use and perceptions. When asked about family planning usage, 47.4% (36/76) reported that they were currently using a contraceptive method, 40.8% (31/76) said that they have used contraceptive methods in the past but not currently, and 11.8% (9/76) indicated that they have never used a contraceptive method. This can be seen in Figure 5 below.

Of the 67 mothers in our sample who currently or previously used a contraceptive method, the most common methods were injections and implants. Some women used multiple types of contraception, resulting in a total response number of 78 contraceptive types. 62.8% (49/78) used or currently use an injection, and 25.6% (20/78) used or currently use some form of implant. This breakdown can be seen in Figure 6 below.

While 25% 1 of the 4 women in our sample who were currently pregnant had unintentional pregnancies, overall: 28% (21/76) had experienced at least one unplanned pregnancy at some point. Of those women reporting an unplanned pregnancy, 52.4% (11/21) reported that the pregnancy was due to unprotected sex, 14.3% (3/21) mentioned contraceptive failure, 23.8% (5/21) stated that they were still breastfeeding when they became pregnant, 4.8% (1/21) reported that she did not need family planning, and 4.8% (1/21) said that she was not aware of family planning at the time of the pregnancy.

Higher than the reported number in our sample, 43.7% of births in Uganda were wanted at a later time or not at all (DHS, 2011). Given that the number of unintentional pregnancies remains high, various factors were explored, including the age at first birth and age at the start of contraceptive use. As previously stated, the median age at first pregnancy was 18 years, whereas the average age at first pregnancy was 18.49 years. The median age at the start of contraceptive use was 22 years, whereas the average age was 22.32 years. Statistical analysis comparing the age at which women report their first pregnancy and initiating contraceptive use shows that there is a significant difference between the age at which women are first pregnant and when they begin family planning methods. Therefore, women are starting family planning methods after their first pregnancy.

As stated earlier, 41% of mothers in our sample previously used at least one form of contraception in the past but do not currently use any family planning method. Of these 31 women, 45.2% (14/31) wanted another child, and 32.3% (10/31) stopped use due to side effects.

Based on our data and recommendations from 2016, we took a closer look at women who stopped contraception due to side effects. We analyzed whether or not women who stopped contraception due to side effects report significantly greater levels of side effect severity when compared to women who stopped contraception due to any other reason. We found that women in our sample who stopped contraceptive use due to side effects reported significantly more severe side effects (t=2.3208, df=20.543, p=0.03068). Figure 10 below visualizes the difference in reported side effect severity between the two groups of women, one indicating that they halted contraceptive use due to side effects and the other stopping use due to any other reason.

From the 2011 Ugandan Demographic Health Survey, 56% of current contraceptive users were given information about potential side effects or complications that may be associated with the contraceptive method that they use. 53% of women were told what steps to take if they experienced these side effects, and 59% obtained information about one or more alternative contraceptive method. As side effects were a significant reason for halting contraceptive use, the severity of side effects based on whether or not information was provided to the patient was analyzed.

We analyzed whether or not provider information made a difference in the painfulness of side effects reported due to contraceptive use. To do so, we grouped participants into two groups. One group reported that they had received any information at all about family planning methods, which was not limited to information about side effects associated with the contraceptive method the participant was using. Women in our sample were asked to rank the severity of the side effects the experienced on a scale from 1 to 10, with 1 being not a bother and 10 being so painful that the participant had to immediately discontinue use of her contraceptive method. For the group of women who received information from their provider, the median painfulness of side effects reported was 6, with an average score of 5.8. For the group of women who did not receive information from their provider, the median painfulness of side effects reported was 7, with an average score of 7.2. Statistical analysis revealed a trending towards significant difference between the two groups, indicating that women who did not receive information from their provider may report more severe side effects associated with contraceptive use.

To further assess whether or not there are mitigating factors for side effect severity, we analyzed the social support women received from female friends. Contrary to what we would expect, in terms of friends, women with more supportive friends have a median side effect severity score of 8, with an average score of 7.2. Women with unsupportive friends have a median side effect severity score of 6, with an average score of 6. While this trend is opposite of what we would expect, it is not statistically different indicating that the support of friends may not act as a mitigating factor for side effect severity associated with contraceptive use.

Another assessment of social support exists in the form of support from female family members. Therefore, we analyzed this type of social support participants have to investigate whether or not having supportive female family members may mitigate the severity of side effects associated with contraceptive use. Women with supportive female family members had a median reported side effect severity of 7, with an average score of 6.3. Women with unsupportive female family members had a median reported side effect severity of 10, with an average score of 8.6. Statistical analysis showed that there was a significant difference between the two groups of women, indicating that women with more supportive female family members report significantly less severe side effects associated with contraceptive use.

One final measure of social support that we explored was partner’s perception of contraceptive use. We asked women in our sample how she thinks her partner feels about contraceptive methods. Of women in our sample with a partner, 55.9% (38/68) reported that their partner supports contraceptive methods, 19.1% (13/68) said that their partner does not support contraceptive use, 16.2% (11/68) responded that they do not know how their partner feels, and 8.8% (6/68) stated that their partner does not know that they currently or previously used a contraceptive method. This breakdown can be seen in Figure 13 below. Note that some women gave multiple answers to this question.

Discussion

The women in our sample show a high level of contraceptive use. However, almost 1 in 3 mothers have experienced an unplanned pregnancy. This remains the case even though women mostly report that the primary use for contraception seems to be family spacing as opposed to individual reproductive control. In Uganda, contraceptives are free and available in local clinics, but the problems of transportation, service availability, and social support are still prevalent. The largest barrier to access for women who want to use contraceptive methods may be side effects. Many women in our sample reported that they had experienced side effects and discontinued use of their contraceptive method due to these side effects. Furthermore, the lack of information by providers is concerning, particularly as it may be a factor that may mitigate the severity of side effects women associate with contraceptive use. When discussing patient education with health workers in a few of the local clinics in Naama, we were informed that it is required for them to provide information about the contraceptive method the patient desires, along with side effects associated with that family planning method and general information about other available methods.

Boosting family planning education for patients serves as a promising prospect for a policy piece in the future. Policies should aim to mitigate misperceptions about the types and effects of contraception, which are potentially due to social networks perpetuating more information than health systems. As women with more supportive family networks report lower side effect severity, this idea has some degree of support. Therefore, a policy piece that aims to boost education provided at the point of procurement of family planning services as well as a community-based model that incorporates VHTs perpetuating information about family planning methods and associated side effects may be the best way to move forward.

Limitations

There are several limitations to our analysis of family planning perceptions and method use. Firstly, our survey relied on self-report method. It is very possible that women have forgotten the age at which they began contraceptive use along with the timeline of other questions. Furthermore, self-report measures for side effect severity may be skewed with time. If women have experienced these side effects more recently, they may be perceived as more severe. On the other hand, women who experienced side effects many years ago may not remember exactly what side effects they had and time may make those they do remember feel less severe. Secondly, we attempted to understand differences between the numbers of actual versus desired children for mothers in Naama. However, our sample only consisted of women who were still of childbearing age. We could not accurately draw conclusions from this sample because they may have more children in the future. A sample that included women beyond childbearing years should have been included to assess actual versus desired numbers of children. Broadening the sample would also allow for some degree of assessment in terms of a generational shift, determining whether or not a trend exists in the number of children desired by age group. Thirdly, we wanted to analyze birth spacing over time for mothers to see if there was a change as time went on or if the start of family planning methods increased birth spacing. However, we did not ask about the birthdays of all children, which prevented us from assessing these measures. Lastly, we did not separate or ask questions about modern versus traditional contraceptive methods. Many women in our sample mentioned that they had an unplanned pregnancy while they were still breastfeeding. Additional analysis would have been helpful to understand perceptions of modern versus traditional family planning methods.

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