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Unmet need for contraception in Kuwait: a developing country without a family planning program
International Journal of Gynecology and Obstetrics 83 (2003) 335–338
Special communication
Unmet need for contraception in Kuwait: a developing country without a family planning program M.A. Shaha,*, N.M. Shahb, I. Menonb a Department of Health Information Administration, Faculty of Allied Health Sciences and Nursing, Kuwait Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait
b
Received 30 December 2002; received in revised form 7 April 2003; accepted 9 April 2003 Keywords: Unmet need; Reproductive needs; Reproductive counseling; Kuwait
The concept of ‘unmet need’ for contraception aims to measure the discrepancy between desire to delay or cease childbearing among fecund, sexually active women and their lack of contraceptive action to achieve the above desire w1,2x. Unmet need has been reported to exist in developing as well as European countries w3x. Approximately 113.6 million women in developing countries had an unmet need for contraception in 2000. In Arab countries unmet need ranges from a high of 38.6% in Yemen to a low of 11.2% in Egypt. Kuwait, a small oil-rich Muslim country has never had a formal family planning program. It has, however, continuously provided contraceptive services and supplies free of charge as part of its maternal and child health strategy during the last 25–30 years. Widespread access to oral contraceptive pills and intrauterine contraceptive devices is available. The level of current contraceptive use stands at approximately 52% w4,5x. *Corresponding author. Fax: q965-483-0937. E-mail addresses: [email protected] (M.A. Shah), [email protected] (M.A. Shah).
Given the above setting, our objectives were to estimate the level of unmet need and examine the characteristics of women with unmet need in comparison with current users. Data for this study were collected in a nationally representative survey of Kuwaiti households conducted in 1999 by the authors covering 1689 households (1.2% of all Kuwaiti households) containing 1502 currently married women. As shown in Table 1 those with unmet need comprised 9.7% of all currently married women; 6.1% wanted to stop childbearing, while 3.6% wanted to space their children. A bivariate comparison of the women with unmet need and current contraceptors shows that the unmet need group was comprised of relatively older women with a significantly higher level of parity. Larger percentages of them belonged to relatively lower socioeconomic status and were Bedouins, or the ethnically more conservative group in the country (Table 2). Couples with comparatively negative attitudes towards contraception and lower interspousal interaction had higher unmet need. A significantly larger percentage of the unmet need group disap-
0020-7292/03/$30.00 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0020-7292(03)00161-9
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M.A. Shah et al. / International Journal of Gynecology and Obstetrics 83 (2003) 335–338
Table 1 Unmet need for contraception among currently married Kuwaiti women (ns1502) Number (1502)
% (100.0)
Women with unmet need Currently pregnant women who: Wanted to delay pregnancya Did not want pregnancyb Fecund, non-contracepting women who: Wanted child after 24 or more monthsa Did not want another childb Total unmet need
30 6
1.9 0.4
25 85 146
1.7 5.7 9.7
Currently using contraception: For spacingyunsure For limiting Total using Total demand for contraception
471 303 774 920
60.8 39.2 51.5 61.2
All other womenc
582
38.8
tive needs of approximately 90% of all currently married women were being adequately met while approximately 10% had an unmet need. Approximately two-thirds of the ones with unmet need perceived themselves to be at a relatively low risk for pregnancy while approximately one-fifth were concerned about side effects and were therefore not using contraception. In terms of health care services and advice, women with unmet need are likely to require specialized attention by concerned gynecologists and obstetricians since they belong to the older, higher risk category w6x. The need for Table 2 Comparison of women with unmet need with those currently using contraception Current Women P users with unmet (ns774) need (ns146)
a
Need for spacing. Need for limiting. c Pregnant who wanted a childs174; fecund who wanted a child within -24 monthsydid not knows332; infecunds76. b
proved of contraception, and believed that Islam forbids family planning compared with current users (30% and 15%, respectively). Approximately 41% of women with unmet need said that their husband disapproved of contraceptive use compared with only 10% of current users (Table 2). Net effects of the correlates of unmet need were examined by running logistic regression (Table 3). Age of the woman had a significant, positive association with unmet need and her ethnic background was marginally significant (Ps0.05). The variable that had the strongest association with unmet need was the wife’s perception of the husband’s opinion about contraceptive use. Unmet need was 4.7 times higher among women who said that their husband disapproved of contraceptive use or they did not know his opinion compared with women who said their husband approved of such use. Also, the woman’s own disapproval of contraception as well as her belief that Islam forbade family planning significantly increased the level of unmet need. Thus, we found that despite the absence of a family planning program the perceived contracep-
Sociodemographics x¯ Age x¯ No. of living children x¯ Grades of education % Currently working % Living in rural area % Bedouin
33.6 4.6 10.5 36.2 45.2 44.2
36.3 5.1 8.6 21.9 54.1 56.6
-0.001 -0.05 -0.001 -0.001 -0.05 -0.001
Fertility desires x¯ No. of desired childrena No. of living children exceeds no. desireda
5.3 24.3
5.2 39.3
NSb -0.01
Service accessibility % Who know four or more modern methods
80.6
71.9
-0.05
32.4
40.7
NSb
12.7
19.4
-0.05
47.7
57.5
-0.05
3.4
13.4
-0.001
15.1
30.1
-0.001
10.0
41.4
-0.001
Husband wife communicationy attitudes % Where husband wants more children than wife % Where husband had more influence % Where spouses did not discuss the number of children to have % Women who disapproved contraception % Women say Islam forbids FP use % Where women said husband disapproves contraception a b
Data were missing for 90 and 29 cases, respectively. NS, not significant.
M.A. Shah et al. / International Journal of Gynecology and Obstetrics 83 (2003) 335–338
337
Table 3 Logistic regression of unmet need B Constant Sociodemographics Completed age Grades of education No. of living children Bedouin (Ref.snon-Bedouin) Woman not working (Ref.swoman working) Living in rural areas (Ref.surban)
Standard error
Odds ratio
y4.396
0.766
0.12
0.053** 0.014 y0.086 0.517 0.388
0.017 0.028 0.057 0.265 0.264
1.054 1.014 0.918 1.677 0.142
0.113
0.242
1.120
0.163
0.260
1.176
y0.227
0.287
0.797
0.053
0.213
1.055
1.547***
0.232
4.698
0.491*
0.238
1.634
0.866**
0.332
2.377
Service accessibility Respondent knows less than four modern methods (Ref.sknows four or more methods) Husband wife communicationyattitude Where husband had most influence in deciding whether to have another child (Ref.swifeyboth equal and others) Respondent never discussed number of children with husband (Ref.sdiscussed) Where respondent said husband disapproves of contraceptiony don’t know (Ref.sapproves) Respondent believes Islam forbidsy don’t know use of family planning (Ref.sapproves) Respondent disapprovesy no opinion about use of contraceptive (Ref.sapproves) R square
11.1
*P-0.05; **P-0.01; ***P-0.001.
professional intervention is further highlighted by the woman’s social circumstances whereby the husband’s attitudes discourage contraceptive use and enhance the level of unmet need. Acknowledgments This paper is based on grant number KFAS-9607-15 from the Kuwait Foundation for the Advancement of Sciences (KFAS).
References w1x Ross JA, Winfrey WL. Unmet need of contraception in the developing world and former Soviet Union: an updated estimate. Int Fam Plann Perspect 2002;28(3):138 –143. w2x Westoff CF, Pebley AR. Alternative measures of unmet need for family planning in developing countries. Int Fam Plann Perspect 1981;7(4):126 –136. w3x Klijzing E. Are there unmet family planning needs in Europe. Fam Plann Perspect 2000;32(2):74 –81, 88. w4x Shah NM, Shah MA, Al-Rahmani E, Behbehani J, Radovanovic Z, Menon I. Trends, patterns and correlates
338
M.A. Shah et al. / International Journal of Gynecology and Obstetrics 83 (2003) 335–338
of contraceptive use among Kuwaitis, 1984–1999. Med Principles Pract 2001;10(34):40. w5x Shah MA, Shah NM, Al-Rahmani E, Behbehani J, Radovanovic Z. Over the counter use of oral contraceptives in Kuwait. Int J Gynecol Obstet 2001;73:243 – 251.
w6x Hollier LM, Leveno KJ, Kelly MA, McIntire DD, Cunningham FG. Maternal age and malformations in singleton births. Obstet Gynecol 2000;96(5 Pt 1):701 – 706.
Special communication
Unmet need for contraception in Kuwait: a developing country without a family planning program M.A. Shaha,*, N.M. Shahb, I. Menonb a Department of Health Information Administration, Faculty of Allied Health Sciences and Nursing, Kuwait Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait
b
Received 30 December 2002; received in revised form 7 April 2003; accepted 9 April 2003 Keywords: Unmet need; Reproductive needs; Reproductive counseling; Kuwait
The concept of ‘unmet need’ for contraception aims to measure the discrepancy between desire to delay or cease childbearing among fecund, sexually active women and their lack of contraceptive action to achieve the above desire w1,2x. Unmet need has been reported to exist in developing as well as European countries w3x. Approximately 113.6 million women in developing countries had an unmet need for contraception in 2000. In Arab countries unmet need ranges from a high of 38.6% in Yemen to a low of 11.2% in Egypt. Kuwait, a small oil-rich Muslim country has never had a formal family planning program. It has, however, continuously provided contraceptive services and supplies free of charge as part of its maternal and child health strategy during the last 25–30 years. Widespread access to oral contraceptive pills and intrauterine contraceptive devices is available. The level of current contraceptive use stands at approximately 52% w4,5x. *Corresponding author. Fax: q965-483-0937. E-mail addresses: [email protected] (M.A. Shah), [email protected] (M.A. Shah).
Given the above setting, our objectives were to estimate the level of unmet need and examine the characteristics of women with unmet need in comparison with current users. Data for this study were collected in a nationally representative survey of Kuwaiti households conducted in 1999 by the authors covering 1689 households (1.2% of all Kuwaiti households) containing 1502 currently married women. As shown in Table 1 those with unmet need comprised 9.7% of all currently married women; 6.1% wanted to stop childbearing, while 3.6% wanted to space their children. A bivariate comparison of the women with unmet need and current contraceptors shows that the unmet need group was comprised of relatively older women with a significantly higher level of parity. Larger percentages of them belonged to relatively lower socioeconomic status and were Bedouins, or the ethnically more conservative group in the country (Table 2). Couples with comparatively negative attitudes towards contraception and lower interspousal interaction had higher unmet need. A significantly larger percentage of the unmet need group disap-
0020-7292/03/$30.00 䊚 2003 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S0020-7292(03)00161-9
336
M.A. Shah et al. / International Journal of Gynecology and Obstetrics 83 (2003) 335–338
Table 1 Unmet need for contraception among currently married Kuwaiti women (ns1502) Number (1502)
% (100.0)
Women with unmet need Currently pregnant women who: Wanted to delay pregnancya Did not want pregnancyb Fecund, non-contracepting women who: Wanted child after 24 or more monthsa Did not want another childb Total unmet need
30 6
1.9 0.4
25 85 146
1.7 5.7 9.7
Currently using contraception: For spacingyunsure For limiting Total using Total demand for contraception
471 303 774 920
60.8 39.2 51.5 61.2
All other womenc
582
38.8
tive needs of approximately 90% of all currently married women were being adequately met while approximately 10% had an unmet need. Approximately two-thirds of the ones with unmet need perceived themselves to be at a relatively low risk for pregnancy while approximately one-fifth were concerned about side effects and were therefore not using contraception. In terms of health care services and advice, women with unmet need are likely to require specialized attention by concerned gynecologists and obstetricians since they belong to the older, higher risk category w6x. The need for Table 2 Comparison of women with unmet need with those currently using contraception Current Women P users with unmet (ns774) need (ns146)
a
Need for spacing. Need for limiting. c Pregnant who wanted a childs174; fecund who wanted a child within -24 monthsydid not knows332; infecunds76. b
proved of contraception, and believed that Islam forbids family planning compared with current users (30% and 15%, respectively). Approximately 41% of women with unmet need said that their husband disapproved of contraceptive use compared with only 10% of current users (Table 2). Net effects of the correlates of unmet need were examined by running logistic regression (Table 3). Age of the woman had a significant, positive association with unmet need and her ethnic background was marginally significant (Ps0.05). The variable that had the strongest association with unmet need was the wife’s perception of the husband’s opinion about contraceptive use. Unmet need was 4.7 times higher among women who said that their husband disapproved of contraceptive use or they did not know his opinion compared with women who said their husband approved of such use. Also, the woman’s own disapproval of contraception as well as her belief that Islam forbade family planning significantly increased the level of unmet need. Thus, we found that despite the absence of a family planning program the perceived contracep-
Sociodemographics x¯ Age x¯ No. of living children x¯ Grades of education % Currently working % Living in rural area % Bedouin
33.6 4.6 10.5 36.2 45.2 44.2
36.3 5.1 8.6 21.9 54.1 56.6
-0.001 -0.05 -0.001 -0.001 -0.05 -0.001
Fertility desires x¯ No. of desired childrena No. of living children exceeds no. desireda
5.3 24.3
5.2 39.3
NSb -0.01
Service accessibility % Who know four or more modern methods
80.6
71.9
-0.05
32.4
40.7
NSb
12.7
19.4
-0.05
47.7
57.5
-0.05
3.4
13.4
-0.001
15.1
30.1
-0.001
10.0
41.4
-0.001
Husband wife communicationy attitudes % Where husband wants more children than wife % Where husband had more influence % Where spouses did not discuss the number of children to have % Women who disapproved contraception % Women say Islam forbids FP use % Where women said husband disapproves contraception a b
Data were missing for 90 and 29 cases, respectively. NS, not significant.
M.A. Shah et al. / International Journal of Gynecology and Obstetrics 83 (2003) 335–338
337
Table 3 Logistic regression of unmet need B Constant Sociodemographics Completed age Grades of education No. of living children Bedouin (Ref.snon-Bedouin) Woman not working (Ref.swoman working) Living in rural areas (Ref.surban)
Standard error
Odds ratio
y4.396
0.766
0.12
0.053** 0.014 y0.086 0.517 0.388
0.017 0.028 0.057 0.265 0.264
1.054 1.014 0.918 1.677 0.142
0.113
0.242
1.120
0.163
0.260
1.176
y0.227
0.287
0.797
0.053
0.213
1.055
1.547***
0.232
4.698
0.491*
0.238
1.634
0.866**
0.332
2.377
Service accessibility Respondent knows less than four modern methods (Ref.sknows four or more methods) Husband wife communicationyattitude Where husband had most influence in deciding whether to have another child (Ref.swifeyboth equal and others) Respondent never discussed number of children with husband (Ref.sdiscussed) Where respondent said husband disapproves of contraceptiony don’t know (Ref.sapproves) Respondent believes Islam forbidsy don’t know use of family planning (Ref.sapproves) Respondent disapprovesy no opinion about use of contraceptive (Ref.sapproves) R square
11.1
*P-0.05; **P-0.01; ***P-0.001.
professional intervention is further highlighted by the woman’s social circumstances whereby the husband’s attitudes discourage contraceptive use and enhance the level of unmet need. Acknowledgments This paper is based on grant number KFAS-9607-15 from the Kuwait Foundation for the Advancement of Sciences (KFAS).
References w1x Ross JA, Winfrey WL. Unmet need of contraception in the developing world and former Soviet Union: an updated estimate. Int Fam Plann Perspect 2002;28(3):138 –143. w2x Westoff CF, Pebley AR. Alternative measures of unmet need for family planning in developing countries. Int Fam Plann Perspect 1981;7(4):126 –136. w3x Klijzing E. Are there unmet family planning needs in Europe. Fam Plann Perspect 2000;32(2):74 –81, 88. w4x Shah NM, Shah MA, Al-Rahmani E, Behbehani J, Radovanovic Z, Menon I. Trends, patterns and correlates
338
M.A. Shah et al. / International Journal of Gynecology and Obstetrics 83 (2003) 335–338
of contraceptive use among Kuwaitis, 1984–1999. Med Principles Pract 2001;10(34):40. w5x Shah MA, Shah NM, Al-Rahmani E, Behbehani J, Radovanovic Z. Over the counter use of oral contraceptives in Kuwait. Int J Gynecol Obstet 2001;73:243 – 251.
w6x Hollier LM, Leveno KJ, Kelly MA, McIntire DD, Cunningham FG. Maternal age and malformations in singleton births. Obstet Gynecol 2000;96(5 Pt 1):701 – 706.