Urban and Rural Differences Regarding Family Planning Outcomes in Assiut District, Assiut Governorate, Egypt

INTRODUCTION

Family planning (FP) is the couple’s ability to attain their desired number of children and the spacing and timing of their birth.¹ FP is being known for its direct and indirect effects on maternal deaths.² It reduces the deaths in two directions; first, by reducing the fertility of women and second, by reducing the risk associated with each birth.³ The most recent Egypt Demographic Health Survey (EDHS) documented an increase in the total fertility rate (TFR) to 3.5, up from a low of 3.0 that was previously recorded.⁴ The increase in TFR coincided with evidence of a shift toward childbearing at younger ages and among more educated women.⁵ FP outcomes are not always a focus of studies and are not routinely evaluated by programs. As a result, many questions on the outcomes and the impacts of FP programs remain unanswered.⁵ Reporting outcomes, even if results are against expectation, is essential to prevent the wasting of limited resources.⁶ Modern FP methods are medical procedures that interfere with fertility. The most common FP modern methods are oral contraceptives pills, intrauterine devices (IUDs), implants, condoms (male and female), injectables, etc.¹ Unmet need for modern contraception is a good indicator of whether women are succeeding in achieving their desired birth timing and family size.⁷ Operationally, unmet need for FP is defined as the percentage of women of reproductive age, either married or in a union, who are in need to stop or delay childbearing but are not using any method of contraception.⁸ Unmet need for family planning remains a useful tool for detecting women at high risk of unintended pregnancy. Unintended pregnancy has an adverse impact on the health and welfare of women and children.⁹

Birth interval, defined as months between childbirth and the immediately preceding birth, has a critical effect on the health status of the mother and her child. Closely births intervals have a negative impact on the health of the mother and also on the FP efforts.¹⁰

The age of the mother is a very important determinant in her pregnancy health. Adolescent pregnancy is a significant problem in the world.¹¹ Despite a steady decline in the prevalence of adolescent motherhood globally, it is still public health problem. Advanced maternal age also predisposes women to adverse pregnancy outcomes.¹²

This study sought to determine the prevalence of use, level of knowledge, and outcomes of modern contraceptive use among reproductive-aged non-pregnant women in Assiut governorate in Upper Egypt.

SUBJECTS AND METHODS

Study Design and Setting

The research applied a cross-sectional, health facility-based study design. The study was conducted in Assiut district that was chosen purposively as it is the most populous district in Assiut governorate, easy to access, and contains both urban and rural domains.¹³ The field study was conducted from October 2019 to March 2020.

Target Population

The target population of this study was current-married, not pregnant women, in reproductive age (15-49 years old), that came to primary health care (PHC) to receive any health services. To avoid the selection bias, any women who reported that they had a pregnancy, were not in a marriage union, and/or above or below the investigated age group (15-49) years, and/or coming to receive emergent or FP services were excluded from the study.

Sample Size Determination

The sample size was determined using epi info version 7 statistical software package by considering confidence level 95% (Z = 1.96), power 80%, depending on contraceptive prevalence that was reported in the last EDHS (60%)⁴ and q, the complementary probability of P (1 - p), =0.40. The estimated minimum sample size required was n=369.

Sampling procedure

A multistage sampling technique was applied to select participants. In the first stage, two PHC facilities were selected randomly by using the lottery technique; one PHC facility from urban and one from rural areas. In the second stage, the proportional size allocation was made from each selected PHC based on the average number of women who came to utilize any health services other than FP 3 months preceding the beginning of the study of each health facility. In the third stage, eligible and consenting women utilizing PHC services, other than FP, were recruited consecutively by a systematic random procedure (every third case) at the point of exit from the health facilities until the required number to each selected facility was obtained.

Data Collection Instrument

Each eligible woman was asked to respond to an interviewer-directed questionnaire that was constructed from the last EDHS ⁽⁴⁾ which is a well-validated questionnaire.

Study Variables

FP outcomes Indicators

Several FP-related outcomes are the focus of our study. The study identified women as current users of modern contraception if they reported that they were currently using IUDs, injectables, implants, pills, male condoms, female condoms, or if they reported having been sterilized. In addition to examining the current use of modern contraception, we look at several FP outcomes such as contraceptive types knowledge which was measured as a woman’s identification of the names and shape of the method. All other indicators (Unintended pregnancy, unmet FP need, mother parity, narrow birth interval, adolescent pregnancy, and pregnancy in advanced age) were categorized as No/Yes category. 

Statistical Analysis

For statistical analysis, we first examined data distribution using the Shapiro–Wilk test. The normal distribution of the data using this test was documented when P≥0.05. The quantitative data are expressed as mean and standard deviation (SD). Pearson’s Chi-square test was employed at the bivariate level to examine the difference between urban and rural Assiut districts. Fisher's exact (FE) test was also used in the cases of 2 by 2 tables or if the expected cell count was less than 5. All associations with P- values less than 0.05 were considered significant values. When Pearson’s Chi-square test was done, the x² value was reported in the table. SPSS Program version 20 was used.

Ethical Consideration

Before beginning, the study was approved by the Ethics Committee in the Faculty of Medicine, Al-Azhar University. Approval from the Health Directorate in Assiut also was obtained. Verbal informed consent was obtained from each participant to perform the interviews.

RESULTS

From a total of 369 sampled mothers, 355 women gave a complete response with a rate of 96.2%.

Table 1 displays the general characteristics of the study participants. According to the mother’s characters, the mean age was 30.1 years. The mean number of living children was 2.7 children. The majority of the women in the studied sample were from urban areas (62,8%), 96.9% were Muslims, 44.5% were university or postgraduate educated, and 67.3% were unemployed (housewife). About 90% of the study participants were in the middle and high socioeconomic group.

 Table 1: General Characteristics of the Studied Sample in Assiut, Egypt, 2020

* Chi-Squared test or Fisher's Exact test when appropriate                  ** Significant < 0.05

Table 2: Differences between Urban and Rural in the Some General Characteristics among the Studied Women

The differences between urban and rural in some selected general characteristics are illustrated in table 2. Significant differences were obvious in education, work, and the socioeconomic level in favor of urban women.

Table 3 describes in detail the modern FP utilization outcome indicators among women in the reproductive age in Assiut district. FP utilization prevalence was 62.8% with a significantly higher level among urban women than rural women (66.8% versus 56.0%, p value=0.04). The percentage of unmet need for family planning was 29% with no statistical differences between urban and rural. Women with 3 children or less were more in urban than rural Assiut with a statistically significant difference (83.0% versus 71.2%, p value=0.01). The percentage of women who didn’t wait for 24 months as a birth space was 20.4% with no statistical differences between urban and rural. Adolescent pregnancy prevalence (pregnancy less than 18 years old) was 3.4% with a significantly higher percentage among rural women than urban women (6.8% versus 1.3%, p value=0.01). The prevalence of pregnancy in advanced age(above 35 years old) was 15.2% with no statistical differences between urban and rural Assiut districts.

* Significant < 0.05

(a) This indicator calculated among currently married not pregnant (Rural=132, Urban=223)

(b) Percentage here calculated as a dominator is women who do not need more children n=179

(C) Exclude Women which was the first pregnancy n=306

(d) Fisher Exact test rural versus urban

Table 3: Main Family planning Outcome Indicators among the Studied Women in Assiut, Egypt, 2020

*Fisher Exact test rural versus urban         ** Significant < 0.05

Table 4: Rural-Urban Differences Regarding Knowledge of Modern Contraceptive Method among the Studied Women