Assessment of the Social Factors Aﬀecting the use of Contraceptives and the Stigma Associated

The factors aﬀecting the use of contraceptives and social stigma associated with it has caused signiﬁcant uncontrolled growth of population, which is the most important problem with developing countries like India. The only eﬀec-tive way of controlling population explosion is through promotion and practice of contraception and family planning. To assess the social factors aﬀecting the use of contraceptives and the stigma associated with it. To assess basic knowledge about contraceptive methods and relationship between knowledge of contraceptives and formal education; Compare knowledge and use of contraceptives in rural and urban populations, diﬀerent occupational categories and economic statuses; Determine the major source of information about contraceptives in diﬀerent age groups and to assess reasons for using and not using contraceptives. The research indicated that, still a signiﬁcant percentage of population do not have proper knowledge, have hesitancy in buying, hesitancy in discussing contraceptive methods. Signiﬁcant portion of the study group are not using contraceptive methods to prevent STDs or for practicing birth spacing. Low socioeconomic status was associated with not using any form of contraception among women with unintended pregnancies. We have received maximum responses from females (67.0%); from males (33.0%). We have received maximum response from undergraduates (41.2%) and least from people with no formal schooling (4.6%). Educational interventions can help increase knowledge of available contraceptive methods, enabling individuals to make informed decisions and use contraception more eﬀectively. Health education may help overcome the issues related to social stigma on the use of contraceptives and family planning.


Abstract
The factors affecting the use of contraceptives and social stigma associated with it has caused significant uncontrolled growth of population, which is the most important problem with developing countries like India. The only effective way of controlling population explosion is through promotion and practice of contraception and family planning. To assess the social factors affecting the use of contraceptives and the stigma associated with it. To assess basic knowledge about contraceptive methods and relationship between knowledge of contraceptives and formal education; Compare knowledge and use of contraceptives in rural and urban populations, different occupational categories and economic statuses; Determine the major source of information about contraceptives in different age groups and to assess reasons for using and not using contraceptives. The research indicated that, still a significant percentage of population do not have proper knowledge, have hesitancy in buying, hesitancy in discussing contraceptive methods. Significant portion of the study group are not using contraceptive methods to prevent STDs or for practicing birth spacing. Low socioeconomic status was associated with not using any form of contraception among women with unintended pregnancies. We have received maximum responses from females (67.0%); from males (33.0%). We have received maximum response from undergraduates (41.2%) and least from people with no formal schooling (4.6%). Educational interventions can help increase knowledge of available contraceptive methods, enabling individuals to make informed decisions and use contraception more effectively. Health education may help overcome the issues related to social stigma on the use of contraceptives and family planning.

Introduction
The most important problem with developing countries like India is the uncontrolled growth of population. The only effective way of controlling population explosion is through promotion and practice of contraception and Family planning. As ironic as it may sound-many in India, even today, hesitate to speak about family planning or contraceptives.
India was the first country in the world to adopt an official population policy and launch official family planning programme way back in 1952, which remains the mainstay of family planning efforts (1) . During its early years, the programme focused on the health rationale of family planning. Though progress has been made since 1952, it's not enough to stop the increased depletion of natural resources or to increase the standard of living of 'the last person' in the nation (2) .
The last few decades have witnessed a contraceptive revolution, that is, man trying to interfere with the ovulation cycle. But the extent of acceptance of the family planning methods still varies among societies and also among different castes and religious groups. This is mainly because of stigmas and superstitions associated with it. The lack of knowledge about-contraceptives, its timely need and various methods available for it are major hindrances towards its acceptance. There is no ideal contraceptive which could meet the social, cultural, aesthetic and service needs of all individuals and communities; so the present approach in family planning programmes is to provide a 'cafeteria choice' that is to offer all methods from which an individual can choose according to their needs and wishes and to promote family planning as a way of life (3) .
After the launch of the National Rural Health Mission in 2005, the official family planning programme has been subsumed in the reproductive and child health com-ponent of the Mission (4) .
However, universal adoption of small family norm still remains a distant dream in India. During 2007-08, only about 54% of the currently married women aged 15-49 years or their husbands were using a contraceptive method to regulate their fertility and the contraceptive prevalence rate appears to have stagnated after 2004 (5) .
Moreover, contraceptive practice in India is known to be heavily skewed towards terminal methods which means that contraception in India is practiced primarily for birth limitation rather than birth planning (6) . With this background, we conducted this study to assess basic knowledge about contraceptive methods and relationship between knowledge of contraceptives and formal education and to compare knowledge and use of contraceptives in different occupational categories and economic status and also to determine the major source of information about contraceptives in different age groups and to assess reasons for using and not using contraceptives.

Methodology
A cross-sectional study was conducted among study population, during October and November 2021. The methodology of measurement was by providing a structured questionnaire to the subject. The subjects were asked about their knowledge regarding family planning and the use of contraceptive methods, whether they've used those contraceptive methods and if so, for what purpose they have used. Purpose of the study was explained to the subjects and their verbal consent was taken to participate in this study and then the questionnaire was handed out to the subjects. The confidentiality of the subjects was guaranteed. We used convenience sampling method and collected data for 284 samples. https://ijpccr.com/

Method of data collection
For collecting data, we formed a structured questionnaire for the rural and urban people about their age, occupation, religion, education, residence, annual income, age of marriage, number of children, knowledge about family planning and contraceptive methods, and their first source of information, have they ever used those or before the last pregnancy, if not -reasons for not using, would they use in the future, if so reasons for using, are they comfortable about discussing among their partner.
Data was collected from the people whose age was more than 18 years, by individually interviewing them and by sharing online via WhatsApp. Data collection was done also by explaining the people about the study in local language wherever required. And they were well-informed about the confidentiality for those concerned.
The main focus to carry out the study was to assess the social stigma associated with contraceptive use or family planning among people of different occupational sectors.
The questionnaire gathered the information about the name, age, occupation, religion, education, residence, annual income, age of marriage, number of children, knowledge about family planning and contraceptive methods, and their first source of information, have they ever used them, if not so, reasons for not using, would they use in future-and reasons for that, are they comfortable in discussing this matter among their partner.

Statistical analysis
The data obtained was entered into Microsoft excel spread sheet and then it was analyzed using statistical package for social sciences (SPSS) version 20.0. Categorical variables were presented as frequencies and percentages. Chi-square test was used for statistical test of significance. Independent sample ttest/ANNOVA was used as test of significance for quantitative variable. A 'p' value of <0.05 was considered as statistically significant.

Results
We found that maximum use of contraceptives is seen among women with no children (45.0%). Women who had 1-2 children were more likely to use contraception than those who had more than 4 children.78.9% people have knowledge about use of contraceptives. Women who have sufficient knowledge about traditional methods were more likely to use contraceptives. Mass media is responsible for knowledge among 24% of the study population. Mass media is an effective way of mass communication. It includes television, newspaper, radio, etc. The second most popular way being knowledge from familythat51.4%havenot used it before the last pregnancyand15.8%haveused. Among the people who are not using any contraceptive methods, a majority of them have limited knowledge (11.3%) about different methods of contraception and its easy accessibility, usage and benefits. 12.3% of people want to conceive and a minor part of the population (8.8 %) are concerned about the side effects (8.8%), which has limited them from using the methods. Other minor reasons for not using contraception are pressure of partners (0.7%), pressure of inlaws (0.7%), religious beliefs (1.4%), and communication gaps between the couple. (Table 3) Barrier methods and sterilization techniques (vasectomy, tubectomy), in that order are the two most common methods of contraception used by the study group, 28.9% and https://ijpccr.com/

Discussion
In the current scenario of India's demographical dynamics complete awareness and proper use of contraceptive methods is imperative for sustained growth of the country with limited resources. So, a study aimed at assessing the social stigma around contraception becomes indispensable to know the current trend in contraceptive use. In this study, among the population, 284 individuals of both the genders, (of which 67.3% are females), form the study group, 79.2% of this population have some knowledge about contraception and family planning. Of the population under study 61.6 % of the people haven't used any method of contraception before, while 32% have used few methods of contraception and 6.3% of people have no idea about it. The study conducted by JFMPC (Journal of Family Medicine and Primary Care) -"A study on contraceptive prevalence rate and factors influencing it in a rural area of Coimbatore, South India" states that, the usage of contraception was significantly higher among those who were aged 35-49 years. The contraceptive acceptance was three times higher than those of aged 15-24years, probably these couples would have completed their family. In this study, contraceptive use was significantly higher among working women as they are more likely to be educated and their socioeconomic status is supposed to be better than the non-working women. Working women are likely to be more knowledgeable; would have wide exposure to media and social contacts which can influence their contraceptive behavior (6) . According to the study done by Prateek SS and R S Saurabh on "Contraceptive practices adopted by women attending an urban health centre" As the socioeconomic status decreases, the usage of contraception also decreases. Contraception usage is significantly higher among class I when compared to Class V. This may be due to the fact that the higher socioeconomic status individuals have better accessibility and availability of contraception, and they have better awareness regarding contraception (7) . The information about contraceptive methods among people who have knowledge about it come from varied sources like Mass media (23.9%), family (20.4%), friends (13.4%), Internet(11.6%), health worker facility (11.3%) etc. Among the people who are not using any contraceptive methods, a majority of them have limited knowledge about different methods of contraception and its easy accessibility, usage and benefits. 12.3% of people want to conceive and a minor part of the population (8.8 %) are concerned about the side effects, which has limited them from using the contraceptive methods. Other reasons for not using contraception are pressure of partners, pressure of in-laws and religious beliefs or communication gaps between the couples.
While according to the survey conducted on -"Why women do not use contraceptives: Exploring the role of male out-migration" states that non-use of contraceptives among women with migrant husbands was mostly driven by lack of contraceptive preparedness before husband's arrival, inability to procure contraceptives due to inaccessibility to health facilities and stigma to procure when husband was away. Other migration environment related factors included low ASHA outreach, myths and side effects of contraceptives, community fertility norms and poor spousal communications around Family Planning (8) . According to another study -"A clinical study on social stigma and trends of contraception at a tertiary care centre" states that Preference for male child was found to be another important reason to have more children. The choice of contraceptives available, perception of risk involved with their use along with socio-religious barriers are the most important factors limiting use of contraception methods (9) .
Ensuring healthy timing and spacing of pregnancies is now one of the key interventions for reproductive, maternal, neonatal, child and adolescent health (RMNCH+A) strategy. At the 2012 London Summit, the Government of India (GoI) made a commitment to increase access to family planning services to 48 million additional users by the year 2020.The renewed emphasis on use of reversible or spacing methods of contraceptives, which are safe and effective for women, has brought the spotlight on improving women's access to oral contraceptive methods (10) .
In our study group 71.8 % of the people use or want to use contraceptive methods for birth limiting and 41.9% of people are aware of using it for birth spacing and 36.6% use them for prevention against STDs. According to the study "Contraceptive Methods: Needs, Options and Utilization" important reasons for use of contraception are (a) growing number of women and men of reproductive age wish to regulate their fertility and have fewer children, (b) their need for protection against Sexually Transmitted Diseases as the transmissibility of several STIs and HIV/AIDS is greater from infected man to uninfected woman than the reverse and (c) usually younger women, married or unmarried, are less likely to be using contraception than older women, even in countries where contraceptive prevalence rate is high, this increases their vulnerability to unprotected sex and its adverse consequences manifold (11) . 58.1 % of the population believes that their partner approves for the use of contraception while 36.3% don't know about it. Most of the people in this study group are comfortable in discussing contraceptive methods with their partners but a significant portion (23.2%) is hesitant to discuss it with their partners maybe because of the stigma around the use of contraceptives (or because of the current family system in some areas where sex is still a taboo or maybe of some other reason unknown).
According to NFHS-4, "37% of currently married women do not make decision about their own healthcare. The lack of reproductive autonomy among women has resulted in high unmet need (13%) for family planning among women of reproductive age group in India, which means they face several barriers in accessing contraception although they want to delay or limit their pregnancies".
The low uptake of male contraceptives and limited male participation in discussion with their partners is due to lack in access of correct information on sexual and reproductive health, including condom use and male sterilization. There is also stigma around discussions on safe sex and relationships (12) . Barrier methods and sterilization techniques (vasectomy, tubectomy), in that order are the two most common methods of contraception used by the study group, 42.6% and 28.5 % respectively. Oral Contraceptive Pills, Intra-Uterine Contraceptive devices, Emergency Contraceptive methods are used by minority of the population. https://ijpccr.com/ While in the study conducted for IJRCOG (International journal of reproduction contraception obstetrics and gynecology) -"A clinical study on social stigma and trends of contraception at a tertiary care centre" states that -Contraceptive prevalence was found to be 27.08%. Among the permanent sterilization methods, the most commonly used method was Tubectomy (21.5%). Among the spacing methods Condoms, Oral Contraceptive Pills and Intra-Uterine Devices were used by 12%, 13% and 13% of the eligible couples respectively (13) .
When asked about the stigma around buying or getting access to contraceptives 59.2 % of the people wouldn't hesitate, but 40.8% were hesitant to buy. Majority (91.5%) did not face any bad experiences while buying a contraceptive. The study focuses on the key factors which determine the social stigma around contraception. This study shows that, still a significant population do not have proper knowledge, have hesitancy in buying, hesitancy in discussing contraceptive methods. Significant portion of the study group are not using contraceptive methods to prevent STDs or for practicing birth spacing both of which are vital for the health of mother, child and father; hence the family and hence the society as a whole.

Conclusion
On the basis of the data collected our finding suggests that 64.8% have never used any family planning or contraceptive methods before, mainly because they wanted more children, had negative perceptions about family planning, or had concerns about side-effects and due to lack of access to information and service. Mass media (24.0%) was found to be the major source of information among the respondents. The contraceptive method generally used is barrier method (28.9%) since it is easy to use, cheap and has minimal side effects. 33.8% mainly use contraceptive method for birth limiting this shows that until they reach their desired family size they do not use it, we must encourage them to use it even for healthy birth spacing and to prevent sexually transmitted diseases. The data shows that 76.7% find it comfortable to discuss it with their partner. 59.1% of people using contraceptive methods do not feel hesitant to buy the contraceptive device in local pharmacy. This study shows that use of contraceptive methods is stigmatized among general population. The percentage of population not using contraceptive methods are more vulnerable for sexually transmitted diseases and lack of proper family planning will lead to increase in population and decrease the socioeconomic status of the family.

Limitations
The limitations of the study include the small sample size that has been used for the study. The use of online forms for data collection present other limitations such as reduced participation and under-representation of parts of the society that do not have proper access to internet facilities.

Recommendations
The stigma associated with contraceptives is deeply connected to stigma associated with sex itself, which in India is still a taboo subject for the majority. Health education should be made compulsory for adolescents, which should also include sex education. To address the population which is not being educated, mass media should be used extensively to reach and educate them. People should be educated about how their family can be benefitted by contraceptives. Skits can be staged in populated areas or villages to attract and educate people effectively. These opportunities can also be used to educate about STDs and their prevention. (We included an option for participants in the study to add their ideas to reduce stigma associated with the use of contraceptives. Here are some selected replies).

Some suggestions by the participants
• "Gift them during wedding, there won't be hesitation to buy. " • "It's very important to prevent unwanted pregnancies and also to prevent sexually transmitted disease, there's nothing to be shy or shame in asking, learning or knowing about contraceptives. " • "People should understand that this is part of life and not make a fuss out of it. Basic Sex education should be given to the new generation. " • "It is your personal affair. Do not worry about others opinion. " • "Sex education in schools and colleges will bring sex out of the closet. Then only can the stigma be removed. " • "A survey/feedback forms given to Teenager to know their view on the topic. This will help in correcting any misnomer and providing them with the correct and required information. A box where they can drop in any questions (anonymous) and an expert can answer the same. The ill effects of going to a quack has to be magnified with the help of gory pictures. • "There should be short ads which keep playing on TV and radio. YouTube should play these ads. • "It should be talked openly. " https://ijpccr.com/