Aqeela Tabassum  ( Department of Sociology, University of Sargodha, Sargodha. )
Yasir Nawaz Manj  ( Department of Sociology, University of Sargodha, Sargodha. )
Tahira Rehman Gunjial  ( Department of Sociology, University of Sargodha, Sargodha. )
Salma Nazir  ( Department of Sociology, University of Sargodha, Sargodha. )

Objective: To identify the perceptions of rural women about modern contraceptive methods and to ascertain the psycho-social and economic attitude of women about family planning methods.
Methods: This cross-sectional study was conducted at the University of Sargodha, Sargodha, Pakistan, from December 2014 to March 2015, and comprised married women. The sample was selected using multistage sampling technique through Fitzgibbon table. They were interviewed regarding use of family planning methods. . SPSS 16 was used for data analysis.
Results: Of the 500 women, 358(71.6%) were never-users and 142(28.4%) were past-users of family planning methods. Moreover, 52(14.5%) of never-users did not know about a single modern contraceptive method. Of the past-users, 43(30.3%) knew about 1-3 methods and 99(69.7%) about 4 or more methods. Furthermore, 153(30.6%) respondents graded condoms as good, 261(55.2%) agreed that family planning helped in improving one\\\'s standard of living to a great extent while 453(90.6%) indicated that family planning methods were not expensive. Besides, 366(71.2%) respondents believed that using contraceptive method caused infertility.
Conclusion: Dissatisfaction with methods, method failure, bad experiences with side effects, privacy concerns and different myths associated to the methods were strongly related to the non-usage of modern contraceptive methods.
Keywords: CPR, Modern contraceptive methods, Family planning, Unmet need, Non-users. (JPMA 66: 1577; 2016)

Introduction
There is great evidence that family planning (FP) improves health, reduces poverty and empowers women.¹ Deliberate high-quality family planning programmes boost fertility declines, thus improving health and advancing economies. In 2002, the Pakistan\\\'s abortion rate was estimated at 27 per 1,000 women of childbearing age, while the rate of post-abortion complications resulting largely from induced abortions stood at 9 per 1,000; by 2012, the abortion rate almost doubled to 50 per 1,000 and the rate of post-abortion complications rose to 15 per 1,000.² This is obvious that contraceptive prevalence rate has been lacking despite an increasing desire to limit pregnancies in all areas of the country.³ Comparison of past years shows that there is a significant increase in the proportion of women who even don\\\'t know whether they will use contraception in the future or not. There are 1.52 billion women of childbearing age in the developing world. An estimated 867 million out of them need contraception, but sadly only 645 million are currently using modern contraceptive methods. So the contraception needs of the remaining 222 million people who want to limit or space their children are unmet.⁴ Reasons for this include limited choice of methods; limited access to contraception, particularly among young people, poorer segments of populations, or unmarried people; fear or experience of side effects; cultural or religious opposition; poor quality of available services; and gender-based barriers. Furthermore, the country\\\'s contraceptive prevalence rate (CPR) for modern methods is only 26 per cent, one of the lowest in the region.⁵ People in every culture have an accumulation of myths and fallacies, which could be social, cultural, religious or biological.⁶ This collective ignorance and lack of understandings create obstacles in achieving the targets set in the Millennium Development Goals (MDGs) 4, 5 and 6.⁷ Unmet need is often portrayed as a problem of access, leaving the perception that women do not use contraceptives because they cannot find or afford them or they have to travel too far to get them. Unsurprisingly, contraceptive discontinuation has been found to be one of the factors leading to the large estimated number of induced abortions in Pakistan.⁸ A study found discontinuation to be driven mostly by perceptions and experiences of side effects of modern  ontraceptives.⁹ A combination of factors like non-availability of services, baseless traditional beliefs and misconception play a big role.¹⁰ Keeping all these factors in view, this study was conducted to observe the knowledge and practice of Family Planning methods among women living in Khushab.

Subjects and Methods
This cross-sectional study was conducted at the University of Sargodha, Sargodha, Pakistan, from December 2014 to March 2015, and comprised married women. Data was collected from 10 randomly selected villages out of 314 in the District Khushab.¹¹ According to recent Population Welfare Department\\\'s estimation, there are 0.14 million eligible couples in rural areas of the district. A sample of married women was selected for interview using multistage sampling technique through Fitzgibbon table.¹² Women aged between 15-49 years with at least one alive baby were included. They were divided into two groups — those who had never used a modern contraceptive method (never-users) and those who had discontinued or dropped modern methods when the survey was held (past-users). Women who were newly-married, widows, divorcees and who were living separately from their husbands for the preceding six months at the time of survey were excluded. Multistage sampling technique was applied to select the primary and secondary sampling units. Proportionate stratified random sampling technique was preferred to allot the sample size. In this technique the sample size from each stratum was carefully chosen, proportionate to the population size of the stratum. For the identification of the sampling units, a list of localities prepared by the Pakistan Bureau of Statistics (PBS) was used.¹³ Equal proportionate households were selected using systematic random sampling technique.
Informed consent was taken from all participants and confidentiality of data was assured. Ethical approval was obtained from the departmental supervisory committee. After getting approval from the departmental supervisory committee, and board of advance studies, data was collected using a comprehensive questionnaire of open-ended and closed-ended questions. Pre-testing ofthe study was carried out on fifteen respondents to examine the workability and suitability of measuring instruments. Data was collected by the authors themselves through face-to-face interviews. Descriptive and inferential statistics were used to analyse the data. SPSS 16 was used for data analysis. In-depth interviews were conducted to estimate the potential contribution of contraceptive discontinuation to current and future unmet needs. An indicator of relevant discontinuation was created by calculating the proportion of past users with an unmet need for modern methods among never-users. A detailed univariate analysis was carried out to see differentials in patterns by demographic, personal and socio-economic variables.

Results
Of the 500 women, 358(71.6%) were never-users and 142(28.4%) were past users. Moreover, 52(14.5%) of never users did not know about a single modern contraceptive method, 148(41.3%) about 1-3 methods and 158(44.1%) about 4 or more methods. Of the past users, 43(30.3%) knew about 1-3 methods and 99(69.7%) about 4 or more methods (Table-1)


The opinion of the respondents about the modern contraception methods is shown in Table-2


The perception of the respondents on the economic aspect of family planning can be seen in Table-3


The psychosocial perception and dysbeliefs of the studied women on the various contraception methods and devices have been stated in Table-4

Discussion
The current study found that almost 90% married women knew about at least one modern contraceptive method. Here, remembrance of modern methods is taken as knowledge of family planning methods. The women who know more names of the methods are considered as more knowledgeable than those who do not know or have never heard the names of the methods. Most women in the study were never users. But interestingly, results showed that majority of the women were aware about family planning methods but still had never used contraceptive methods. So it can be interpreted that ignorance about methods is not the only barrier and there are other factors as well. This leads and paves the way for researchers to explore other important obstacles which hinder the use and influence upon women\\\'s behaviour of non-use. Another study observed that knowledge regarding appropriate use of method was poor, especially among women, even among those men and women currently using that method.¹⁴ The finding of our study concurs with that of Hardee and Leahy¹⁵ who found more than 96 per cent of currently married women to have heard of at least one method of contraception.

The current study also found that most respondents approved the condoms, pills and injections for birth spacing. These findings are also supported by national data in which major strength of users were using condom as their favourite method.¹⁶ Different studies conducted in Pakistan.^17-20 and Bangladesh²¹ found that condoms and pills are the most preferred contraceptive methods among married couples. Data shows that condom is the most favourite method among the respondents and least common method is vasectomy which is not acceptable for men. Contraceptive services are almost free in all the areas of the country and there is no economic issues related in obtaining the devices. So there may be other socio-cultural reasons for low prevalence of modern family planning methods. The same indicator focused on the notion that if people concentrate more to raise their standard of living, then they can be motivated to decline fertility.²² Once they keenly notice that more children means more expenses, more mouths to eat, low standard of living and more poverty, then they can understand the benefits of family planning.²³ Theory of intergenerational flow of income is also much important in this context that flow of income is not from children to parents, but it is from parents to children.²⁴

More than one-fourth respondents in this study pointed out that contraceptives caused health problems and side effects. The present study was in agreement with the findings of Aqeela²⁵ who found that perceived side effects, such as excessive bleeding and abdominal pain, were the major reasons for not using contraceptive methods. Apart from the actual side effects, fear of side effects and the personal, social and economic costs of living with side effects also force women to discontinue contraceptive use. Heavy bleeding has been reported as the major side effect of contraceptives in the study, which in turn leads to inability in performing household chores, taking care of children, offering prayers, maintaining marital relations, attending social gatherings, and managing the cost of side effects. Religion is no longer the most significant factor in family planning decision-making and use. According to present research, a large majority of the mothers were of the opinion that contraceptives caused infertility in the future. A study conducted in Kenya²⁶ also found the biggest fear for not using the method was infertility. Almost half of the women surveyed said they did not intend to use contraception due to concerns that it may affect their fertility and reproduction. Widespread misconceptions include the belief that the contraceptive pill will cause infertility and that herbal concoctions will induce abortion. It was not surprising that majority of the myths and misconceptions were heard from friends and relatives.²⁷ Another inhibiting effect on contraceptive use has not vanished completely, particularly in Khyber Pakhtunkhwa (KP) where it is still widely held that Islam does not allow family planning.²⁸

Conclusion
There was high demand for contraception among both Pakistani women and men but usage was quite low. This could be seen in the proportion of couples wanting to practice spacing between births or limit childbearing. These women did not practice contraception at the time of the study, not because of the desire to have a child, but because of problems related to the method and others. Biological constraints, general myths prevailing in the society, and socio-cultural and psycho-personal factors were the major reasons for not using the modern contraceptive methods.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

References
1.Bongaarts J, Cleland J, Townsend JW, Bertrand LT, Gupta MD. Family Planning Programs for the 21st Century. Rationale and Design. New York: The Population Council Inc; 2012.
2.Sathar Z, Singh S, Rashida G, Shah Z, Niazi R. Induced Abortions and Unintended Pregnancies in Pakistan. Studies Family Planning. 2004; 45: 471-91.
3.Aga Khan University, International Advocacy Seminar on Family Planning and Reproductive Health, February 12-13, 2013 (Karachi: Department of Community Health Sciences, Aga Khan University, 2013). NOT FOUND
4.Guttmacher Institute. "Are you in the know?" New York: Guttmacher Institute.[Online] [accessed: 2015 February  20]. Available from; URL: https://www.guttmacher.org/ sections/contraception.php.
5.National Institute of Population Studies. Family Planning Pakistan Demographic and Health Survey 2012-13.Islamabad: NIPS. Measures DHS ICF International Calverton, Maryland, USA: Preliminary Report; 2013, pp 15-16.
6.Qureshi N, Shaikh DBT. Myths, Fallacies and Misconceptions: Applying Social Marketing for Promoting Appropriate Health Seeking Behavior in Pakistan. Anthropol Med. 2006; 13:131-9.
7.Asim M, Mahmood B, Sohail MM. Infant health care; practices in Pakistan: a systematic review. Professional Med J. 2015; 22:978-88.
8.Sathar ZA, Singh S, Shah ZH, Rashida G, Kamran I, Eshai K. Post-Abortion Care in Pakistan: A National Study. Islamabad, Pakistan: Population Council; 2013.
9.Population Council. Prioritizing Family Planning for Achieving provincial Maternal Child Health and Development Goals; 2014.
10.Ali A. Pakistan: Debating Islam and family planning." IRIN. UN Office for the Coordination of Humanitarian Affairs; 2011.
11.Contraceptive Logistics Manual 2015. USAID-DELIVER PROJECT. Chapter 4. Health and Population Welfare Departments, Government of the Punjab Pakistan; 2015.
12.Fitzggibbon CT, Lynn LM. Table for Determining Sample Size from the Given Population. How to design a program evaluation. Newbury Park, CA: Sage Publications; 1987.
13.Federal Bureau of Statistic. District Census report of Khushab. Islamabad Statistics Division, Government of Pakistan; 1998.
14.Fikree FF, Saleem S, Sami N. A quality of care issue! Appropriate use and efficacy knowledge of five contraceptive methods: Views of men and women living in low socio economic settlements of Karachi, Pakistan. J Pak Med Assoc. 2005; 55:363-8.
15.Hardee K, Leahy E. Population, Fertility and Family Planning in Pakistan: A Program in Stagnation. Population Action Int. 2007;4:1-12.
16.Pakistan Demographic and Health Survey. National Institute of Population Studies, Islamabad: 2013; pp 93.
17.Ghulam M, Syed KA, Waqas H, Safdar A.. Family Planning Knowledge, Attitudes, and Practices among Married Men and Women in Rural Areas of Pakistan: Findings from a Qualitative Need Assessment Study. Int J Reprod Med. 2015; 2015:190520.
18.Azmat SK, G Mustafa, Hameed W, Ali M, Ahmed A, Bilgrami M. "Barriers and perceptions regarding different contraceptives and family planning practices amongst men and women of reproductive age in rural Pakistan: a qualitative study. Pak J Public Health. 2012; 1:17-23.
19.Rozina M, Uzma A, Haleema AH. Contraceptive Knowledge, Attitude and Practice Among Rural Women. J Coll Physicians Surg Pak. 2008; 18:542-5.
20.Khawaja NP, Tayyeb R, Malik N. Awareness and practices of contraception among Pakistani women attending a tertiary care hospital. J Obstet Gynaecol. 2004; 24:564-7.
21.Shahela A. Non-user Women\\\'s Perception about Use of Family-planning Method in Selected Areas of Bangladesh. Annual Scienteific Conference. Dhaka, Bangladesh; 2011.
22.Davis, K, Blake J. Social structure and fertility: an analytical framework\\\'. Economic Develop Cultural Change. 1956; 4:211?35.
23.Asim M, Sohail MM, Manj YN. Reproductive health issues of mothers; A study in Faisalabad. Professional Med J. 2015; 22:1164-9.
24.Uttam KS. Empirical Test of the Caldwell\\\'s Fertility Theory of Intergenerational Wealth Flows in India: Evidence from National Family Health Survey Data. Am Int J  Res Hum Arts & Soc Sci. 2015; 15: 77-80.
25.Tabassum A, khan AE, Arif M, Ali MW. Exploring the Socio-Cultural Barriers to Modern Contraceptive Use among Pakistani Women. IOSR J Hum & Soc Sci.2014; 19: 98-102.
26.Ochako R, Mbondo M, Aloo S, Kaimenyi S, Thompson R, Temmerman M, et al. Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study. BMC Public Health. 2015; 15:118.
27.RhouneOchako, Mwende Mbondo M. 2013. Contraceptive Myths and Misconceptions: Using Evidence to Inform Communication for Behaviour Change among Young Women in Kenya. [Online] 2013 [cited 2015 March 12]. Available from; URL: http://paa2013.princeton.edu/papers/130672..
28.Zaidi BH, Sabahat. Reasons of low Modern Contraceptive Use insights from Pakistan and other neighboring countries lunched by the Population Council, 1956.