Received Date: October 08, 2012; Accepted Date: October 26, 2012; Published Date: October 28, 2012
Citation: Shafei MN, Shah MS, Tengku Ismail TA (2012) Knowledge and Attitude towards Family Planning Practice and Prevalence of Short Birth Spacing Among Residents of Suburban Area in Terengganu, Malaysia. J Community Med Health Educ 2:180. doi: 10.4172/2161-0711.1000180
Copyright: © 2012 Shafei MN, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Introduction: Family planning allows couples to determine and ascertain the desired number of children as well as the spacing of their births. Short birth spacing has negative effects on mothers, children as well as the family. The aims of the study were to determine the prevalence of family planning practice and short birth spacing among married couples residing suburban area and to determine their knowledge and attitude levels towards family planning practice.
Methods: A cross sectional study was conducted involving 86 married couples. A systematic random sampling was applied and consented respondents were interviewed using a validated questionnaire. In the study, short birth spacing was defined as any birth-to-pregnancy interval which was less than 24 months.
Results: The prevalence of family planning practice was 38.7% (95% CI: 28.7, 49.3). Whereas, the prevalence of short birth spacing among the respondents was 36.0% (95% CI: 25.9, 46.1). The proportion of good knowledge on family planning was higher among husbands compared to wives (P-value=0.041, Chi-value=6.371). Despite good knowledge, husbands had a higher proportion of poor attitude compared to wives (P-value=0.002, Chi-value=9.952).
Conclusion: The prevalence of family planning practice in this community was relatively low. As for short birth spacing, the prevalence was low compared to some other studies locally, but higher than findings from other countries. In addition, the knowledge and attitude towards family planning practice were still inadequate in the community of suburban area.
Prevalence; Short birth spacing; Family planning practice; Knowledge; Attitude
Family planning allows individuals and couples to determine and ascertain the desired number of children as well as the spacing of their pregnancies. Contraceptive methods and the treatment of involuntary infertility are used to achieve the purpose. Spacing and limiting pregnancies has a direct impact on women’s health and well-being as well as on the outcome of each pregnancy . Short birth spacing has significant health effects on both mothers and children. Low birth weight, premature birth and small for gestational age are among its consequences to babies . To women, they are more likely to suffer from third trimester bleeding, premature rupture of membrane and anemia .
Millions of women want to use safe and effective family planning methods, but are unable to do so due to lack of access to information and services as well as support from their husbands and communities. In Malaysia, family planning services are provided by various governmental, private and non-governmental organizations. The main providers are Ministry of Health clinics and hospitals, National Population and Family Development Board clinics, Malaysian Federation of Family Planning Associations clinics and private clinics and hospitals.
It was found that knowledge on family planning was relatively low among women in Malaysia [4,5]. In addition, the prevalence rate of contraception use in Malaysia, both traditional and modern, was 51.8% . Refusal of practicing family planning is because of a few misconceptions among people. Many women repeatedly stated that modern family planning would cause birth defects, infertility and adverse health effect. Some of them faced spouse objection to practice family planning .
Poor family planning practice leads to short birth spacing which refers to the amount of time between births and/or pregnancies. Birth spacing is an important issue related to health, nutrition, economic and social aspects of women and their families. It has significant health effects on both the mothers and children. Too short or too long birth spacing are both associated with maternal and child morbidity and mortality.
Knowing the women’s and their husband’s knowledge and attitude towards family planning may help us to intervene so that the practice can be increased. This might ensure the right of women to have child as they wish. This will later reduce unwanted pregnancies and abortions. This study was aimed to determine the prevalence of family planning practice and short birth spacing among married couples and to determine their level of knowledge and attitude towards family planning practice.
Study design and subjects
A cross sectional study was conducted among 86 married couples residing suburban area in Terengganu, Malaysia. There were 1136 people residing the area.
Sample size was calculated using a single proportion formula. The calculation gave the largest and feasible sample size using 95% confidence level, 26% for good knowledge on family planning  and difference was set at 10%. Considering 20% non-response, the required sample size was 86 couples.
The reference and source population for the study was married couples residing suburban area of Terengganu, Malaysia. The researchers mapped all houses in the area and chose 86 houses to select married couples using a systematic random sampling. The inclusion criteria were married couples whose age ranged from 15 to 50 years old and having at least two children or one child and currently pregnant. Women who had attained menopause were excluded from the study. Those couples who did not fulfill the study criteria were replaced with the next house (couple).
The study protocol was reviewed by the Research Ethics Committee, School of Medical Sciences, Universiti Sains Malaysia on 11th October 2009 and approved on 12th November 2009 (Ref No: USMKK/PPP/ JEPeM 22.214.171.1243). A detail explanation about the study was given to the respondents and enough time was allocated for them to make a decision to participate. After agreed, a written informed consent form was given to them for signature. Confidentiality of the data was strictly maintained as only researchers could access to the data.
For data collection, the study used a proforma containing socio-demographic data and obstetric history as well as a validated questionnaire on knowledge and attitude towards family planning practice . In this study, short birth spacing was defined as any birthto- pregnancy interval that was less than 24 months . The study also referred to their current family planning practice or their practice prior to the current pregnancy for those who were pregnant, in order to reduce limitation in recall.
Data entry and analysis were done using IBM SPSS Statistics 20. Prevalence of family planning practice was calculated as the percentage of couples practicing family planning with all study couples as the denominator. Whereas, prevalence of short birth spacing was calculated as the percentage of couples with short birth spacing and all study couples as the denominator. The study addressed the frequency and percentage for categorical variables, and chi-square test was applied to determine association. For numerical variables, the mean (SD) or median (IQR) were presented and independent t-test was applied to compare differences between group.
Categorical responses which were ‘true’, ‘false’ and ‘don’t know’ were used for the knowledge domain and they were awarded 2, 1 and 0 mark for right answer, don’t know and wrong answer respectively. As for attitude domain, the responses were recorded using Likert scale which ranged from 1 (strongly disagree) to 5 (strongly agree). The questionnaire consists of 22 items; 14 items for knowledge and 8 items for attitude.
Total score was calculated for each domain and transferred into ‘percent score’ by dividing the score with the possible maximum score, and multiplying by 100. Based on the discussion among experts, the cut off points were set. For knowledge domain, respondents scored less than 75% were categorized as poor, between 75%-80% as average and more than 80% as good. For attitude domain, those scored less than 85% were categorized as unsatisfactory whereas more or equal to 85% as satisfactory. P-value of less than 0.05 was judged to be statistically significant.
There were 86 couples participated in the study. Their mean age was 43.0 (SD 7.86) and 33.5 (SD 7.05) years old for husbands and wives, respectively. As for household income, there were 41 (47.7%) couples with income below the poverty line (monthly income of less than RM 691). Table 1 shows the socio-demographic characteristics of the respondents. There was a significant difference in education level between husband and wife (P-value=0.001, Chi value=13.1).
|Variable||Husband (n=86)||Wife (n=86)|
|Level of Education
College and higher
Table 1: Socio-demographic characteristics of the respondents.
The mean parity of the couples was 5.1 (SD 2.38) and it ranged between one and eleven. Among the couples, we found that the prevalence of family planning practice was 38.7% (95% CI: 28.7, 49.3). On the other hand, the prevalence for short birth spacing among them was 36.0% (95% CI: 25.9, 46.1). Among 86 married women, 23 (26.7%) and 11 (12.8%) of them had history of abortion and premature labour respectively.
Table 2 shows the levels of knowledge and attitudes towards family planning among the respondents. There was a significant difference in knowledge level between husbands and wives. The proportion of good knowledge was higher among husbands compared to wives (p-value=0.041, Chi-value=6.371). For attitude level, there was also a significant difference between husbands and wives. Despite good knowledge, husbands had a higher proportion of poor attitude compared to wives (P-value=0.002, Chi-value=9.952).
|Variables||n (%)||95% CI|
Table 2: Level of knowledge and attitudes towards family planning among wives and husbands (86 couples).
Table 3 shows a comparison of proportion of correct answers for the questions on knowledge of family planning between husbands and wives (n=86 couples). Whereas, Table 4 shows a comparison of proportion of positive attitudes (strongly agree) for questions on attitudes towards family planning between husbands and wives (n=86 couples).
|n (%)||n (%)|
|1.||Pregnant mothers with birth spacing of less than two years are considered as high risk pregnancy||31 (36.0)||31 (36.0)|
|2.||Mothers who are pregnant with birth spacing more than five years are at higher risk to deliver a premature baby||24 (27.9)||27 (31.4)|
|3.||A birth spacing which is too close do not allow the mother’s body to provide enough nutrition to the fetus||72 (83.7)||74 (86.0)|
|4.||Per-vaginal bleeding during pregnancy may happen to mothers with too short birth spacing||40 (46.5)||46 (53.5)|
|5.||The most suitable age for a woman to have a baby is between 20 to 35 years old||71 (82.6)||73 (84.9)|
|6.||Age of a woman is an important factor in determining the suitable type of contraception to be used||40 (46.5)||54 (62.8)|
|7.||Oral contraceptive pill is contraindicated for a woman who has breast cancer||37 (43.0)||36 (41.9)|
|8.||Injectable contraception is administered every 2 to 3 months depending on its type||45 (52.3)||36 (41.9)|
|9.||Intrauterine contraceptive device is made of plastic with various shapes and sizes||23 (26.7)||33 (38.4)|
|10.||Condom is a sheath made up from a soft rubber material||62 (72.1)||76 (88.4)|
|11.||The use of condom may provide protection against sexually-transmitted diseases such as AIDS||64 (74.4)||74 (86.0)|
|12.||Condom must be removed immediately after ejaculation when the penis is still erected||47 (54.7)||57(66.3)|
|13.||A woman may use a calendar method to avoid unprotected sexual intercourse during her fertile period to prevent pregnancy||58 (67.4)||61 (70.9)|
|14.||During ovulation (fertile period), a woman will have a vaginal discharge which is colorless and smooth||55 (64.0)||51 (59.3)|
Table 3: Comparison of proportion of correct answers for the questions on knowledge of family planning between husbands and wives (n=86 couples).
|n (%)||n (%)|
|1.||Pregnancy must be properly planned and not just allow it to happen on its own||25 (29.1)||32 (37.2)|
|2.||A mother who has just delivered and her husband should be given adequate information regarding family planning||35 (40.7)||27 (31.4)|
|3.||Pregnancy should be planned and discussed together between husband and wife||41 (47.7)||36 (41.9)|
|4.||Pregnancy which is too closely spaced should be avoided by using family planning method||29 (33.7)||27 (31.4)|
|5.||Husband should involve during the planning and ensuring the use of contraceptive method by his wife||35 (40.7)||31 (36.0)|
|6.||Modern contraceptive method is more effective than traditional method||20 (23.3)||18 (20.9)|
|7.||The use of contraceptive method will not interfere sexual relationship between husband and wife||19 (22.1)||18 (20.9)|
|8.||Support from husband is important to determine the success of family planning programme||21 (24.4)||17 (19.8)|
Table 4: Comparison of proportion of positive attitudes (strongly agree) for questions on attitudes towards family planning among husbands and wives (n=86 couples).
All respondents in our study were Malay with 80 (93.0%) of husbands and 82 (95.3%) of wives had undergone up to secondary level of education. Most of the husbands, 52 (60.5%) were self-employed and mostly work as fishermen. Meanwhile, 74 (86.1%) of the female respondents were housewives. More than half (52.3%) of respondents had household income above poverty line which indicates that poverty was not a major factor of not practicing family planning among the respondents.
In this study, we found that prevalence of family planning practice was 38.7%. This was slightly higher as compared to prevalence of family planning practice among Malay women who delivered at Hospital Universiti Sains Malaysia, which was 34.4%  and among those who delivered at Muar Hospital, Johor which was 33.2% . The differences might be due to the respondents in their studies were selected among patients who were admitted to the postnatal wards after delivery, therefore they were from reproductive age group and less likely to practice family planning. Meanwhile, our study selected respondents from the general community.
However, finding from this study was lower than the reported prevalence rate of contraception in Malaysia, both traditional and modern, of 51.8%  and 61.0% globally . It was also lower than the prevalence of contraception use among women attending Obstetric and Gynecological Clinic at Klang Hospital, which was 60.0%  and among post-partum mothers attending child welfare clinics in Beruwala, Sri Lanka, which was 41.1% . Therefore, it is important to improve family planning practice in this community.
On the other hand, the prevalence of short birth spacing in the community was 36.0%. This was lower as compared to the study among women who delivered in HUSM by Alina  who found that 45.1% of them had short birth spacing. A study conducted among nursing staff in Kota Bharu, Kelantan also found that 41.1% of them had short birth spacing . The differences might be explained by the higher percentage of family planning practice among respondents in our study. However, the prevalence was still high compared to findings in Michigan and Nepal, which were 22.0%  and 23.0%  respectively.
As far as knowledge towards family planning is concerned, we found that good knowledge category among respondents regarding family planning were only 27.9% and 31.4% among wives and husbands, respectively. It was significantly higher among husbands. However, the findings were lower as compared to a study by Alina  where 53.5% of wives and 57.7% of husbands had good knowledge category on family planning. This could be due to low education background among the respondents as most of them had undergone up to secondary school only. Therefore, we should provide a better knowledge and information related to family planning so that their practice could be improved and sustained.
Pertaining to attitude towards family planning, 77.9% of wives and 79.1% of husbands had unsatisfactory attitude towards family planning. These are higher as compared to the study by Alina  who found that 74.9% of husbands and 69.0% of wives have poor attitude. Thus, it shows that our respondents have poorer attitude towards family planning. There is also a significant difference in the attitude towards family planning between husbands and wives in which husbands had poorer attitudes compared to wives.
This study showed that knowledge alone did not influence the attitude. We found that husband who had higher percentage of good knowledge did not have a better attitude compared to their wives. Therefore, other factors that influenced the attitude towards family planning should be identified and improved. Those factors include support or barrier from friends, family members, community and health services, beliefs and culture.
This study was subjected to recall bias as it uses a pro forma which requires history on obstetric as well as contraceptive practices. Even though certain information was cross-checked with antenatal cards, the information from the cards were also obtained from the women retrospectively, thus still subjected to the bias. As the interviewer in this study was a health practitioner, it is possible that the respondents were not telling the truth, especially on the questions of modern contraception use and their perceptions toward it.
The prevalence of family planning practice in this community was still low. As for short birth spacing, the prevalence was low compared to some other studies locally, but higher than findings from other countries. In addition, the respondents’ knowledge and attitude towards family planning were still inadequate. Therefore, we need to explore the measures used by the community to space their pregnancies. Traditional family planning method might be one of the reasons for the above findings since their usage was not counted in this study. We might get more information on their experiences and beliefs regarding the traditional method in future study. Intervention such as health education on family planning and recommended duration of birth spacing is vital to improve the knowledge and attitude towards family planning.
Financial support for this work was provided by USM Incentive Grant. The authors are indebted to the members of Group 13 CFCS Phase 2 2008/2010 for their contributions in completing the study. We also acknowledge all respondents of the study and all staff of the Department of Community Medicine and CFCS Program, USM Kelantan. Special thanks to the Research and Ethics committee of USM for reviewing and approving the study.