|Year : 2011 | Volume
| Issue : 3 | Page : 368-374
Sociodemographic variables of contraceptive practice in Sikkim
YD Chankapa1, Dechenla Tsering2, Sumit Kar3, Mausumi Basu4, Ranabir Pal3
1 Department of Health, Secretariat office, Gangtok, Sikkim, India
2 Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok, Sikkim, India
3 Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim, India
4 Department of Community Medicine, SSKM Hospital, Kolkata, India
|Date of Submission||09-Apr-2011|
|Date of Decision||25-May-2011|
|Date of Acceptance||07-Jun-2011|
|Date of Web Publication||3-Sep-2011|
Department of Community Medicine, Sikkim Manipal Institute of Medical Sciences and Central Referral Hospital, Gangtok, Sikkim
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : The objective was to assess sociodemographic characteristics of men who use contraceptive and to compare them with men whose wives use contraceptive. Materials and Methods : Study design: A population-based cross-sectional study was performed. Study setting: It was performed in rural setting of the Sang PHC and Pakyong PHC service areas in Sikkim, India. Study participants: A total of 596 currently married men enrolled in the eligible couple registers. Interventions: No interventions occurred. Measurements: Sociodemographic correlates of contraceptive use were analyzed: occupation, religion, ethnicity, literacy, age, loss of children, and distance from health facility. Results : The use of contraceptive was high among the cultivators - men (44.45%), spouse (36.01%) followed by persons in Government service, respectively, 31.49% and 31.55%. Hindu men (55.42%), women (69.25%), and other backward communities (OBC) men (47.53%) and their wives (52.31%) were the majority users. A significantly higher number of users of contraceptive were literate men (72.33%) and their wives (86.17%) (χ2 =0.021, P> 0.05). Highest use was found in men and women (44.47%) in the 35 years and above (43.83) age group. But this difference was not significant. With the increase in the number of losses of children the contraceptive use declined among men and their spouses. Contraceptive users were higher at distances 1 hour and above from the health center compared to others. Conclusions : The finding of the research indicated that sociodemographic correlates determine the magnitude of the contraceptive use among couples in a rural community. A research agenda should define factors at both macro and micro levels that interact to adversely impinge on reproductive health outcomes.
Keywords: Age, contraceptive, literacy, occupation
|How to cite this article:|
Chankapa Y D, Tsering D, Kar S, Basu M, Pal R. Sociodemographic variables of contraceptive practice in Sikkim. J Pharm Bioall Sci 2011;3:368-74
|How to cite this URL:|
Chankapa Y D, Tsering D, Kar S, Basu M, Pal R. Sociodemographic variables of contraceptive practice in Sikkim. J Pharm Bioall Sci [serial online] 2011 [cited 2020 Feb 20];3:368-74. Available from: http://www.jpbsonline.org/text.asp?2011/3/3/368/84439
In the last century the conventional family welfare interventions had largely been designed and implemented with gender bias toward women. These programs inevitably overlooked or neglected the role of men in fertility decision in the predominantly male dominant world-making, contraceptive use as well as reproductive health needs. The agenda to promote gender equality in all spheres of life and to encourage and enable men to take responsibility for their sexual and reproductive behavior and their social and family roles was generally overlooked. The discrepancy of varying degree still exists throughout the developing world and much more is yet to be achieved in the field of reproductive health. It is estimated that more than 100 million women across the globe have unmet need for spacing and limiting birth. Encouraging involvements of men in family planning is one of the key strategies to address the problem of unmet need. In a systematic review authors however concluded that the rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly. 
Family planning is one of the important tools in the strategy to lower maternal deaths and morbidity by reducing unintended pregnancy and abortions. 
Declines in fertility rates typically follow a reduction in desired family size; parents increasingly want to invest more in the health and education of their children, which raises the "costs" of each child. As these costs increase, couples become more interested in regulating their fertility. Worldwide, fertility rates have fallen from an average of about six children per woman in the 1950s to fewer than three today. , Rates of contraceptive use among women of reproductive age have increased from 10% in 1965 to well over 50% in 1999. 
Still true reports of access to family welfare services continues to be an imperative factor in promoting healthy pregnancies and preventing unwanted pregnancies in the developing nation. High fertility and rapid population growth can pose serious public health problems for developing nations. It is well established that women are more likely to use and continue to use contraceptive if they have support of their husbands or male partners. Only when men have a better understanding and are better informed of reproductive responsibility could they be effective partners with the women in that area. 
Conventionally the family planning efforts did not cover men's involvement in determining the family size and contraceptive use. Spouses might have disparate reproductive goals and data from partners were necessary to ascertain these differences. Fertility and family planning and research must continue to expand their focus on men's attitudes and behavior. Centre for Women's Development Studies in recent times argued strongly in favor of bringing men into the center of debate and research on family planning, population control, and the reproductive health of women. However, women continue as always to be treated as objects in families and communities, as well as in policies and programs. The entire reproductive process from pregnancy to childbirth is a complex phenomenon that is socially and culturally determined, and women are excluded from decision making on issues concerning their own lives and bodies. Further, state policies and contraceptive technologies are mostly targeted at women. The implications of both social norms and state policies are reflected at the micro level of household. Based on a larger study, the paper shows that religion is a less influential factor than male dominance and cultural norms. The provision of better health and medical facilities by the government could, however, make a big difference to women's health as well as population control. Since 1950s and 1960s, the research and writings on population programs and their impact on women's fertility and choices have been enormous but one would hardly find many surveys and articles on men. 
Not only there is general paucity of studies focusing on difference between men and women's reproductive goals, but also men are rarely interviewed in fertility surveys of any kind.  Though lately many researches have provided some of the much needed information about the male fertility-related attitudes and behavior still more information is needed. Also, because much of the information about male's family planning behavior is based on reports from women, it is crucial that more effort should be put to obtain information directly from the men. Male involvement in family planning and use of male methods are associated with the fertility decline and resulted in long-term benefits for women.  Individual motivation rather than the choice of methods was more important for positive male participation in family planning. In a country like India, the husband's attitude, preference, and decisions regarding family planning are often more important and most often it is the husband who exerts the greater influence in couple communication and fertility decision.  There is an urgent need to conduct more qualitative research to identity male perspective on ranges of issues. There is a need for deeper understanding of male behavior and attitudes toward sexual relations and reproductive responsibilities. And the identification of potential parts of program intervention that will be culturally acceptable and effective should be a major priority. 
In societies that have not yet entered the fertility transition, both actual fertility and desired family sizes are high (or, to put it another way, childbearing is not yet considered to be "within the calculus of conscious choice")  In such societies, couples are at little (or no) risk of unwanted pregnancies. The advent of modern contraception is associated with a destabilization of high (or "fatalistic") fertility preferences. Thus, as contraceptive prevalence rises and fertility starts to fall, an increasing proportion of couples want no more children (or want an appreciable delay before the next child), and exposure to the risk of unintended pregnancy also increases as a result. In the early and middle phases of fertility transition, adoption and sustained use of effective methods of contraception by couples who wish to postpone or limit childbearing are still far from universal. Hence, the growing need for contraception may outstrip use itself. 
Our study aims to determine variables leading to the knowledge and practice toward conventional contraceptive as manifested through reproductive health and sexual decisions and to assess socio-demographic characteristic of men who use the contraceptive and to compare the characteristic with the men whose wife are using contraceptive. So far there has been no study done in this field in the state of Sikkim in India.
| Materials and Methods|| |
A population-based cross-sectional study was performed.
The study period was from October 1, 2003 to March 2004 (six-month activity).
The study was performed in rural setting of Sang PHC and Pakyong PHC in Sikkim, India.
No interventions occurred during the study.
The study population was 596 currently married men whose names were enrolled in the eligible couple registers (wife 15-45 years of age) of the study area.
Multistage random sampling was used as the sampling technique.
Main outcome measures
The main outcome measures were socio-demographic correlates of contraceptive use: occupation, religion, ethnicity, literacy, age, loss of children, distance from health facility.
Content validity and reliability of study instrument
A pretested close-ended questionnaire contained questions relating to socio-demographic variables that may influence the use of contraceptive by married couples in India. The module was developed on an anonymous interview schedule developed for the study in Department of Health and Family Welfare, Government of Sikkim, with the assistance from my guide in Sikkim and other public health experts. By initial translation, back-translation, retranslation followed by a pilot study in a community in Sikkim before the actual study, the questionnaire was custom-made for the study. For the pre-testing around 20 men from the adjacent subcenter fulfilling the criteria were administered the interview schedule by the investigator herself. The investigator was satisfied with the response following which some of the questions from the interview schedule were modified.
Data collection procedure
The state of Sikkim has four districts namely East (Gangtok), West (Gyalshing), South (Namchi), and North (Mangan). Gangtok is the capital city of Sikkim. There are four district hospitals, 24 primary health centers, and 147 subcenters in Sikkim, one referral hospital 500 bedded at Gangtok and Semi Govt. Medical College situated at Gangtok. The population of the East district is around 233,000. East is the most populous district with density being 257 persons/km 2 and North is the least populated district with density of population 10/km 2 . Out of the four districts the East district was selected, as per the convenience of the researcher, given time and resource constraints. Under the East district there are eight primary health centers. East primary health center caters to around 7,000-15,000 population in Sikkim. The first and foremost permission from the office of principal directors was sought as the study involved subcenters. The chief medical officer and medical officers were informed from the office of the Health directorate for co-operation to the investigator regarding the study. In the first stage, two primary health centers under the east district were selected randomly (by the lottery method) in the office of the chief medical officer, East district. The selected PHCs were Sang and Pakyong PHCs. In the second stage, from each of the selected PHC, three subcenters were selected randomly (by the lottery method). The selected subcenters were Ranka, Rumtek, Martam, which are under Sang PHC and Assam Lingzey, Aaho, and Changay Sente, which are under Pakyong PHC. In the third stage, 100 men were selected from the random number table. The process was done separately for all the subcenters. In this way, total required numbers of new 600 men were obtained. But during the survey, information could not be collected from four selected participants, as they could not be located even after repeated visits. So in the total number of respondents was 596 from a reference population of 53,174 (Sang PHC-24,586, Pakyong PHC-28,588).
The investigator visited the individual subcenters and meeting was arranged with the male multipurpose health workers posted there. Full cooperation from them was ensured after explaining everything about the study in detail. The main point stressed was that the study was totally for research purpose and not for any kind of evaluation of their performance. All the eligible couples' registers maintained in the subcenter were checked and a list was prepared of the men whose names were enrolled there. All relevant information necessary for the study was noted down (name and proper address where he/she was residing at that time). For each center a separate list was prepared with the help of the male multipurpose worker of the particular subcenter from the eligible couple register. The sample selections were done randomly by the random number table. A rough guide map and location of the selected households were prepared for identification and to prevent duplication with the help of Panchayat and multipurpose worker. The households and men were identified with the help of the multi purpose worker. The intention of the research was explained to each of the participant in the study. Maintenance of strict confidentiality was ensured. And oral informed consent was obtained from each of the participants. On average the investigator could interview 7-8 men per day.
The data collected were thoroughly cleaned manually and entered into Microsoft Excel (version 7.5) spread sheets and analysis was carried out. The procedures involved were transcription, preliminary data inspection, content analysis, and interpretation. A chi-square test for proportions was used to analyze the data in this study.
| Results|| |
A total of 596 married men whose names are enrolled in the eligible couple register were interviewed. Information about the demographic characteristics, found to be relevant for the study, was collected. The use of contraceptive was high among the cultivators, men (44.45%), spouse (36.01%) followed by persons in Government service respectively 31.49% and 31.55%. However, no significant association was noted with occupation in contraceptive use (χ2 = 0.61, P > 0.05) [Table 1].
|Table 1: Distribution of men using contraceptive and men whose wives are using contraceptive according to occupations|
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Hindu men (55.42%) and women (69.25%) were the majority users of contraceptive followed by Buddhist and Christian. However, no significant association was seen with religion in contraceptive use (χ2 =0.07, P> 0.05) [Table 2].
|Table 2: Distribution of men using contraceptive with those wives are using contraceptive according to religion|
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Other backward communities' (OBC) men (47.53%) and their wives (52.31%) were the majority users of contraceptive followed by men (35.81%) and wives (33.87%) in schedule tribes. There was significant association between contraceptive use and ethnicity (χ2 =0.03, P < 0.05) [Table 3].
|Table 3: Distribution of men using contraceptive with those whose wives are using contraceptive according to ethnicity|
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The significantly higher number of users of contraceptive were literate men (72.33%), their wives (86.17%) (χ2 =0.021, P> 0.05). Still, in our study sample it was notable that, with the increase in literacy, the reported use of contraceptive was decreasing [Table 4].
|Table 4: Distribution of men using contraceptive with those wives are using contraceptive according to education|
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The significant majority of contraceptive users of our respondents were in the age group 25 years and above, men (95.68%) and their wives (90.09%). Highest use was found in men and women (44.47%) in 35 years and above (43.83) age group. But this difference was not significant (χ2 =0.2, P > 0.05) [Table 5].
|Table 5: Distribution of men using contraceptive with those whose wives are using contraceptive according to age of the respondent|
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With the increase in number of losses of children the contraceptive use declines among men and their spouses. In men contraceptive use decreased from 84.57% use with no loss to 1.86% with loss of one child. In the case of womenfolk these figures were respectively 78.81% and 5.53%. With the loss of more children it decreased further [Table 6].
|Table 6: Distribution of men using contraceptive with those whose wives are using contraceptive according to loss of children|
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Among the contraceptive users maximum were at a distance 1 hour and above from the health center compared to others. No association was seen with travel time to the nearest center in contraceptive use [Table 7].
|Table 7: Distribution of men using contraceptive with those wives are using contraceptive according to travel time to the nearest health center|
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| Discussion|| |
It is found that of the female contraceptive methods, oral pills 41.6% was the most common method of contraception, female sterilization 16.6% was the second one, and then condoms 16.5%, the least used methods being IUD 4.4% and vasectomy 4.7%. Although 98% of women in Sikkim knew about female sterilization, IUD was the best known spacing method among women with 90% knowing about it. The least used method was condom, only 79%.  Better educated men, those in government service, cultivators, and those in private sector were seen to suggest the use of contraceptive more. These groups had lesser number of children then those who are less literate. Contraceptive users were also higher in this group. This findings are in agreement with the many findings of past studies like those of DHS and family survey carried out sub-Saharan African countries where higher education was found to be consistently associated with reduce fertility and more use of contraceptive. 
In our study sample it was notable that, with the increase in literacy, the reported use of contraceptive was decreasing. This may be because of the traditional, religious beliefs, and practices. No association was seen with education in contraceptive use; this may be due to the lack of motivation and general health education. Highest contraceptive use was found in men and women (44.47%) in the 35 years and above (43.83) age group. This could be due to the fact that men whose age is more than 25 years usually have a mindset of at least one child norm and opt for contraceptive. Contraceptive users were higher at distances 1 hour and above from the health center compared to others. We can assume that the health providers were reaching the beneficiaries of distant places. It also indicates that most health centers were situated away from population dense areas, like the village center.
The sociodemographic variable found to be strongly influencing the use of contraceptive was the number of losses of children. With the increase in the number of losses of children use of contraceptive declined. This shows that the number of living children has strong positive influence on current contraceptive use. The loss of children was found to have a strong influence on the use of contraceptive in some studies.  Studies in some regions have shown that one reason women give for nonuse of contraceptive is husband's disapproval.  Even in developed societies studies have shown important effects of the husband's desire on a couple's fertility. Couple, or spouse, communication can be a crucial step toward increasing men's participation in reproductive health. Since men, as well as women play key roles in reproductive health, communication is necessary for making responsible, healthy decision. 
Some studies have shown that a substantial number of married men know of at least one method of family planning but only a small proportion of these who know a method are practicing contraception.  Overreporting by men have been highlighted by many studies. In this study it is the wives who are using contraceptive 73% more than the husband 27%. A total of 83.8% of men in other studies reported to be using contraceptive whereas it was reported to be 54% by women. 
When comparison was done between the men using the contraceptive and the men whose wives were using contraceptive, it was found that men whose wives were using contraceptive were 73% more than men who were using contraceptive 27%, whereas in studies it is seen that husbands often report greater method use than their wives.  Only for approval of the family planning did the proportion of women exceeds that of men. Otherwise men reported greater use of contraception in all several factors, multiple sexual partners, differential reporting of condom use by husbands and wives, difference in perception of rhythm among marital partners, and underreporting of method use because of the presence of other adults during wives' interviews. 
Men and women have somewhat different priorities when choosing a contraceptive method. Despite many similarities between women and men in their perceptions about the characteristics of each method type, numerous differences between them may have an important influence on how couples made their method choices. 
Research on male involvement demonstrated that men are more likely to support FP and to use a method themselves if services and educational programs are targeted to them. Because men fear that contraception reduces their control over their wives' sexuality, male-friendly approaches can enhance gender equality in reproductive health decisions. 
The most practiced method in the study was found to be oral pills followed by tubectomy, condoms, and vasectomy. Oral pills, tubectomy, and condoms are more in use because of high motivation of the group who are constantly in level with the government healthcare provider and might have received lots of motivation. Increased use of condoms may be because condoms have been extensively promoted for the prevention of HIV infection; a large proportion of community is expected to know the contraceptive benefits of condoms. The result of the study indicates that despite the increase in knowledge about contraceptive, the female contraceptive method still continues to dominate the contraceptive method mix.
Researchers have cited varied reasons for not using contraceptive. Some men fear that, if a women is not at risk of pregnancy, she will be promiscuous; other reasons for not intending to use family planning include lack of communication between spouses, lack of access to contraceptive, the belief that women are responsible for fertility control, and the need for more family planning information. Fear of side effects, want for more children, wife pregnancy, and want for a child may be other reasons for no use of contraceptive among married men.
A major reason for using contraceptive by wives of married men (73%) was availability at the nearest center. So making choice of the method available at community level should be the priority of the family planning program in Sikkim.
Strength of the study
The investigator has obtained all the responses personally after detail probing. The investigator took utmost care to avoid interviewer bias during the time of interview. Enough time and space were given to the respondents to answer their responses. Any doubts faced by the respondents were cleared to their satisfaction without altering their original belief.
Limitations of the study
Although the sample selections were done by the random number method, it had included only married men whose name were enrolled in the eligible couples register. So the responses elicited could have been different if the studies had included even those married men whose names were not included in the eligible couple register. Response bias cannot be denied as the study had sought help of MPWs posted in the area, to contact and locate the men from the selected households. Another limitation of the study was that the information available to measure the husband-wife communication was insufficient to measure the actual dimension and depth of communication. Neither any information could be collected concerning the duration, extent, and result of husband-wife communication on family planning or the intimate partner violence. Other limitations are those which are inherent to most of the cross-sectional data, i.e., inability of make causal inference. The study could not be developed and followed up later for deeper understanding of the problems as the principal investigator stayed far away from the study centre.
| Conclusion|| |
Male involvement is not limited to male sterilization and condom use. It refers, rather, to the supportive attitudes that males have toward their wives and proactive sharing of responsibility in reproductive health matters, including contraception. Men are currently getting interest on family welfare activities.  The finding of the research indicated that awareness and the prevalence of contraceptive use among married men in a rural community in the east district of Sikkim were quite high which are very positive about family planning. Researchers and providers often ignore the social significance of men. A research agenda should define factors at both macro and micro levels that interact to adversely impinge on reproductive health outcomes.
| Recommendations|| |
Given the findings in the present study, the following recommendations are made. -
The health education system needs to improve knowledge about contraceptive among the male with lesser educational level that could be done by means of behavior change communication (BCC) tools preferably based on audiovisual techniques.
Removal of myths and misconceptions
The information education and communication system should have some productive advertisements to motivate the general public to focus on clearing the myths and misconceptions about contraceptive and keep the people well informed about the importance of family welfare.
Provision of incentives
The general public must be encouraged and motivated by provision of incentives in different forms apart from cash benefits like follow-up, free advice, free higher education for children, etc.
Provision of better facilities
The provision of better facilities and making people aware of recent findings and techniques, like nonscalpel vasectomy, is associated with a lower risk of medical problems during and after the procedure.
What is the level of knowledge and practice regarding contraceptive use prevalent among adult male?
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]