Women ’ s Preferential Contraceptive Methods in Publics ’ Family Planning Centers in Lomé ( Togo , West Africa ) : A Prospective Study of 734 Cases

Justification and Objectives: The reasons for the choice of contraceptive methods in Lomé were insufficiently documented. The current study aimed to identify preferential contraceptive methods in women in Lomé and the reasons for the choices. Materials and Methods: Prospective study conducted on 734 clients recruited in five family planning centers in the municipality of Lomé over a period of 3 months (30th September to 30th December 2005). Data were collected by direct interview and processed by Excel and Epi info 7 software. Results: Contraceptive methods preferred in descending order were: Medroxyprogesterone acetate injection (51.6%), Norethisterone enantate injection (17.3%), inert Intra Uterine Device (12.0%), Progestogen implants (11.0%), combined oral pills (8.03%) and spermicide jelly (0.1%). The main reasons for choices were the method’s reversibility (32.56%) and its long acting property; especially in illiterate women (p < 10−10). Friends and medical staff counted for the choice in 9.26%. In 76.87% of cases, the husbands were reported to agree with the chosen methods. Conclusion: The choice of contraceptive methods in Lomé was mainly guided by the notion of reversibility and its long acting property. The focus should be put more on the quality of counselling towards women with low education level.


Introduction
Family planning is defined as the use of different methods of fertility control by an individual or a couple in order to space births or to promote desired pregnancies [1].It can therefore be considered as a factor of development since it helps to avoid unwanted pregnancies, it enables good health for mothers and children, and further more allows a better distribution of the resources of a country [2]- [4].Until 2003, only 25 African countries (two-thirds of the total) have adopted an active family planning program [5].The request for family planning services was increasing in some countries on the continent although their use was still low.
In Togo, the urban population's growth rate has been estimated at 4.3% in 2005 [6] and the need for contraception in the country was becoming greater because of the high number of illegal induced abortions and their complications recorded at health centers [7] [8].However, the use of contraceptive methods often encounters difficulties because of ignorance, taboos related to culture and religious affiliation.Studies on the activities of family planning services have been made in Lomé [9] [10] According to the last Health Demographic National Survey, women's common family planning modern methods which were available in publics facilities were: intrauterine device (IUD), Progestin injections, implants (Norplant*), oral combined pills, male and female condom, vaginal methods (spermicides, foams and jellies), method of breastfeeding and amenorrhea, emergency contraception (Levonorgestrel tablets) and sterilization methods as Fallopian tube ligation [10].It was shown that several women received during post natal checking were reluctant to choose some types of contraceptive methods [9].Among women in union in Lomé, only 19.7% were using a modern method and the married ones preferred Progestin injections and the implant [9] [10].These proportions did not virtually change since the previous Health Demographic National Survey of 1998 [10].None of these studies has focused on the reasons for the selection of different contraceptive methods among women in the country.For the implementation of various strategies that could help to increase contraceptive prevalence in Lomé, it was necessary to identify the reasons that supported the choice of each type of method among clients.In this way, this work was undertaken to determine the reasons in choosing the different contraceptive methods among women of Lomé in main family planning services.

Patients and Methods
The study was conducted in five main centers of family planning selected from the five health districts of the municipality of Lomé (it has been selected one main center per health district).It was a prospective and descriptive study conducted over a period of 3 months (30 th September to 30 th December 2005).Socio-demographic characteristics, reasons for choosing a type of method and the preferred methods according to the socio-demographic parameters were studied.
Were included in this study, all women who came in one of the five centers for the choice of a contraceptive method or those who were there for a routine checking (for a planning method in use).Were excluded, clients who had come in order to stop a current method.
Data have been collected by private individual interviews (without the husband's presence) from 734 clients with open questions based on a pre-established survey form.Information regarding the preferences of partners on contraceptive methods were those reported by the women during private talks.Each woman has been questioned immediately after her choice and the administration of the family planning method.The counseling before choosing the family planning method and its administration was made by the nurse or the midwife regularly involved in this activity in the center (we did not intervene at this moment).The data collection in the five centers was made alternatively by the same person.

Statistical Analysis
The data processing and analysis were treated based on Excel and Epi Info7 software.Chi 2 Test Exact of Fischer was applied to establish significance between variables.The results were expressed with 95% confidence interval (p value < 0.05).

Socioeconomic Characteristics of the Women-Medical, Surgical and Obstetrical History
In total, 734 women were surveyed.In Table 1 and Table 2 were notified the socioeconomic characteristics of the women and their medical, surgical and obstetrical history.Women's age ranged from 15 to 50 years with an average of 32 years.The majority (91%) of clients were living in couples and had already three children or more (41.9%).Christian were the most represented (71.55%) and 24.9% of the clients were illiterate.
There were clients who had more than one gynecological and obstetrical history.Total of cases were sometimes higher than the number of the women because some patients had used more than one method of family planning.

Selected Preferential Methods-Reasons for Choice and Profiles According to Long Acting Methods
Preferential methods chosen by women were as well distributed: The reasons for choosing several methods of family planning given by the women were represented in Table 3.According to this table, reversibility of the planning method (58.6%) and its long acting property (53.0%) have been the main reasons of choice.The next reasons were: termination of maternity, discretion of the method.Friends' advice and position of the medical staff have also influenced the choices.These reasons coincided with the choice of long acting methods as Progestin injections, implants or intra uterine device (47.0%).
Several chosen methods of family planning according to women's profile and their partner's preferences (as reported by their women), has been distributed in Table 4.In this table, intra uterine device (IUD) seemed to be preferred by women over 35 years old and with low education level.As for DMPA injections it has been attractive to married women (51.0%) from 25 years (57.4%) with agreement of the partner (53.8%).
The long acting effect has counted secondly in the decision of choice.The profile of women according to long acting methods has been analyzed in Table 5. Age groups (as adolescents, young and aged adults) and marital status of the women did not influence the choice of long acting methods.In opposite, illiterate women choices were significantly linked with long acting methods as DMPAinjections, Norethisterone injections*, IUD and Progestogen implants* (96.1% vs 3.9%, p < 10 −10 ).

Discussion
The present study was undertaken to identify the main reasons for the choice of contraceptive methods among women in family planning centers in Lomé.During this work, respect of the clients' privacy and their choices was regularly sought.For this reason the interviews were conducted in closed session.We have not been able to interview the women's husbands because they did not used to come to the family planning clinic with their wives.Information regarding their opinion were only reported by the women surveyed.This aspect seems to us important because choosing a contraceptive method is better if both partners are really involved in this decision.The duration of the investigation could have been longer (may be six months or one year).This would help to appreciate other parameters that can influence the reasons for choosing a contraceptive method.
The majority of the clients (about 72.1%) recruited in the five family planning centers were between 25 and 39 years old.The average age was 32 years with extremes of 15 and 50 years.This is different from the results of Sepou et al. [11] in Central African Republic in 1997 who found a rate of 43.2% women aged from 25 to 34 years.Indeed, in this age, the need for contraception is important because sexual activity is increased in this period of the life of the woman.After 40 years, sexual activity decreases as well as contraceptive needs; and beyond 40 years, many women end up with maternity and must be approaching pre menopause.This study also revealed that 91% of respondents were living as a couple and most of the clients (39.2%) had a primary school education and there was very few university level (4.6%).Contrary to these results, Sepou et al. [11] had found 16.2% of primary and 32.96% university.It is important to notice that the level of education of a population influences greatly the socio-cultural habits.Women with university level probably went for family planning in private clinic, reducing their number in public family planning centers.
The study of the obstetrical histories showed that 41.93% of clients had more than 3 living children and clients had at least an abortion notion in 18.34% of cases.These results were lower than those of Ravolamanana et al. [12] in Madagascar in 1995 who found a prevalence of 76.9% of women over three living children and 45.4% of users with one or more history of abortion.Compared to those of Rissy [13] (from a national study in Togo in 1998) who found 57.94% of clients with more than 3 living children, our rate is also lower.It appeared that over the years, women of Lomé seemed to opt rapidly for contraceptive methods after their first pregnancies.
The preferred method that came out on top in this study was represented by Progestin injections (68.9%) with a predominance of Depo-Provera (51.6%).This was not the case in the study of Koudan [14] who found that the IUD (45.12%) was the most used method.It was almost in line with those of Ravolamanana et al. [12] in Madagascar, who regained on top injectable Progestin methods (23.8%).
Out of the 734 women surveyed, the main reasons behind the choice were the reversibility in 239 cases (32.56%) and the long acting effect in 85 (11.6%).There was 53% of respondents for Norplant and 47% for IUD concerning long acting effect as reason for the choice.These results differed from the observation made by Black [15] who noticed that clients who were seeking for reversibility opted for the pill.In this study, clients have probably dismissed the pill because of the risk of forgetting the tablet.As for the first three preferential methods (injectable progestin, IUD, Norplant), the long acting effect has greatly influenced the choice.It appeared that, whatever the duration of the method, the users wanted to ensure that their subsequent fertility would not be under stress.Stratified analysis has shown that regardless of the age group, clients are opting more for Depo-Provera than other contraceptives.But it was found that beyond 45 years old, clients also opted for IUD.Age is a determining factor in the choice of contraceptive methods.In the US, adolescents began to benefit from the method of implants [16] [17] with an average age of 16.4 years.Although Depo-Provera was the most chosen method, the stratified analysis shows that among those who preferred the IUD, there was a high proportion of illiterate (34.09%).Clients of primary, secondary and university education levels chose firstly Progestin injection (58.69%) and secondarily IUD.However, Koudan [14] in the same town, two years ago, found in his study that 45.12% and 21.50% of the clients who chose respectively IUDs and pills were enrolled with high level education.Ravolamanana et al. [12] in Madagascar have found that 82% of Norplant users had been educated.It was noted that illiterate clients are often reluctant or opposed to the use of contraception as they did not definitively finish with motherhood [11] [18].In the stratified analysis, apart from Depo-Provera, which was the most chosen by all married women, single women secondarily preferred pills (13.5%) and widows, Norplant (33, 33%).Ravolamanana et al. [12] noticed that, married women in Madagascar, most chose Norplant (77.5%).Ma-rital status has necessarily influenced the choice of a contraceptive method.Women living in couples and widows prefer long acting effect method to singles who prefer the methods of short term duration.
In this study, in 76% of cases, the spouse agreed with the chosen method.Women who had the same preference as their spouses by choosing Progestin injections represented 76.87%.This result differed from those found by Sepou et al. [11] which discovered in 23.3%, the husband's role in blocking the use of contraceptive methods in black Africa.Although the maternity-related problems were still experienced by husbands in terms of financial cost, however they used to look constantly for sexual availability of his partner [11].This could explainthe choice of long acting methods mostly carried by the clients.

Table 1 .
Socioeconomic characteristics of the women.

Table 2 .
Medical, surgical and obstetrical history of the women.

Table 3 .
Preferential contraceptive methods chosen and reasons for choice.

Table 4 .
Profile of women and partner's preferences according to the chosen methods.

Table 5 .
Profile of women according to long acting methods.