Problems of Contraception in Commune IV of the District of Bamako about 109 Cases ()
1. Introduction
Family Planning (FP) is the set of medical or non-medical means and techniques made available to individuals and couples to enable them to ensure their sexuality in a responsible manner, so as to avoid unwanted pregnancies, space births, have the desired number of children at the desired time [1] .
It affects the lives of women and men, from conception to old age, including birth and adolescence. It covers both access to health, health protection, disease prevention and treatment [2] .
The growth of the current population and the problems associated with it are considered to be a brake on the socio-economic development of low-income countries [3] . This situation draws more and more the attention of the public authorities to the control of the natural movement of the population, which for several years has been an issue for the majority of the governments of developing countries [4] .
According to the World Health Organization, in 2019 out of 1.9 billion women of childbearing age (15 - 49 years old) in the world, 1.1 billion need family planning; of these, 842 million use contraceptive methods, and 270 million do not have access to the contraception they need. The proportion of women of reproductive age (15 - 49) using modern methods of family planning, Sustainable Development Goal indicator 3.7.1 was 75.7% globally in 2019; however, less than half of family planning needs were met in Central and West Africa [5] . Every minute that passes, a woman in the world dies from complications related to pregnancy or childbirth; 26 to 53 million abortions are performed each year worldwide [1] . These risky abortions are performed by people outside the medical environment and in poor hygienic conditions [6] .
FP considered an essential component of primary health care and reproductive health. It plays a key role in reducing maternal and neonatal morbidity and mortality rates, as well as the transmission of HIV/AIDS [7] [8] .
It has contributed to the achievement of the Millennium Development Goals (MDGs) and it is currently contributing to the achievement of the Sustainable Development Goals (SDGs): Agenda 2030 [9] .
Contraceptive prevalence is 25% in Africa, but a little higher in some African countries such as Tunisia 75%, Kenya Botswana 30% and Zimbabwe 43% [10] .
In Mali, despite the actions undertaken, the level of fertility remains among the highest in the world (6.3 children/woman). Nearly a quarter of married women (24%) have unmet FP needs [11] .
The Mali Demographic and Health Survey (EDSM) VI of 2018 in Mali places the fertility rate down by 0.5 compared to 2006 when it was 6.6 children/woman [11] . This study also showed in 2018 that three out of 10 married women aged 15 - 49 (30%) said they wanted to delay the birth of a child (delay a first birth or space births) by two years. or more. Additionally, 12% of women said they don’t want any more children. Women who want to delay the birth of a child and those who want no more children have a demand for family planning. The total demand for FP in Mali is 41% [11] .
To reverse this trend, annual campaigns to promote FP are organized by the National Health Directorate (DNS). In 2016, during the twelfth edition, the central theme chosen was: “A constructive commitment of leaders and decision-makers in favor of FP for a fulfilled youth and sustainable development”.
Indeed, contraceptive prevalence in Mali is low at only 17% according to EDS VI of 2018. The priority challenges in family planning in Mali are:
- Challenges in demand for FP services;
- Challenges in providing FP services;
- Challenges in the enabling environment;
- Challenges in monitoring and coordinating interventions.
Faced with this observation, we found it necessary to carry out a study on the problems related to family planning in commune IV of the district of Bamako to understand the difficulties that could explain the low contraceptive prevalence in our context, in order to propose recommendations allowing improve client access and adherence to contraception.
2. Methodology
This was a descriptive and multicenter prospective cross-sectional study, carried out on the offer of contraceptive services in the reference health center of commune IV of the district of Bamako, in the ten (10) CSCOMs and the RENEE maternity hospital. CISSE (MRC). The study period appalled from June 1 to December 30, 2019.
Two subgroups of the study population were involved in the study:
- Service providers;
- Users (clients) made up of women of childbearing age (13 - 45 years old).
The premises of all the PF units of the reference health center of commune IV in the district of Bamako, of the ten (10) CSCOMs and of the RENEE CISSE maternity hospital (MRC); the providers, the clients who agreed to answer our questionnaires made up our sample, the providers surveyed were also assessed for their capacity in counseling with the different methods used.
The variables retained for the analysis concerned the provision of contraceptive products, the socio-demographic characteristics of the clients, the characteristics of the personnel, the organization and operation of FP services, and the opinions of the clients.
The study was conducted under the study direction of a co-director; the questionnaires were developed, pre-tested at the reference health center of the commune IV and corrected before being used in the field. Data were collected by non-participant observation of the practitioner before and during the consultation by completing the questionnaire and administering a questionnaire to each client about their opinions on the services received. A data collection form was used to assess the equipment, the physical environment and the organization and functioning of the elements to be assessed and their compliance with the standards.
Providers were also interviewed to assess their working conditions and to gain their opinions on the services provided.
The forms were anonymous and the confidentiality of the information collected was guaranteed with access reserved for members of the research team.
Data analysis and entry were performed on SPSS 20 with a significance level of 0.05.
The text was entered in Microsoft Word 2013. The statistical tests used were:
- Parametric tests: mean and standard deviation.
- Non-parametric tests: the Chi-2 test.
3. Results
Our survey covered 109 clients and 12 service providers from the various health centers, namely: Commune IV reference health center plus the 10 CSCOMs and the Renée CISSE Maternity Hospital in Hamdallaye.
FP Service Demand Challenges (Tables 1-9 and Figure 1, Figure 2)
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Table 1. Distribution of clients according to the contraceptive methods chosen.
The most used method was implants, i.e. 49.5%.
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Table 2. Distribution of clients according to age group.
The 20 - 34 age group was the most represented at 61.5%. Extreme ages (13 - 45 years old), Average age: 28.05± 7.53.
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Table 3. Distribution of clients according to level of education.
In our study more than 60% of the clients were educated.
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Figure 1. Distribution of clients by marital status. Married women accounted for 74%.
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Figure 2. Distribution of clients by residence. The majority of customers resided in commune IV, i.e. 67%.
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Table 4. Distribution of clients by profession.
Housewives were the most represented at 28.4%.
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Table 5. Distribution of clients according to the number of living children.
80.7% of clients had at least one living child.
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Table 6. Distribution of clients according to the chosen method and age.
F = 25.860, dof = 1, P = 0.001. The p-value is less than 0.05, so age influences the method of contraception chosen.
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Table 7. Breakdown of users by contraceptive method and marital status.
F = 12.495, dof = 1, P = 0.19. The value of p is greater than 0.05, so we can conclude that marital status does not influence the choice of method of contraception.
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Table 8. Distribution of users of contraceptive methods according to the level of education and the contraceptive method chosen.
F = 15.039, dof = 1, P = 0.08. p-value is greater than 0.05; therefore there is no significant difference between the level of education and the method of contraception chosen.
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Table 9. Distribution of users of different contraceptive methods and number of living children.
F = 27.771, dof = 1, P = 0.040. The p-value is less than 0.05; we can therefore conclude that there is a significant relationship between the number of living children and the method of contraception chosen.
FP Service Delivery Challenges (Tables 10-17)
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Table 10. Distribution of clients according to the source of information on contraception.
Health workers were considered the main sources with 34.4%.
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Table 11. Distribution of clients according to the number of contraceptives they know.
56% of clients could name several methods.
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Table 12. Distribution of clients according to previous use of FP.
Former clients were the most represented at 70.6%.
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Table 13. Distribution according to the availability of contraceptive methods within the FP unit of the CSRéf of the C IV during six months.
The methods available during our study were: the pill, the implant, the injectable, the IUD, the condom and the cycle necklace.
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Table 14. Distribution of clients according to their satisfaction during the service.
87.2% of the clients were satisfied with the service.
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Table 15. Distribution of clients according to the assessment of the cost of contraceptive products.
The majority of customers say the cost was affordable at 79.8%.
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Table 16. Distribution of clients according to the causes of non-satisfaction.
Waiting too long was the main cause of non-satisfaction, either 64.3%.
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Table 17. Distribution of clients according to reasons for abandonment.
50% of clients have given up because of their husband’s refusal.
Enabling Environment challenges (Tables 18-24)
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Table 18. Distribution of clients according to the partner’s agreement.
Only 21.1% had their partner’s agreement.
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Table 19. Distribution of service providers according to their qualification.
83.3 of providers were midwives.
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Table 20. Distribution of clients according to their reception.
91.7% of customers were well received.
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Table 21. Distribution of service providers according to their attitude of carrying out rocking counseling.
GATHER counseling was 100% performed by providers.
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Table 22. Breakdown of service providers according to the barriers cited as obstacles to the use of FP.
The husband’s opposition was the main obstacle to the use of PF, either 50%.
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Table 23. Breakdown of service providers according to actions to be taken during consultations.
Hand washing before and after each examination was systematically practiced during our study.
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Table 24. Breakdown of providers by type of training received.
All providers were trained in FP.
The challenges of monitoring and coordinating interventions (Table 25)
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Table 25. Number of new consultations monthly and per year of the different FP units of the CV.
The commune IV of the district of BAMAKO has as new monthly consultation: 580; The commune IV of the district of BAMAKO has as new annual consultation: 7012; At the level of the different FP units.
4. Discussions
We conducted a descriptive cross-sectional study of 109 clients and 12 service providers from the Commune IV Reference Health Center + ten (10) CSCOM + Renée CISSE Hamdallaye Maternity Hospital.
We have taken the age group of 13 to 45 years as being those of women of childbearing age. Most clients were at least 20 years old 83.5%. The youngest client was 13 years old; the mean age was 28.05 years with a standard deviation of 7.53. The oldest was 45 years old. Our result is similar to that of Moussa S et al. who found that most clients were at least 20 years old in 2009 in Bamako in Commune V [12] . Sango S finds that the majority of women of childbearing age are less than 30 years old 68.3% in 1996 in Bamako in Commune IV [13] .
Married women represented 74.31%, single women represented 21.10% and divorced women 4.59%. Singles are ashamed to discuss sex with providers who are older than her, and divorcees because of their status. They prefer to plan with the injectable form or the oral form, available in pharmacies rather than coming to the FP units. Marital status has a great influence on attendance at FP services. Moussa S et al. found that 71.3% of clients were married women in 2009 in Bamako in commune V [12] . Sango S found that 71% of women were married in 1996 in Bamako in commune IV [13] . Zalha Sani M finds that 66.4% of women were married in 2004 in Burkina Faso [14] .
Clients who had at least a basic level of education represented 41.3% against 23.9% with no schooling. The level of Koranic school was the lowest represented with 11%. Attendance at FP services by educated women testifies to their occupation other than childbearing. Sango S found that 69.5% of women had at least a basic level of education in 1996 in commune IV [13] .
Clients without a profession represented 6.4% against 12.8% who are civil servants. Female students and traders accounted for 29.3%. Civil servants visit the FP center less for scheduling reasons; they prefer to come in the afternoon or just on the descent or on weekends. Moussa S et al. found that 49.7% of clients were unemployed in 2009 in Bamako in commune V [12] . Sango S found that 74% of women were housewives in 1996 in Bamako in Commune IV [13] . Zalha Sani M. finds that 16.1% of women were housewives in Burkina Faso in 2004 [14] .
Clients who resided in Commune IV were 67% against 33% who resided outside Commune IV. Access to the center is easy. Moussa S et al. found that 79.4% resided in the commune in 2009 in Bamako in commune V [12] .
Regarding the source of information on FP, the media were cited in 6.4%; friends and neighbors reported in 2.8%; personal reflection 17.4%. The majority were informed by medical personnel with 34.4%. Our result was different from that of Diall et al. [15] who found that the most cited source of information was the media at 82.6%. These differences were due to the fact that the study by Diall et al. was carried out in a school setting only on adolescent girls.
In our study, 38.5% had 2 to 4 children and 32.1% had at least 5 children at the time of the survey. A study conducted by Dembélé S. et al. [12] had found that 17% of respondents had at least 5 children at the time of the survey in 2010 in Bamako in commune V.
All women could name at least one modern contraceptive method. The least known method is 100% male sterilization. Clients who knew only one method accounted for 44%, while 56% knew at least two. Sango S. found that 99.7% of women knew at least one contraceptive method in 1996 in Bamako in commune IV [13] . Zalha Sani M found that 94.2% of women knew at least one modern contraceptive method in 2004 in Burkina Faso [14] . Kodjogbé N. and collaborators found that 91% of women knew a modern contraceptive method in 2001 in Benin [16] .
The result of our survey reveals that 70.6% were former FP clients against 29.4% who were new. The interview with the clients was done in a discreet place in the form of Counseling with the supporting methods.
91.7% of clients were well received; the most used method at the time of our survey was Norplant 49.5%; the least used was the pill 1.8%. The majority of clients at 87.2% were satisfied of the service offered; Le BERCER counseling was performed at 100%. The most common reason for dissatisfaction was waiting too long at 64.3%. Married women used Norplant more. The marital status does not influence the choice of the method, as well as the level of education contrary to the age of the users. Parity has a great influence on the use of modern contraceptive methods. The more children women have, the more they think about spacing births. Sango S. found that 78.6% of women chose the pill against 21.4% who chose other methods in 1996 in Bamako in Commune IV [13] .
DHS III found that 80% of women used the oral form at the time of the demographic and health survey [17] .
Zalha Sani M. found that 70% of women chose the pill.
Kodjogbé N. found that 68% of women used at least one modern contraceptive method in 2001 in Benin [16] .
“Population report” finds, during a survey in South Africa, that 98% of women of childbearing age knew at least one modern contraceptive method: in Ghana 94%; 100% in Tunisia; 100% in Egypt; 86% in Senegal; 99% in India; 100% in the United States and Ukraine [18] .
As for barriers to FP use, some products, such as the diaphragm, cervical cap, female condom, and spermicide, are not available in the various FP units. Side effects were the cause of discontinuation for 17.9% of our clients; 50% against the husband; 10.7% for no reason; 21.4% for desire for children.
20.2% of clients reported that the cost of contraceptive products is not affordable.
Clients who attend the FP unit with their partner’s consent accounted for 21.1% versus 78.9%. Diall et al. [15] in 2010 and Sidibé. I et al. in 2015 [19] , who found that the majority of respondents thought they did not need it with 52.6% and 40.5% of cases respectively.
All providers were female. They only resort to Doctors in case of tubal ligation and resection. The preference of the female provider was explained by:
• Religion: “For Muslims, it is preferable to have one provider”.
• Personal convenience: “Some women don’t want to be examined by a man”.
• Convenience: “Women feel more comfortable with each other”.
The number of new annual consultations was evaluated 7012 consultations in commune IV of the district of Bamako.
During the interview, many providers were looking at gynecological and obstetric ATCDs as well as medical ones interested in diseases such as hypertension, the taking of certain medications for example: uncontrolled high blood pressure is a contraindication to certain contraceptive methods (hormonal).
Infection prevention is acceptable (preparation of contamination water, use of cutting edge box and color-coded bins). All clients benefited from taking BP, only clients who accepted the IUD benefited from a gynecological examination. Providers who thought that the opposition of the husband prevents women from practicing FP were 50%, 33.4% of the providers attribute it to the high cost of the products, 8.3% of them attribute it rather to the religion. During our survey, providers received training on FP, STIs, infection prevention.
List of Acronyms and Abbreviations
AMPPF: Malian Association for the Protection and Promotion of the Family
APF: Family Planning Association
ATCD: History
ASACOLA2: Community Health Association of Lafiabougou 2
ASACOHAM: Community Health Association of Hamdallaye
ASACOLABASAD: Lassa Community Health Association
ASACOLAB5: Community Health Association of Lafiabougou Bougouni
ASACO of Kalabambougou: Community Health Association of Kalabambougou
ASACOSDJIP: Community Health Association of Djicoroni
ASCODJENEKA: Community Health Association of Djenekabougou
ASACOLA1: Community Health Association of Lafiabougou 1
ASCOSEK: Sebenicoro Community Health Association
ASACOSEKASI: Community Health Association of Sebenicoro Kairabougou-Sibiribougou
CSREF: Reference Health Center
CSCOM: Community Health Center
IUD: Intra Uterine Device
STI: Sexually Transmitted Infection
FP: Family planning
BP: Blood Pressure
HIV/AIDS: Human Immuno Virus/Immune Deficient Syndrome
Appendices
SURVEY SHEET
• FOR USERS
I. IDENTIFICATION OF THE PERSON
No
1-Age …………………………………………………………………………….
2-Address ………………………………………………………………………..
3-Occupation ……………………………………………………………………
4-Religion ……………………………………………………………………......
5-Ethnic groups …………………………………………………………………
II. SOCIO-ECONOMIC CHARACTERISTICS
a-Level of education
1-Primary
2-Secondary
3-Superior
4-Koranic School or Medersa
5-No schooling
b-marital status
1-Single
2-Bride
-Polygamy 2a-Yes 2b-No
3-Divorced
4-Widow
c-Obstetric history
1-Gesture
2-Parity
3-Inter-birth interval
4-number of living children
5-Number of child deaths
6-Abortion
6a-provoked
6b-spontaneous
d-Gynecological history
-Cycle:
1-regular
2-irregular
-Plenty:
1-abundant
1-not abundant
-Cycle duration:
1-≤28 DAYS
2-(28 - 35) days
3-≥35 DAYS
-Dysmenorrhea:
1-YES
2-NO
-Dysuria
1-YES
2-NO
-Pruritus
1-YES
2-NO
-Leucorrhoea
1-YES
2-NO
-Pollakiuria:
1-YES
2-NO
-History of contraception
1-YES
2-NO
e-Other antecedents
-Medical:
Diabetes
1-YES
2-NO
Asthma
1-YES
2-NO
Hemoglobinopathy
1-YES
2-NO
hypertension
1-YES
2-NO
heart disease
1-YES
2-NO
Hepatopathy
1-YES
2-NO
Other
1-YES
2-NO
If yes, specify:………………………….
Surgical:
1-YES
2-NO
If yes, specify: …………………………
III. METHOD OF CONTRACEPTION
1 Method of contraception currently used
1-Condom
2-Implant
3-Injectables
4-IUD
5-Pill
6-Diaphragm
7-Spermicides
8-None
9-Other
2 Why did she change her method
1-Dizziness
2-Vomiting
3-Weight gain
4-Vaginal dryness
5-Amenorrhea
6-Metrorrhagia
7-Forgetting
8-Desire for a child
9-Menometrorrhagia
10-hypermenorrhea
11-Other to be specified
IV. WHY DO YOU PRACTICE FAMILY PLANNING
1-Avoid pregnancy
2-Birth spacing
3-Limitation of births
4-Fight against sterility
5-Fight against STIs/AIDS
6-Other
V. WHO ADVISED YOU TO PRACTICE FAMILY PLANNING
1-After personal reflection
2-Friend
3-Husband
4-Media
5-Health worker
6-Parents
7-Neighbors
8-Other to be specified
VI. WHY DID YOU CHOOSE COMMUNE IV OF THE DISTRICT OF BAMAKO FOR PLANNING
1-Good quality
2-Geographical accessibility
3-Greater discretion
4-Financial accessibility
5-Staff skills
6-Other (to be specified)
-How much the PF service cost you
-Does this price seem reasonable to you?
1-Yes
2-No
-Do you find it acceptable for information on the FP to be broadcast on radio, TV, theaters or other?
1-Yes
2-No
Do you think that we reduce morbidity and mortality related to pregnancy and/or childbirth?
1-Yes
2-No
Have you (or your partner) ever used birth control?
1-Yes
2-No
Did the provider give you the right to choose the FP method you wanted?
1-Yes
2-No
Do you feel you have been treated with dignity?
1-Yes
2-No
Was the interview with the provider comfortable for you?
1-Yes
2-No
Follow-up: Has a provider told you when to come for another visit?
1-Yes
2-No
Did the provider give you time to ask them questions?
1-Yes
2-No
• FOR PROVIDERS
1-Number of new consultations /monthly/year……………………
2-How does your center get its supplies:…………………………
3-Training: Do you believe you have access to the training and knowledge necessary to perform all the tasks required of you?
1-YES 2-NO
4-Information: Are you kept regularly informed of information concerning your functions?
1-YES 2-NO
5-Infrastructure: Do you consider that you have the physical premises and the organization necessary to provide services at an acceptable level of quality?
1-YES 2-NO
6-Products: Do you continuously receive reliable products and materials necessary to provide services of appropriate quality?
1-YES 2-NO
7-Directives: Do you receive clear directives from your superiors to proceed, when necessary, with the changes to be made?
1-YES 2-NO
8-Do you think that the number of customers you receive daily allows you to offer a quality service?
1-YES 2-NO
9-Support: In case of work overload, do you receive support or support from other units?
1-YES 2-NO
10-Respect: Do you feel recognized for your skills and respected for your human needs?
1-YES 2-NO
11-What are your difficulties? .......................................................................