Background

Worldwide, contraceptives prevalence (the percent of couple currently using contraception) is estimated to have reached 58% [1,2]. At 70%, the average level of use is higher in developed region than in the less developed regions, where average use is estimated at 55% [1,3]. While overall levels of contraceptive use remain higher in the more developed regions the gap is narrowing in developing countries [1,3]. Creating awareness of people concerning family planning always influences their decision to use or not to use a particular family planning method [4,5]. In Nigeria, [6] revealed that women said they were not going to practice family planning because it was not effective. They stated that those who had practiced family planning before often complained of it ineffective. However, in a similar study conducted in Lagos, Nigeria, by [7] it was showed that women said they were practicing family planning because it was effective against unintended pregnancies. In Ghana, [8] findings revealed that women had high knowledge on family planning with their sources of information being coming from the media, friends and relatives.

Similarly, in Basra city South of Iraq, a study has showed that health personnel (54%), relatives (41.2%) and friends (4.8%) were the major sources of information of participants’ knowledge of family planning [9]. A study conducted by [10] among women revealed that there was an association between women age and knowledge concerning family planning information and service. The analysis of the results was found to be statistically significant at p >0.001. But contrary to that a study in South Indian by [11] revealed no statistical significant association between women age and they having knowledge on family planning service p >0.008. However, according to [12], there was an association between women educational level and knowledge of family planning service. This difference in findings may be due other factors such as difference in research setting, population and sample size.

According to [13] women who were aged 30 years and above were 2 times more likely to make the choice to use family planning methods as compared to those who were less than 30 years (OR = 2.0; 95% CI: 0.9- 4.2; P = 0.000). Implying that age of women was a significant factor for family planning service usage.

According to [14], there was a statistical relationship between women marital status and using family planning methods in Ghana. Similarly, marital status was found to be a predictor of women using family planning methods in Kenya [15]. This relationship could be due to the seriousness that married couple attach to family planning method in order to plan for their families as compare to single women. Occupation of women was found not to be a significant factor of family planning practice [16]. For instance, a descriptive sectional study of women in Kenya revealed that there was no statistical association between occupational status of women and the practice of family planning methods [17]. On the aspect of husbands, [18] also observed that women husbands’ occupational status did not significantly influence them to go in for family planning service. However, according to [19] women whose husbands were employed in the formal sector were 4.5 times more likely to influence them to use family planning methods as compared to those who husbands were not working (OR =4.5; 95% CI: 0.9- 4.2; P= 0.003).

Method

Research design

A facility based descriptive cross-sectional study was used to solicit the views and experiences of a cross section of women in Bawku Presbyterian hospital about their knowledge on family planning method. The researcher considered that women were exposed to family planning in the study institution and the outcome was their knowledge and utilization in relation to family planning. This type of research design was considered because the researcher was not able to sample all the study population at the study setting.

Research setting

The Republic of Ghana is centrally located on the West African coast. It has a total land area of 238,537 square kilometers, and it is bordered by three French-speaking countries: Togo on the east, Burkina Faso on the north and northwest, and Côte d’Ivoire on the west. The Gulf of Guinea lies to the south and stretches across the 560-kilometre coastline [20]. The Bawku Municipality is one of the thirteen districts and municipalities of the Upper East region in Ghana. The municipality has a total land area of 247.23720 (sq.km) and it is located approximately between latitudes 11⁰ 111 and 100 4⁰1 North and longitude 0⁰ 181w and 0⁰ 61 E in the north-eastern corner of the region. It shares boundaries with Pusiga District to the North, Binduri District to the South, Garu-Tempane District to the East and to the West with Bawku West. It should also be noted that it borders Togo to the North of Togo and Burkina Faso to the South of Burkina Faso internationally [20].

The study was conducted in the Bawku Presbyterian Hospital in the Bawku Municipal of the Upper East region. The Bawku Hospital was established in 1953 by government of Ghana and was handed over to the Presbyterian Church in 1956 [21]. The hospital is made of 331 bed capacity of 12 wards. The hospital has major specialty areas/departments such as; Obstetrics/Gynaecology, Orthopedic/Physiotherapy, Eye, General Surgery, Ear/Nose and Throat, Dental, Family Planning units as well as general out patient’s departments and Medical/Surgical and Paediatric Wards. The Obstetric/Gynaecology department is made up of maternity block of 35 bed capacity which was under expansion; it also has separate antenatal and postal clinics, family planning unit and child welfare clinic. The department is the referral center for the various health facilities within the Bawku Municipal [21]. The hospital is headed by the general manager appointed by the Presbyterian Church and various line managers to support in the administrative activities of the hospital. The line managers are however appointed by the general manager in consultation with the Presbyterian board.

Research population

All women in the study area who attended the Bawku Presbyterian Hospital were considered as the target population. The accessible population was drawn from this population particularly Women in Their Fertile Age (WIFA) who met the study inclusion criteria.

Sample size determination

A total population of 344 women were sampled. This sample size was calculated using Snedecor & Cochran (1989) formula.

Formula; n= z²pq/d²

Where;

n= sample size

p= estimated women using family planning services

q= 1-p, estimated population not using family planning services

z= statistical certainty chosen (confidence level)

d= precision desired (type one error)

If the acceptor rate of family planning is 30% [22] (p=0.30), d=5% (0.005) and z=95% (1.96)

Then;

n= z²pq/d²

n= (1.965)² (0.30)(0.70)/(0.005)²

n= 322.7

An additional value of 21.7 was added to 322.7 to obtain a sample size of 344

Sampling technique

A simple random sampling technique was used to sample respondents in the hospital. Women who attended the facility on daily basis were asked to pick pieces of papers after they had consented to take part in the study from a bowl. These pieces of papers contained “yes” or “no” All those who picked yes were used as study participants. Simple random sampling technique was used in order to avoid bias and to ensure that each woman had an equal chance of being selected for the study. This was done at the time women were waiting for their turn to be attended to by health care personnel.

Data collection instruments

A structured questionnaire with both closed and open-ended questions was used to collect the data. The questionnaire was designed in line with the study objectives. The questionnaire was administered to the women in the hospital setting. Research assistants were employed to read and administer the questionnaire to women who could not read and write. The research assistants were employed to do the exercise because of the large numbers of respondents. The researchers took four weeks to collect the data from the respondents in the hospital environment.

Reliability and validation of the instrument

The initial draft of instrument was subjected to face validation. The essence of validating the instrument was to ensure that it would elicit the information it was designed for. According to [23], validity refers to the extent to which an empirical measure adequately reflects the real meaning of a concept under consideration. The relevance of the items to the purpose of the study was checked, clearly stated and confirmed to be capable of eliciting for the right response from the respondents. To determine the reliability of the instruments, the research instrument was tried and tested using 10 randomly picked women in the Urban East Health Center located in ‘North Natinga’ closer to the hospital in the Bawku municipality.The pretesting was done to get firsthand information on the trends in the difficulty of questions expressed by respondents. The questions were then restructured and the necessary corrections made before the actual field work was carried out. To avoid false information during the actual field study women used for the pre-test were different from those used for the actual study. Lessons learnt from the test study were used to make the necessary amendments to improve the reliability and validity of the study in general.

Data analysis and presentation

The completed questionnaires were crossed checked for completeness and accuracy. The data was analyzed using Statistical Package for Social Science (SPSS) software package (version 22.0). Descriptive and inferential statistics such as Analysis of Variance (ANOVA) and Cross tabulations were used to describe the data where applicable. The findings are presented mainly in tables and charts.

Ethical considerations

Ethical clearance was obtained from the University for Development Studies and submitted to the study institution. The head of the study institution granted the permission for the study to be conducted with women attending the hospital. Written consent was obtained from each woman participating in the study after the researchers explained about the purpose of the study. No compensation was rendered as direct incentive to the participants. No harm or discomfort was inflicted on any respondent or any non-respondent. The decision to participate or not rested solely with each participant.

Results

Demographic characteristics of respondents

The demographic background of the respondents is shown in (Table 1). The table depicts the following variables; age, religion, marital status, educational status, occupational status, educational status of their husbands and occupational status of their husbands. Age is an important factor in maternal health. From (Table 1), the demographic profile of the respondents in this study showed that majority of the respondents (55.9%) were in the age group (25 to 34) years old, 36.3% were in the age group of (15 to 25) years old and 7.6% were in the age group (35 to 45) years. The mean age of the respondents was 22.2 (SD 2.9). From the (Table 1), there was a married preponderance of 78.2% whilst 18.9% respondents were single or in a consensual relationship and 2.9% respondents claimed there were divorced from their husbands. The average age of marriage among the respondents was found to be 21.1 years and the average age of first pregnancy was found to be 22.8 years.

The educational background of the respondents is also important since it could contribute to the reliability of the results as respondents could have a fair understanding of the variables that were investigated. Analyses showed that 18% respondents had at least some form of Senior Secondary School Education (SHS), 34.9% respondents had at least some form of Tertiary education, 21.8% respondents had at least some form of Junior Secondary School (JHS) education and 13.4% respondents had no formal educational training.

From the analyses, majority of the respondents were from the Islamic faith (61.3%) whilst 36% respondents and 2.7% respondents were from the Christianity faith and the African Traditionalist Religions (ATRs) respectively. This finding of the study is not surprising as many people in Bawku Municipality are predominantly Muslims. The occupational status of the respondents was assessed. From the results in (Table 1), (58.7%) of the respondents were in the informal sector while 41.3% respondents were salaried workers. the mean occupational status of the respondents was 1.40 ± 0.61 (mean ± SD). The educational level of respondents’ husbands was also assessed. From the results in (Table 1), most of them representing 31.1% had some form of Secondary school education whilst few (25.6%) had no form of any educational training. From the results in (Table 1), also, most of respondents’ husbands were salaried workers (41.9%) whilst others were unemployed (20.9%). Respondents were asked to indicate the number of children they were currently having. More than half 55% said they had 1-4 children, 25% said they had 1-2 children, 10% respondents were evenly distributed at having 4 or more children and primigravida.

Knowledge level of respondents on family planning

The current study had shown that Inadequate knowledge concerning family planning practice have continuously exacerbated the vulnerability of women, culminating into high maternal and infant mortality, increasing hard core poverty, disintegration of the extended family system, high incidence of HIV/AIDs and sexually transmitted infections among other [3].

Meaning of family planning

Respondents were asked to explain how they conceptualized and understood family planning, majority of respondents (83%) explained family planning in the context of controlling pregnancy and 14% respondents said family planning is spacing birth. Whilst 3% respondents said family planning is preventing Sexually Transmitted Infections (STIs) and pregnancy. Even though only 3% of the respondents conceptualized family planning services to be prevention of STIs, it is good since the first step in seeking health care is the acquisition of knowledge of the condition. If these respondents are aware of the fact that if they do not use family planning methods they are susceptible to STIs during sexual episodes, it means they would take measures to prevent such occurrence or measures to reduce the occurrence of STIs during sexual intercourse.

Duration of use of family planning methods

From (Table 2), most 82 (44.3%) of the respondents who were using contraceptives at the time of the research said they had used it between 1-2 years and 74 (40%) said they had used it less than a year. It also showed that 49 (26.5%) respondents said contraceptives can be used immediately after birth whilst 44 (23.8%) respondents said contraceptives can be used after birth between 4-5 months. The rest are showed in the (Table 2). Having the right knowledge of when to use family planning service could prevent unwanted pregnancies especially immediately after birth.

Effectiveness of family planning methods used by respondents

Most (47%) of those who had ever used family planning service before said it was effective. With this number of respondents testifying to the effectiveness nature of family planning methods may motivate them to still continue to adopt family planning or even be in the position to encourage others to also take family planning services and information issues seriously whilst 13% respondents said it was moderate.

Age and use of contraceptives

The analysis showed a statistical relationship between respondents age and usage of family planning methods (χ²=315.55; P˂ 0.001). There was also a statistical relationship between respondent’s educational status and usage of family planning methods (χ²=48.16; P ˂ 0.001). This could possibly be due to the fact that educated women might have been informed of the benefits of using family planning services at various places or by reading more about them. It could also be due to the fact that educated women may dispel rumors associated with the usage of family planning services being spread around even by non-users.

Marital status and usage of contraceptive

From the results in (Table 3), there was a statistical relationship between respondent’s marital status and having used family planning service before (χ²= 174.76; P = 0.004). This could suggest that married women could have been receiving some form of social and financial support from their partners and that could account for their comparative advantage of being more likely to use family planning methods over their single counterparts. It could also be due largely to the fact that married women were more likely to be influenced by their husbands to use family planning to curb the number of children they were more likely to give birth to. It could also be due to the fact that married women may have been influenced by significant others to stop using family planning methods.

Occupation and ever used contraceptive before

The analysis showed no statistical relationship between respondent’s occupational status and respondents ever using family planning services before (χ²= 36.70; P = 1.104). This could explain that both employed and unemployed were found to be using family planning services and provided respondents could get the cost of the service they were offered. This could be so because women’s empowerment was often measured by these three proxies, thus education, employment and knowledge. In their assessment, these proxies or characteristics were important but conceptually distant, and they do always reflect women empowerment on how they make certain decisions in life.

Husband occupation and ever used contraceptives

From the results, there was a statistical association between respondent’s husband’s occupational status and respondents ever using family planning service before (χ²= 201.77; P ˂ 0.001). This could explain that respondents who husbands were not workers and wanted to get a proper work because they begin to start child bearing may have been influenced by that to allow their wives to use family planning methods. It could also suggest that respondents who husbands were workers in the health related sector and had proper knowledge on family planning might have encouraged their wives to use family planning methods. There was however, no statistical relationship between respondent’s husband’s educational status and respondents ever using family planning service before (χ²= 16.70; P = 0.714).

Various types of family planning methods known to respondents

Respondents’ knowledge on the various types of family planning methods available in the hospital was assessed. From the analyses, 320 (93%) said there were various types of family methods to choose from whilst 24 (7%) said they had no idea. Among the former, the various methods were mentioned; Pills, intrauterine device (IUCD), injectable (depo-provera), norplant (buried under skin), condom, spermicidal, tubal ligation/female, sterilization, vasectomy/male sterilization and periodic abstinence/calendar. From (Table 4), 119 (34.6%) respondents indicated that they had ever used pills before whilst 225 (65.4%) said they had never used it before. From the (Table 4), only 4 (1.2%) respondents said they had ever used spermicidal before whilst 340 (98.8%) respondents said contrary.

Additionally, 100 (29.1%) respondents claimed they had used injectable (depo - provera) before whilst the rest said contrary. The rest of the results are shown in the (Table 4). Respondents’ knowledge on natural family planning methods was assessed. From the (Table 4), 194 (56.4%) said they were aware of the calendar method, 137 (39.8%) respondents said they were aware of the withdrawal method whilst 78 (22.7%) respondents said they were aware of lactational amenorrhea. The rest of the results are shown in the (Table 4).

Marital status and knowledge of calendar as a natural method

From the results in the (Table 5), there was a statistical association between respondent’s marital status and knowledge of calendar as natural family planning methods (χ²=125.21; P ˂ 0.001). Socially, women believed that the use of emergency contraceptives, can lead to brake in marriage, it encourages promiscuity, it may also cause stigma, protrude stomach (even when they are not pregnant) and it may finally lead to untimely death.

The opportunity to initiate emergency contraceptive is time-limited, and therefore, using it soon after unprotected intercourse is critical to its effectiveness. Women must know about it before they need it or quickly upon identification of need.

Discussion of Results

Knowledge level of respondents on family planning

In this study, 320 (93%) respondents said they had ever heard of family planning before. This is not surprising at all since there have been campaigns on family planning at the study place due to the declining level of subscribers in the municipality. This finding from the study is similar to the report presented by the [24] where it was revealed that women had high level of knowledge concerning family planning in the world. The result of this study also concurs with that of [25] where female students of Jimma University, Southwest Ethiopia had high knowledge concerning family planning. The study results however, disagree with the findings presented by [26] where women in a rural village in Uganda had no knowledge on family planning. The results showed that, majority of the respondents identified friends, health centers and workshops they had ever attended and the media among others as their main sources of information on family planning services. This finding from the study is similar to the findings presented by [27] where women in Ghana identified similar sources concerning family planning services and information. From the results, most (47%) of those who had ever used family planning services before said it was effective for them.

This finding from the study disagrees with the findings presented by [6] where women in Nigeria said they were not going to practice family planning because it was not effective. However, the results agree with the findings presented by [7] where women in Nigeria said family planning was effective and were encouraging others to go in for it to prevent unwanted pregnancy. While the overall increase in contraceptive prevalence at the global level has been spectacular, the progress in the effectiveness of family planning programs and in the range contraceptive methods used has been uneven at the community level. In 2007, Africa had the lowest level of contraceptive prevalence of 28 % as compared to 71 % in Latin America and the Caribbean and 68 % in Asia [24]. Additionally, there was a statistical relationship between respondents age and usage of family planning methods (χ²=315.55; P ˂ 0.001). This finding from the study is at variance with the findings presented by [28] where there was no statistical relationship between age and using family planning among women in Kenya in an evaluative study (χ²=35.55; df=3; P = 2.22).

However, the results are similar to the findings made by [13] where women who were aged 30 years and above were two times more likely to make the choice to use family planning methods as compared to those who were less than 30 years (OR =2.0; 95% CI: 0.9 - 4.2; P ˂ 0.001). Furthermore, the results showed that there was a statistical relationship between respondent’s marital status and having used family planning service before (χ2= 174.76; P ˂ 0.004). This could be due to the fact that married women were being supported by their husbands to go in for family planning. This finding from the study is at variance with the findings made by [29] where there was no significant association between marital status of women and usage of contraceptives methods in Egypt.

However, the results support the findings made by [14] where marital status was found to be a strong predictor of women using family planning in Ghana. The results also concur with that of [30,31] where marital status in all their studies was a significant factor in women using family planning methods. The results revealed that there was no statistical relationship between respondent’s occupational status and respondents ever using family planning services before (χ²= 36.70; P = 1.104). This could possibly be due to the fact that family planning services were available for everyone to use.

This finding from the study supports the study done by [16,17] where occupation was found not to influence women usage of family planning methods. From the results there was no statistical relationship between respondent’s husband’s educational status and respondents ever using family planning services before (χ²= 16.70; P = 0.714). This finding from the study concurs with the findings made by [18] where women husbands’ occupational status did not significantly influence them to go in for family planning. However, the findings disagree with [19] where women husband’s occupational status was 4.5 times more likely to influence them to use family planning service compared to those who husbands were not working (OR =4.5; 95% CI: 0.9 - 4.2; P˂ 0.003).

Various types of family planning methods known to respondents

From the results, respondents had knowledge on the various types of family planning methods available for them to choose from except that usages of these available methods were not being utilized. It was revealed that only 119 (34.6%) respondents said they had ever used the pills before. This finding from the results supports the study done by [16] where women in a cross sectional study mentioned that they had ever used the pills before. The study also showed that nearly all the respondents’98.8% said they had never used spermicidal before. This finding from the study is at variance with the finding made by [6] where women in Nigeria stated that they had ever used spermicidal before. However, the study concurs with [32] where women in Kenya stated that they had never used spermicidal before. Natural methods of family planning among respondents were also assessed. Findings indicated that 137 (39.8%) said they had ever used withdrawal method as a natural family planning methods before. This finding from the study supports the study done by [33] where women in Bangladesh stated that they had ever used withdrawal method as a family planning method with their husbands.

The finding however disagrees with [34] where women in Nigeria stated that their husbands did not like withdrawal method as a natural family planning method. It is said that some men are knowledgeable about family planning. This assertion is based on the high knowledge of men on vasectomy, injectable, pills and IUDS as effective birth control methods [34]. The study however, blamed men’s low approval of family planning method in the matrimonial homes.

From the study also, 194 (56.4%) respondents said they had ever used calendar method as a natural family planning methods. This finding from the study supports the study done by [35] where women in Malaysia stated that they had ever used calendar method as a natural family planning method before. The findings however, disagrees with the findings made by [32] where women in Kenya stated that they did not know of the calendar method as a natural family planning method since the calendar kept changing and was not reliable for them to observed.

Additionally, there was a statistical association between respondent’s marital status and knowledge of calendar as natural family planning method (χ²= 125.21; P ˂ 0.001). This finding from the study is at variance with the study done by [36] where women who were married had good knowledge on the use of the calendar as natural family planning method than those who were not married. The ability of women to start a successful, uninterrupted and suitable family planning method is influenced by different factors; such as poor access to the health center, community and cultural attitudes as well as individual attitude can all be considered as obstacles to the use of appropriate and effective method of family planning for women. Due to the increasing number of therapeutic abortion, lack of awareness of woman of their right to a have a healthy reproductive life, the stress of family and societal demands on women as well as their ability to be able to cope with motherhood and her role in society, identifying possible methods of family planning that could make it easy for them is vital.

Conclusion

The results demonstrate that good knowledge among respondents was observed concerning family planning services, yet the uptake of family planning among women was very low. The study revealed that mere physical access and awareness of family planning methods are not sufficient to ensure that family planning services needs are met. It is evident from this study that high knowledge on family planning services is not matched with the high family planning services use. This could be due to cultural and other barriers perceived by the women in the study institution. Among reasons for not using family planning services, some respondents said they wanted to have a child and side effects of family planning services were given by respondents. The decision to use or not is primarily influenced by others from within the social network, whose views and perceptions are often more important than an individual’s own. Therefore, family planning campaigns should look beyond the individual woman to include other significant social networks in order to drive demand and remove barriers affecting the uptake of family planning among women.

Declaration

Ethics approval and consent to participate

Ethical clearance was obtained from the University for Development Studies and submitted to the study institution. The head of the study institution granted the permission for the study to be conducted with women attending the hospital. Written consent was obtained from each woman participating in the study after the researchers explained about the purpose of the study. No compensation was rendered as direct incentive to the participants. No harm or discomfort was inflicted on any respondent or any non-respondent. The decision to participate or not rested solely with each participant. I have attached a copy of the introduction letter from the University for your perusal.

Consent for publication

Not applicable

Availability of data and material

The datasets used and analysed during the study are available from the corresponding author and can only be made available on reasonable request.

Competing interests

The authors declare no competing interests.

Funding

The research was self-financed by the author.

Authors contribution

SSA is the main author of the manuscript. The author collected data and analyzed. AY is the main supervisor who read through the manuscript and made the necessary corrections. ABA also helped in organizing the manuscript. All authors have read and approved the manuscript.

Acknowledgements

The authors are most grateful to the hospital management and the clients who participated in the study.

Variable	Frequency	Percent (%)
Age (years)
15-24	127	36.9
25-34	191	55.5
35-45	26	7.6
Total	344	100
Educational status
No formal education	46	13.4
Primary	41	11.9
Middle/JHS	75	21.8
SHS	62	18
Tertiary	120	34.9
Total	344	100
Marital status
Single	65	18.9
Married	269	78.2
Divorced	10	2.9
Total	344	100
Occupational status
Salaried workers	142	41.3
Non salaried workers	202	58.7
Total	344	100
Husband occupational status
Salaried worker	144	41.9
Farmer	89	25.9
Unemployed	72	20.9
Student	39	11.3
Total	344	100
Source: Field data, 2016

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