Further report on the higher frequency of withdrawal as contraception among Iranian women: demand for more powerful education programs in health care systems

Background : Family planning has critical role in improvement of various aspects of community health. Owing to the limited and incomplete previously performed studies, the present work was conducted to determine the frequency of contraception methods and most important factors in selection of them among women of Tehran province. Methods : The present assay was designed as analytical and observational cross-sectional study. A questionnaire including 24 questions was filled for 395 women (18-40 years old) refereed to multiple private clinics in three selected strict of Tehran. Questions were designed in order to address the type of contraception method besides multiple social, economic and cultural factors which may affect the selection and demographic characteristics of enrolled samples. Results : The frequency of the type of contraceptive methods was significantly different among women in different age categories (p-value=0.01). Overall rate of using contraceptive methods was 75.2% while remaining of the participants believed in no need for contraception. The most prevalent contraceptive methods were traditional methods (55.9%), modern methods (29.1%), combination of methods (8.1%) and surgery methods (6.8%), respectively. Status of housing was the only factor among economic issues which was meaningfully associated with the selection of the method. Conclusion : High prevalence of natural contraceptive methods even among highly educated women is relying on the demand for more education regarding the selection of best methods based on the background information, obstetrics history, age and economic status of women. Results of the present study can be implicated


Introduction
Family planning is considered as an effective strategy in improving community health through decreasing maternal and children mortality and morbidity (1). It is included in United Nations children's fund and fundamental health interventions required to be performed for women's health. In developing countries with increasing rate of live birth and deliveries as well as abortion of unwanted pregnancies, selection of the most appropriate contraception tools can dramatically affect the community health score (2). In recent years by increasing the tendency of families to have lower number of children and illegal sexual relationship especially among young women, demand for contraception control is feeling more than ever.
Despite global education and free informative programs, there are many different socioeconomic and cultural factors which can interfere in the selection of the appropriate choice of contraception. Although, Iran was one of the most successful countries in family planning especially among Muslim communities, having no contraception or traditional methods as well as withdrawal is still one of the most acceptable method of choice among married and in relationship women (3).
Improper selection of the most safe contraception tools has resulted to high frequency of criminal and illegal abortion and its health side effects as well as infertility (4). In addition, recent economic sanctions and high price of modern tools There are many reported factors which have been shown to be meaningfully associated with the choice of contraceptive tools including fertility history, income, education and job, age and some of other demographic characteristics of women and their husbands (5). The present study was conducted to determine the most important socioeconomic and cultural factors which may be the reason behind choosing methods of contraception. To the best of our knowledge, it is the primary multicenter study which was designed to determine the frequency and the reasons of choosing the contraceptive tools among married and in relationship women resident in Tehran.

Materials and Methods
The present study was designed to be performed in three selected area of Tehran city. Four hundreds married women aged 18-40 years old whom were randomly recruited to multiple gynecologic clinics and offices during the period January to July 2019. All the enrolled women have filled the consent form according to 1964 Helsinki declaration and its later amendments or comparable ethical standards. Of note, considering the total number of women who are resident in selected three areas and are using contraception, studying > 290 samples is enough to reach confidence level of 90% and generalize the results to remaining of the population.
Women whom were included in the study were in reproductive age and had at least one male partner. Data was gathered using a semi-structured and pretested questionnaire via interviewer-administered method and the questionnaire was

Results
Five surveys were excluded from further analysis due to more than two questions have been unanswered and therefore the assay was performed on the remaining 395 questionnaires. The mean of age of participants was 30.75 ± 8.00 years old and there was no significant correlation between age and type of contraception. More than 97% of the participants were familiar with various types of contraception and there was no meaningful correlation between this familiarity and selection the type of contraception, as well. Forty three (10.8%) participants were using of more than one contraception meanwhile. In spite no meaningful correlation, academic sources (28.1%) and using of multiple methods (26.9%) were the most frequent ways of introducing women with contraceptive methods. Among economic factors, there was significant association between the location of house and the type of contraception as in low economic levels strict the resident women had more trend toward having no contraceptive tools (p-value: 0.04). Moreover, the size of house and family income were in significant association with the type of contraception except of withdrawal method, as well (p-value = < 0.0001 and p-value = 0.007, respectively).
Withdrawal was the most frequent type of contraception followed by condom (and 6 spermicide) and calendar rhythm method (Fig. 1). Withdrawal method demonstrated similar distribution among women with different socioeconomic status and age ranges. Moreover, it was found that using of withdrawal method has been insignificantly increased in women older than 37 years old (p-value = 0.06). Among women with higher number of offspring, intermittent methods as well as condom and spermicide were the most frequent type of contraceptive selection. Nighty one women (23.03%) had history of abortion (including criminal abortion) which was not in meaningful association with type of used contraception as well as history of unwanted pregnancy (p-value = 0.23).
Among studied women, 220 persons had a specific job and the rest of them were housekeeper and, there was no meaningful association between the job and type of contraception (p-value = 0.45) as well as education (p-value = 0.08). In assessment of the most important factor determining the type of contraception, user-friendly and availability of the method was the most frequent cause of selection (33.2%).
Attitudes of women and their husbands have been shown to be significantly associated with the type of used contraception (p-value < 0.0001) (Fig. 2). LDSt test demonstrated that the number of offspring had significant effect on the selection of contraceptive methods (p-value < 0.0001) (Fig. 3).

Discussion
Herein, it was found that the withdrawal method is the most frequent way of contraception among the studied population regardless of socioeconomic status, age and education level. It is in line with this evidence that except of a few studies (6), withdrawal has been introduced as the most frequent traditional contraceptive method worldwide including Iranian population. Owing to the high rate of user error, it is considered as ineffective method associated with high rate of unwanted pregnancy (up to 27% in the first year) (7) (8). It was previously reported that easy to use, low expense and no need to medical care and advice are the most important factors behind selection of withdrawal as method of contraception (9) was associated with economic factor among Afghani women but also affected by the age range in order that the use of contraception was increased in higher ages (14).
However, in the present study, it was shown that in spite of no meaningful association with age, using of contraception methods was lower among women less than 20 years old and higher than 40 years old. It is relying on the importance of education among lower aged women as the rate of induced criminal abortion has been reported to be higher in younger women considering their fertility potential (15).