Predictors of family planning usage among multiparous women in the Nkwanta-South Municipality of Ghana

Background: Family planning use is one of the most cost-effective public health interventions; averting unplanned pregnancies, reducing maternal deaths, and helps individuals and couples to decide freely and responsibly when to have children. Despite these benets, several research ndings have reported low levels of family planning usage hence the need to determine factors inuencing family planning usage among multiparous women in the Nkwanta South Municipality. Methods: A descriptive cross-sectional study was done using a structured questionnaire to collect data from 328 selected multiparous women living in the Nkwanta south municipality. Data were analyzed using STATA 16. Descriptive statistics were performed to determine the levels of knowledge, acceptance, and family planning usage, while multivariate analysis was done to determine the factors inuencing family planning usage. Results: The ndings of this study show that 318 (96.9%) of the multiparous women had already heard of family planning. Most of the respondents, 204 (62.6%) had good knowledge of family planning, however, a little above average 172 (52.4%) accepted family planning. The proportion currently using some form of family planning was 75 (22.9%), of which 31 (41.3%) were using Jadelle. Multiparous women with good knowledge of family planning were 4.5 (95% CI: 2.30-8.89) times more likely to use family planning compared to those with poor knowledge, while multiparous women with poor acceptance of family planning were 0.43 (95% CI: 0.25-0.75) times less likely to use family planning compared to those with good acceptance of family planning. Conclusions: The result of the study shows low levels of knowledge, acceptance, and usage of family planning among multiparous women. Thus, there is a need to improve health in the municipality to increase knowledge, acceptance, and usage of family planning among multiparous women.


Background
Increased birth rates have been identi ed by many people including community health workers and the staff at the Nkwanta South Municipal Health Directorate as one major health and social problem in the municipality, and most of these births are as a result of unintended pregnancies. High incidence of unintended pregnancies can be attributed to low usage of available family planning methods, resulting in unsafe abortions, pregnancy complications, and maternal deaths (1).
The districts' total fertility rate is 4.0 whilst the general fertility rate is 121.4 births per 1000 women aged 15-49 years, and this is higher than the regional average. This means that on average, a woman in the Nkwanta South municipality would have four children in her lifetime. These women are referred to as being multiparous. The proportion of children below ve years of age is 17%, and the population below 15 years (0-14) is 45%. This was higher than the proportion of children below 15 years for the then Volta region (36.3%) (2). These occurrences of the high number of births could be due to low usage of family planning and could burden the country and obstruct the efforts of the Ghana Health Service and other stakeholders in achieving the Sustainable Development Goal 3, which focuses on good health and wellbeing.
Also, the inadequate availability of data on family planning in district health information management system (DHIMS) from the municipality means that the prevalence and acceptor rates of family planning usage could not be determined. There is also no information in DHIMS on the number of children family planning users have. These situations cause a large number of multiparous women in the municipality who are not using family planning and they keep giving birth more than they could cater for. The inadequacy of data could limit the implementation of an intervention to increase family planning usage (3), reported that the district still had very low use of modern family planning despite the efforts being made to improve family planning usage in the country.
Additionally, a study conducted by (4) to determine the prevalence of contraceptive methods accessed by person, place, and time in the Volta Region of Ghana, between 2009-2014 found that in 2016, Volta Region was one of the two regions in Ghana that recorded a high prevalence of teenage pregnancy due to the non-use of modern contraceptives, accounting for 15.5% of all adolescent pregnancies in the country.
They recommended research to ascertain factors in uencing uptake of contraceptive use in all the districts in the Volta region.
Based on the ndings of the studies above, it has become necessary to conduct a study on the factors in uencing family planning usage among multiparous women in the Nkwanta south municipality of Ghana.

Study design and settings
A cross sectional study was conducted in the Nkwanta south municipality in the Oti region in Ghana, between August 2021 to November 2021. Nkwanta municipality was purposely selected because it was among districts and municipalities with low family planning acceptors in the region (5).

Study Population
The sample for the study comprised selected multiparous women living in the Nkwanta South municipality during the period of data collection.

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The study included selected multiparous women who were residing in the Nkwanta-South municipality during the period of data collection and consented to participate in the study. On the other hand, multiparous women who were seriously sick, in their menopausal stage and require medical attention were excluded from the study.
Sampling and sample size determination Using systematic probability sampling techniques, participants for this study were selected from all the six (6) sub-districts that make up the Nkwanta south municipality. This was to ensure that different population characteristics were captured representatively in the study. The sample size for this study was determined using the single proportion formula by (6), with 95% con dence level, precision of 5%, based on a 27% prevalence of family planning in Ghana among married women according to the (7). Adding an anticipated non-response rate of 5%, the calculated overall sample size was 328 multiparous women.
The existing six sub-districts in the municipality were marked as clusters (i.e., six clusters), and the study community within each cluster (sub-district) was chosen using a simple random sampling technique. Community entry and sampling of participants were done with the help of community health volunteers within each selected community. Secondly, deploying the systematic sampling technique; the households within each selected community were numbered, the rst household selected at random and subsequent ones selected at a suitable interval, (1, 2, 3, …), that corresponded to the number of households in that community. Participants in each selected household were chosen using a simple random sampling method. In all, 53 participants were selected from each sub-district, to get the required minimum sample size of 318 participants. However, an additional 10 were added, making a total of 328 participants.

Data collection and quality management
A structured questionnaire deployed on the Kobo collect tool kit was used to collect data from the study participants. The questionnaire was adapted based on the review of literature from previous studies. Two data collectors were recruited and trained by the principal investigator for 2 days on the various sections of the questionnaires and also on some ethical issues bothering the research. A simulation exercise was conducted among the data collectors. The questionnaire was pretested among 10 multiparous women before the actual data collection.

Data analysis
The collected data ware extracted in Microsoft Excel 2016 and exported into STATA version 16.0 for cleaning and analysis. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to summarize the data. Inferential statistics (logistic regression) were used to nd the associations between demographic variables, level of knowledge, acceptance, and family planning usage. A test of probability value less than 5% was considered statistically signi cant at a 95% con dence interval. The logistic regression model was used to test the signi cance of associations. Findings were presented in tables, graphs, and charts.
Ethical approval and consent to participate Ethical approval was obtained from the University of Health and Allied Sciences Research Ethics Committee (UHAS-REC A. 9 [32] 20-21). Permission was also obtained from the Municipal Director of Health Services of the Nkwanta South Municipality and also from the chiefs of the study communities.
The content or subject matter of this study was disclosed and explained to participants in the language they best understood and their consent obtained before commencement of the study. Participants who agreed to partake in the study were required to sign the informed consent form, while with regards to participants less than 18 years of age, permission was sought from their parents or guardians and they were required to sign the parental consent form while the participants signed the child assent form. There were no expected risks associated with this study. The researcher ensured that participants put on their nose masks and also kept a social distance of two (2) meters before and during the entire period of administration of the questionnaire. However, participants without nose masks were provided with one (1) disposable surgical nose mask before the commencement of the administration of the questionnaire.

Limitations of the study
The interpretation of the results of this study must be done with caution since not all the multiparous women in the municipality were used in the study. Recruitment of participants was done with the help of community health volunteers, and data collection was conducted by individuals recruited by the researcher. However, data collectors were adequately trained and simulation exercises were organized to enable them to understand the need, and how to collect data appropriately.

Results
Socio-demographic characteristics of multiparous women     Reasons for the high number of multiparous women who had ever heard about family planning could be due to the education and sensitization campaigns on family planning across various platforms in the Nkwanta South municipality and the country. This recent nding is also similar to those of other countries, 96% in Mbouda District, Cameroon (8), and 88.9% in Tripura, India (9). The similarity could also be due to the availability of community health workers in the various communities, as most of the multiparous women surveyed heard about family planning from a health worker and also because of information from the media, friends, and relatives.
Also, from the current study, the average knowledge level among multiparous women was 62.6%. This is higher as compared with other studies from, 44% in Nigeria (10) and 40% to 45% in Lahore, Pakistan (11). This could be due to the difference in socio-demographic characteristics.

Level of acceptance of family planning
In this current study, the level of acceptance of family planning among multiparous women was 47.6%. This nding is lower compared to those of other countries reported by (12) (82.2%) in Ethiopia and (13) (62%) in Kenya. The difference in the level of acceptance of family planning between this study and that of the ndings from other countries could be linked to several reasons for which women use family planning or factors that in uence their acceptance of family planning, which includes, fear of family planning side effects, wanting to have another child, family planning use con icts with their ethnicity, disapproval or opposition from husbands on family planning practice and the perception that the use of family planning causes infertility (Table 4.3). The difference could also be because the majority of the multiparous women (52.4%) surveyed in this study who had poor acceptance of family planning may be in uenced by other confounding factors. The poor acceptance of family planning among multiparous women in this study because of the disapproval or opposition from their husbands was 20.4%. This is lower than what was reported in Ho West, Ghana (64.2%) by (14). The difference could be due to differences in healthcare services and socio-demographic characteristics of the locations of these two studies.

Factors in uencing family planning usage
There was no association between socio-demographic characteristics of participants and family planning usage in this study. This is contrary to the nding of (3) in which some socio-demographic characteristics such as level of education and ethnicity were associated with family planning usage.
Knowledge and acceptance were factors in uencing family planning usage in this current study. Multiparous women who had good knowledge of family planning were 4.5 times more likely to use family planning compared to those with poor knowledge. This is similar to the ndings of other countries; (8) found lack of knowledge to be a reason precluding women from using family planning in Cameroon, while (13) similarly found knowledge to be a signi cant predictor to use family planning methods. The reason why knowledge is in uencing the usage of family planning could be because, when women know about the various methods available, they may be more likely to use the methods which they prefer. Also, multiparous women with poor acceptance of family planning were 0.43 times less likely to use family planning compared to those with good acceptance of family planning. This could be due to several factors such as spousal approval, which in uence family planning usage.

Conclusions
Variables capable of measuring the levels of knowledge, acceptance, and family planning usage were selected. The average of knowledge and acceptance was computed giving a score of 62.2% for good knowledge and 47.6% for a good acceptance. This shows an above-average level of knowledge and a below-average level of acceptance. The level of current family planning usage was 22.9%, which was determined using the number of multiparous women who cited that they were currently using some form of family planning. The ndings of this current study revealed that the current usage of family planning among multiparous women was low.
A Chi-square test was done to determine the factors associated with family planning usage. However, the results show that only the enabling and need factors (knowledge and acceptance) were associated with family planning usage. The logistic regression model was then used to determine the strength of associations. The model shows that multiparous women who had good knowledge of family planning were 4.5 times more likely to use some form of family planning. Also, multiparous women with poor acceptance of family planning were 0.43 times less likely to use family planning.
The ndings of this study necessitate the implementation of health promotion interventions to increase family planning usage among multiparous women in the Nkwanta South Municipality of Ghana.
Concentrating on increasing knowledge of multiparous women on family planning and addressing the factors that in uence acceptance such as the fear of side effects of family planning, and con iction between ethnicity and family planning usage.  Level of acceptance of family planning among multiparous women