In the present study we started with the analysis of the situation in contraceptive method used by women who gave birth recently, to investigate (A) The degree of information (awareness of) about contraceptive methods; (B) Contraceptive methods used during the last year before pregnancy; (C) Determining the mode of occurrence of the present pregnancy: planned, unintended or failure/lack of a contraceptive method and reasons for unmet need in FP; (D) Assessing the perspective of using modern contraception methods after the current birth.
A. We initially proposed to analyse the situation regarding information about contraceptive methods among the women who planned a pregnancy and among those whose pregnancy was unintended.
The age of the women included in the study ranged from 18–47 years, with the vast majority being between 21–30 (59.3 ± 1.7%) years old. At the same time, 33.1 ± 1.6% of the women, enrolled in the study, were 31–40 years old, and in six cases (0.9 ± 0.3%) the age of the patients exceeded 40.
Having analysed the obstetric anamnesis of the women under study, it was found that most of them were primiparous − 33.5 ± 2.0%, secundiparous in 31.8 ± 2.0% cases and had 3 and more pregnancies in anamnesis − 34, 7 ± 2.0%. At the same time, among the interviewed females, multiparous (3 and more births) were 84 women (14.0 ± 1.9%). In the past, these women had voluntary abortion in 15.4 ± 1.3% (94 women), of which 57.4% (54 cases) abortion was in place due to the fact that contraceptive methods had not been used. Miscarriages were reported by 13.4 ± 2.1% and 6.3 ± 1.5% of the surveyed women, and one female had a history of extrauterine pregnancy.
Figure 1 shows the age of onset of sexual life in women included in the study, demonstrating that approximately 50.6% of the females started their sexual life at the age of ≤18, but only 34.2% of the total number started using a method of contraception simultaneously with the onset of sexual life, which denotes the importance of informing and educating adolescents about safe methods of contraception. The age group under 18 represents a risk group for both unwanted pregnancies and sexually transmitted infections, therefore informing adolescents about contraceptive methods is of high importance, and including this information in the (school) curriculum would increase the level of knowledge and training of young people. Also, in some cases (1.3 ± 0.3%), unintended pregnancies occurred in young women who did not finish schooling. Postponing pregnancy by using a contraceptive method would have allowed these girls to finish their pre-university education.
Study data showed that, on average, it takes 2 years from the onset of sexual life to start using a contraceptive method. In women aged 15–18 years, there was a 4-5-year difference between the onset of sexual life and the beginning to use a contraceptive method, which from the start includes these women in an increased risk group for an unwanted pregnancy.
Based on the analysis about the level of information in family planning methods, it was found that only 63.7 ± 2.7% of the study respondents knew that the right to contraception or information on contraceptive methods is a state-guaranteed sexual and reproductive right as well as the right to a risk free maternity and the right to abortion. Analysing the data obtained from Pearson correlation, there was a significant positive correlation between informing on sexual reproductive rights and knowledge about such methods of contraception as implants (0.237 **, p < 0.05), combined oral contraceptives (COC) (0.136 *, p < 0, 01), contraceptive patch (0,142 *, p < 0,01), vaginal ring (0,222 **, p < 0,05), diaphragm (0,116 *, p < 0,01). This means that the patients who are aware of the notion of reproductive sexual rights and its components are better informed about the diversity of the existing contraceptive methods.
The survey questionnaire included the questions regarding informing the population about different methods of contraception. The results presented in Fig. 2 conclude that most women are familiar with: male condom (98.3%), intrauterine device (IUD) (93%), COC (88.3%), calendar methods (87.7%) and withdrawal (81%), female sterilization (78%), emergency contraception (72.3%).
The present study showed that 42.3% of the surveyed women did not have enough knowledge or never heard about the contraceptive vaginal ring - a hormonal contraceptive method available in the Republic of Moldova for about 5 years. Also, the women confused oral contraceptives with pills containing progesterone (POP) alone. The study participants/ respondents noted that only 13% of the women knew about POPs, although this method of contraception is suitable for many women, including breastfeeding mothers, right after giving birth [8]. Unfortunately, some very effective methods of contraception are not available for women in the Republic of Moldova (RM), which explains the lack of awareness of the contraceptive implant (70%), contraceptive patch (66.3%) and injectable contraceptives (55.3%). Although 55.3% of women are informed about male sterilization (vasectomy), this procedure is very rarely chosen by a partner in the RM as a contraceptive method.
Despite the fact that 92.6% of women would like to be consulted by a doctor about the methods of family planning, 62.3 ± 2.8% of them did not refer to it. At the same time, 22.7 ± 2.5% of women consulted the gynaecologist in the outpatient department, 6.0 ± 1.2% - a family doctor and 9.0 ± 1.6% of women consulted other specialists (e.g. oncologists, endocrinologists for contraception), or referred to gynaecologist in private consultations.
According to the study results, 82.3 ± 2.2% of women choose family planning methods by discussing in couple and 16.0 ± 2.0% consider that only women are responsible for choosing the contraceptive method.
Women were asked how comfortable they feel when discussing contraceptive methods. Thus, 17.1 ± 2.3% of women considered that they felt themselves uncomfortable during discussions about contraceptive methods, and the majority (81 cases, 79.4%) responded that contraception is too intimate to discuss with someone. At the same time, 80.0 ± 2.3% of women discussed contraception with their partner and 69.3 ± 2.6% talked to their mother, sister, or friends.
Taking into consideration the fact that the population of the RM is not informed enough about the effectiveness of contraceptive methods, that information being obtained from unreliable not evidence-based sources, we have proposed to determine which method from the perspective of the women included in the study is the most effective one. We also asked about what method of contraception they would recommend to a friend (Table 1).
Table 1
Efficiency of contraceptive methods in women surveyed (%).
| Considered to be the most efficient method (%) | Method you would recommend to a friend (%) |
Male condom | 39% | 44% |
COC | 24.7% | 287% |
IUD | 16.7% | 13.7% |
Do not know | 7.7% | 7.7% |
Abstinence | 2.4% | 0% |
Withdrawal | 2.3% | 1.7% |
Female sterilization | 2.3% | 0% |
Implants | 1% | 1.3% |
Vaginal ring | 0.7% | 0.3% |
Fertility awareness methods | 0.7% | 0% |
Spermicides | 0.7% | 0.7% |
Combined methods | 0.6% | 0.6% |
Emergency contraception | 0.3% | 0.3% |
Injectable contraceptives | 0.3% | 0.7% |
Diaphragm | 0.3% | 0.3% |
Vasectomy | 0.3% | 0% |
During the questionnaire, the women were informed about Multiple Indicator Cluster Survey (MICS) data, 2012, according to which about 40% of Moldovan women do not use a modern method of contraception. Being asked about the reasons for not using contraception, most women (65.3%) responded that the underlying reason is the lack of sufficient knowledge about different contraceptive methods, 27.0% of women consider that contraceptive methods are costly, 20.3% do not want to use contraception, while 5.3% think that they can do an abortion in case of unwanted pregnancy (Fig. 4). Several women gave more than one answer to this question, the total amount thereby exceeding 100%.
B. In addition to assessing the level of information about PF methods, we intended to find out which contraceptive methods the women had used in the last year, both the women who planned pregnancy (Group #2) and those who did not (Group #1.) (Fig. 5).
Following the data analysis and semi-structured interviews, we have found that 60 ± 2.6% of the women surveyed did not have a permanent contraceptive method although they periodically used one of the methods listed in Fig. 5 during the last year before pregnancy. Thus, even though the women mentioned, for instance, the use of a male condom, they also confirmed that they had had unprotected sex contacts periodically. Thus, we can conclude that the women in the study used a modern contraceptive method in 53.0% cases, in 28.3% cases they used a traditional method, and in 18.7% of cases they had never used a contraceptive method (Table 2).
Table 2
Use of modern vs. traditional contraception methods during the last year before pregnancy (planned or unintended) (abs.,%).
FP methods | N (abs.) | M ± m (%) |
Modern FP methods | 318 | 53.0 ± 2.8 |
Traditional FP methods (withdrawal and fertility awareness methods) | 170 | 28.3 ± 2.0 |
They have never used a FP method over the course of their life | 112 | 18.7 ± 2.2 |
Although most of the couples used male condom (36.2 ± 2.7%), the second place goes to withdrawal (14.1 ± 2.1%), while COC and IUD were by used 8.7% and 5,4% of the participants. Women using withdrawal as a contraceptive base method face a higher risk of unwanted pregnancy than women using other modern methods as traditional methods have higher failure rates [9].
Mention should be made that only in 5.4% cases the LARC, a long-term reversible contraception method, was used In 8.2 ± 1.4%, the women used combined methods: "fertility awareness methods + withdrawal" − 4%, "COC + male condom" − 1.3%.
While 19.7 ± 1.9% of women used emergency contraception at least once in their lifetime, 1% of the interviewed patients used emergency contraception as the main or single method of contraception. Of the total number of women who used emergency contraception at least once in their lifetime, about 68% turned to this method because of unprotected sexual contact, 18% because they did not have a permanent method, and 12% reported the failure of other contraceptive methods used (tearing, condom slipping).
Regarding women's satisfaction with contraceptive methods, 58.3 ± 2.8% of the women reported that they were totally satisfied with the chosen contraceptive method, 25.0 ± 2.5% were partially satisfied and 3.0 ± 1, 0% were not satisfied with the family planning method used. Based on the obtained data, there was tracked a positive correlation between the patients’ satisfaction with the chosen contraceptive method and whether the patients discusses the family planning methods with their partners (Pearson correlation 0.228 **, p < 0.05). Regarding the women with unmet, or partial satisfaction with the chosen contraceptive method, 13.3% ± 1.9% of the respondents argued that they were afraid that the chosen method could fail, 5.0 ± 1.3% of the women mentioned that the method was inconvenient in use, and in 3.7 ± 1.0% of cases the women’s partners did not like the chosen method.
C. At this stage of the analysis, we proposed to divide women into two groups: those who had not planned the pregnancy, but once they learnt they were pregnant, they chose not to interrupt the pregnancy and to give birth - Group #1, and those who became pregnant due to planning - Group #2. Group #2 included 326 women, representing 54.4 ± 2.9% of the women who were planning pregnancy, and the use of contraception was consciously abandoned.
Group #1 study cases, that make up 274 (45.6 ± 2.9%) of the women are of special interest (Table 3). Despite the fact that the present pregnancy was not planned, only 1% of women believe that the contraceptive method used had failed. It is worth mentioning that 2 patients who abandoned postpartum children were included in the study, in both cases the women had not used any contraceptive method, and in one case the patient had been deprived of parental rights over her older child.
In the studied group of 274 women who did not plan pregnancy 26.7% used modern contraception methods and 25.2% used traditional methods of contraception (Table 3). Given the high Pearl index of modern contraceptive methods, the use of the method was probably sporadic or incorrect. On the other hand, according to the results of the study, a more commonly used contraceptive method is the male condom, which has an efficacy of 15–18 pregnancies per 100 women in the first year of use, according toWorld health organization (WHO) data. To that end, unintended pregnancies could be explained by the fact that most of the women included in the study chose a method with moderate efficacy [9]. The most effective methods are long-term reversible contraception methods, namely IUDs and implants that have an efficacy of less than 1 per 100 women in a year of use. Since the implant is not available in the RM, the IUD remains the only long-term reversible contraceptive method, which a small number of women have chosen.
Table 3
Use of contraceptive methods before pregnancy occured: women from Group #1 and Group #2 (%).
Group of the study | Use of FP methods | % |
Group #1: Women who did not planned a pregnancy, but remained pregnant 45.6% | Did not use any FP method | 47.1% |
Used modern contraception methods | 26.7% |
Used traditional methods of contraception | 25.2% |
The failure of a modern contraception method | 1% |
Group #2: Women who planned a pregnancy 54.4% | Did not use any FP method | 14.1% |
Abandoned modern contraception methods | 55.9% |
Abandoned traditional contraception | 30% |
One of the objectives of the study was to determine the reasons for not using contraception despite the fact that they wanted to avoid a pregnancy. In this study, we did not use the classical methods of calculating the unmet need for contraception by questioning fertile women, but decided to analyse the situation from a different angle, from the perspective of women who recently gave birth and admit that pregnancy was not planned and has occurred spontaneously, following the non-use of a contraceptive method. Therefore, the analysis of the unmet need in this study is limited to the women who have recognized that they did not used any contraceptive method. Thus, women in the study responded with no contraception in 47.1% (129 women), and 24.1 ± 2.2% of them (31 women) never used any contraceptive method.
Analysis of the data from Group #1 showed that 47.1% (129 women) of women did not consistently use contraceptives in the last year, although they did not plan a pregnancy. Some of them mentioned that they had sporadically used a contraceptive method, at the same time confirming that they had unprotected sexual contacts.
When asked about the reasons for not using permanent contraception, about 50% of the women did not provide any reason, either because of feeling uncomfortable to answer the question of the kind or because they did not have well-defined reproductive plans. Thus, 5.8 ± 0.8% claimed they did not have enough knowledge about different methods of contraception, 14.6% were afraid of adverse effects, 8.8 ± 0.8% of the respondents reported the increased cost of contraception, 6,6 ± 1.1% considered family planning methods inconvenient to use, in 2.2 ± 0.8% the partner did not want to use contraception, while 1.4% of the women did not use contraception for religious reasons. Comparing the results of the present study with those of the Guttmacher report, the reasons listed by women in the Republic of Moldova did not reveal the rare sexual intercourse and the fear of social disapproval, especially for unmarried women, this being determined by the socio cultural context of the country [6]. At the same time, it is interesting to observe that in the RM the role of a partner and his opinion is very important for a woman, and rarely, in 2.2 ± 0.8% of cases, women accuse the partner of non-contraception.
Identifying these reasons is crucial because these unmet needs must be met, and national health and educational programmes must be specifically geared towards removing barriers and motives listed by the women in the socio-economic context of the country.
D. Another section of the study was to analyse the future use of birth control methods in both groups (N = 600). Thus, 274 (46.0 ± 2.8%) women plan a pregnancy, of which 56.9% - over 1–3 years, and 34.3% over the next 4–8 years. Interestingly, not a single woman plans a pregnancy within next 12 months. International estimates of the unmet need for postpartum contraception are up to 62% in the first year after birth [10]. Thus, the gap between pregnancies is important for women, and should be considered during consulting on contraceptive methods. According to WHO, after birth per vias naturales, the recommended interval until the next pregnancy is at least 24 months to reduce the risks of maternal, perinatal and infant negative effects [11].
At the same time, despite the fact that 54.0 ± 2.9% of the women under study no longer plan a pregnancy, 10.4% of them do not want to use any contraceptive method. However, other women plan to use one of the following methods: male condom − 33.2 ± 2.7%, IUD − 24.5 ± 2.5%, COC − 15.8 ± 2.0%, as well as FP methods after current birth. Male condom remains one of the most popular methods used by the women included in the study, being a modern method with lesser efficacy though than other contraceptive methods such as IUD or hormonal methods. Among the advantages of using this method of contraception we can mention the protection of sexually transmitted infections.
Analysing the correlation between pre-pregnancy contraceptive methods and the use of contraceptives after the current birth, we can conclude that the majority of the women included in the study will use the same postpartum contraceptive method as before (Pearson correlation 0.240 **, p < 0.05). However, some women plan to change the contraceptive method. We analysed the male condom use data because, according to the questionnaire, it is considered to be the most requested method for the women in the study. Thus, out of 218 women, who used male condoms before pregnancy, 124 women (56.8%) stated they will continue using the method, 40 women (18.3%) will change it for IUD, 36 women (16.5%) will use COC, 2 women (0.9%) - the vaginal ring, and 2 women (0.9%) have already chosen female sterilization during birth (caesarean section).
When asked about an unintended pregnancy, despite the fact that 54.0 ± 2.9% no longer planned a pregnancy, 82.6 ± 2.3% of the women in the study responded that they would accept an unwanted pregnancy and would give birth.
The postpartum period is an ideal time to access contraceptive services, as women are certainly not pregnant, motivated to initiate contraception and receive qualified health care from providers. It is necessary to take into account women's desire for a gap between pregnancies, their preferences for contraceptive options, breastfeeding at the moment [10].