Chapter 2 REVIEW OF RELATED LITERATURE This chapter presents the conceptual and research studies both from local

and foreign sources which are related to the relationship of the knowledge on the contraceptive use and its effect on family size. Research Literature Foreign

In the study conducted by Oyeridan, K., Isiugo-Abanihe,U., Bankole, A. (2006) they concluded that husband and wife discussion about reproductive issue is fairly high in the study areas, with 59.2 percent and 66.4 percent of couples reporting spousal communication on family size and family planning respectively which contradicts earlier studies that suggested low interaction on fertility related issues among marital partners. It is believed that the Nigerian Economic crises that started on 1980s that continuously progressed until 1990s might have served as a catalyst for the apparent close conjugal relationship that precipitated the sharing of views on family size and family planning by husbands and wives in contrary to the traditional Yoruba belief about procreation that prohibits discussion of the said matter and of counting the number of children. They believed that it is evident in their study that a considerably higher proportion of couples were willing to discuss contraceptive use than the desired family size. Further investigations through focus group discussions reveal that the majority of couples hold strongly to the traditional beliefs that discussing family size or its regulations is a taboo and almost true to all ages, sex and educational groups. The extent of discussion of husband and wife about family size and contraceptive use differs according to the socio-cultural and demographic

characteristics. Differences in spousal communication on desired family size and contraceptive use are found to be associated with personal attributes such as demographic and social background of the individuals and couples. The study reveals that there is a marked difference on the level of spousal communication on family size and family planning by the study areas. They also concluded that demographic and socio-cultural factors significantly influence spousal communication about family size and family planning. Spousal age gap, joint education and religious affiliation of partners, type of marriage, frequency of couples' exposure to radio and television as well as association membership are the socio-cultural factors that influence the discussion of husband and wife with regards to family size and contraceptive use. Significant proportions of individuals and couples reported husband-wife discussion on reproductive health issues indicates an emerging egalitarian society where equity and respect of each others' opinion and view is becoming a norm among marital couples. As a result, marital partner are likely to increasingly express and discuss their reproductive goals and thereby reach some agreement on a desirable family size and the use of family planning to achieve it. Furthermore, spousal communication about fertility and use of contraceptive is positively associated with education and must be noted. Though, they believed that higher education is not the only factor that is found in this study to enhance discussion between husband and wife on reproductive matters, it is the only variable that could be easily manipulates to achieve the desired close marital relationship. However, the major obstacles to spousal communication on fertility-related issues are cultural opposition and ignorance about modern norms and values. Efforts should be made to reinforce the existing population control enlightenment or education programs to make them reach more people. For example, interest groups (religious, social, etc) should be educated, through their leaders, to appreciate the need for close conjugal relationship rather than the

familiar male-dominant culture. The education programs should show through research that the religious doctrines are not at variance with the principles of modern society.

On the other hand, Irans condition on overpopulation was cited in the works of Larsen (2003) stated . Irans all-time high population growth rate dropped from a 3.2 percent in 1986 to 1.2 percent in 2001. This decrease in Irans population growth rate is one of the fastest drops ever recorded. Iran has become a model for other countries that want to lessen the risk of overpopulation because of its population reduction in that level. During Irans war with Iraq between 1980 and 1988, a large population became an advantage. Accordingly, Ayatollah Khomeini pushed procreation to bolster the ranks of soldiers for Islam, aiming for an army of 20 million. There was a severe job shortages ensued and at the same time, the cities became overly crowded and populated. The population growth of Iran was finally viewed as an obstacle to the development of the country. Dialogue on the subject of birth control was reopened by Ayatollah Khomeini because the nations problems. Programs on family planning were again revitalized effective December 1989. The family planning programs encourage women to discourage childbearing for females younger than 18 years old or older than 35 and limit family size to three children. Three to four years gap between pregnancies was also emphasized as part of their family planning programs. These have been called for the Ministries of Education, of Culture and Higher Education that have incorporated information about effective family planning. A national family planning law was passed by the Iranian government in May 1993 that encouraged couples have fewer children through restricting maternity leaves after having three children. Awareness about family planning matter is vital. Information about population, family planning and mother and child health care in curriculum materials were also incorporated by the Ministries of Education, of Culture and Higher Education, and of Health and Medical

Education. The Ministry of Islamic Culture and Guidance was in fact allowed raise the awareness of population issues and family planning programs to be shown by the media. The first choice for Muslims countries in terms of contraception is male and female permanent sterilization and the provision of birth control pills and condoms are free. In Iran, the promotion of family planning involves the husbands. Their country is the only country that requires both men and women to attend classes on modern contraception before being given a marriage license. In 30 years, the literacy rate for adult males nearly doubled from 48% in 1970 to 84% in 2000. From 25% in 1970 to more than 70% today, female literacy climbed even faster. Iran has gained universal access to health care and family planning, sudden rise in female literacy, premarital contraceptive counseling for couples became mandatory, the participation of men in family planning programs and strong support from their religious leaders. Other developing countries with growing population can improve their family planning program by following Iran in their promotion of population stability. Local In the study conducted by Macam, F., Mapa, R., Porol, J., et al. (2010), they concluded that the level of awareness of the mothers in the area studied was moderate. This may be due to the fact that poor counseling, inadequate response to the needs of clients, irregular field visits, and poor supervision and monitoring affects family planning methods awareness. Withdrawal method was the most preferred natural family planning method of mothers while the least preferred was the Basal Body Temperature. This may be due to its convenience where it involves no other steps or procedures and also due to lack of cost. In the artificial family planning methods the most preferred was the pills while the least preferred was the IUD and diaphragm. Since pills are provided in their Brgy Health Unit and it is cost effective while other methods are

not use due to low economic status and lack of knowledge on its usage. There was no significant difference in terms of the level of awareness in family planning methods when mothers in the area were grouped according to age and number of children. This may be due to the fact that mothers were not educated properly on the different methods of family planning since what they knew were the old and traditional methods. They were not up to date with the latest developments on this matter. The information dissemination in their place is not also effective. There was no significant difference in the preferences on the natural and artificial family planning methods when the mothers in the area were grouped according to age and number of children. This might be due to the fact that they preferred the methods with no side effects, easy to use, cheap, effective and readily available. Lack of knowledge, unfamiliarity, fears, confusions and misconceptions toward other family planning methods may also be the factors why they were not using them. The result of the study conducted by Sumande, D., Saputalo, A., Sipe, J., et al. (1994) reveals that the natural methods of contraceptives that has the most or the highest degree of preference of most wives is rhythm, one can draw out the conclusion that wives have the previous knowledge that using the method will not cause them any emotional or psychological effect which could be bad for their health, compared to the other methods or douching, withdrawal and abstinence. This method proves very effective. Another conclusion that can be drawn from this study is that, since the highest degree of preference is artificial method of contraception used by wives were oral pills; its the wives that do the greatest effort to prevent conception. Pills were the highest preference since it is easy for the wife to use this method. By using this method, the respondents were able to prove its effectiveness and no serious physiological, emotional and psychological effects were felt by them. It can be concluded that

pills are safe to use. It can also be concluded that if the wives understand about the side effects of using this natural or artificial methods is because of the lectures or seminars given to them by the Family Planning Program of their Barangay. Conceptual Literature Foreign Decherney, A.H., Goodwin, T.M., Nathan, L., and Laufer, N. (2007) strongly believed that Contraception is practiced by most couples for personal reasons. Many couples use contraception to space their children or to limit their family size. Others desire to avoid childbearing because of the effects of preexisting illness on the pregnancy, such as severe diabetes or heart disease. For all of these types of decisions, clinicians must provide accurate information about the benefits and risks of both pregnancy and contraception. However, medical conditions that may substantially increase the risk of using some form of contraception usually increase the risk associated with pregnancy to an even greater extent. As a matter of public policy, some countries, especially those that are less developed, promote contraception in an effort to curb undesired population growth. International family planning perspectives was cited in the book of Rosenberg (2006) . In the analysis of 96 countries with the least population of 1 million people and of Demographic and Health Survey conducted since 1980, 34 have skewed contraceptive method mix-defined as 50% or more of all contraceptive users reporting use of a single method. Withdrawal and periodic abstinence prevails mostly in 16 countries located in Sub-Saharan Africa. Contraceptive method mix was dominated by female sterilization in three Latin American countries including India. A single reversible female method; the pill, IUD or the injectable accounts for at least half

of all use in the remaining 14 countries. Many factors contribute to skewed method mix, but suggest that government policies can strongly influence method prevalence according to a complimentary review of the literature on the topic of method choice. Limited method availability may result in a self-perpetuating cycle of acceptance of a method that has been available and widely used for a long time. Skewed contraceptive method is not a problem in itself, but is particular problematic if driven by supply factors such as restrictive population policy, lack of information on method choices or provider bias toward one or two methods. According to (Cunningham, et al., 2001), Family Planning involves choosing the time to have children. It includes contraception, the prevention of pregnancy as well as methods to achieve pregnancy. If both partners are fertile, approximately 90% of women will conceive within 1 year if they do not use contraception. Meanwhile, (US department of health and human services [USDHHS], 2000) concluded that those who wish to control the timing of pregnancies cannot live contraception to chance. A healthy people 2010 goal is to increase the number of pregnancies that are intended to 70%. (MOOS, 2003) discusses that approximately half of all pregnancies are unintended. Unintended pregnancies are those that are unwanted or mistimed. Mistimed pregnancies are those that occur in women who want to become pregnant at some time in the future but not at the time the pregnancy occurs. Furthermore, (Paukku,Quan, Darney, and Raine, 2003) discusses that these unintended pregnancies may result in economic hardship, interference with educational or career plans, heath problems, and other disruptions in the lives of women and their families. About half of the unintended pregnancies occur in women who are using a contraceptive method but use it incorrectly or have a contraceptive failure. Many adolescent have little knowledge about their own physiology, including how and when conception occurs. They are likely to learn about contraception from other teenagers, who often

pass on incorrect information, even adolescents who have been pregnant do not understand contraceptive techniques, and they may become pregnant again because of lack of information about family planning. In addition, adolescent mothers are more likely to use non-hormonal, less effective methods like condoms and to use them consistently than sexually active adolescents who have never been pregnant. Moreover, (Peterson, Gazmararian, Clark, & Green, 2001) discusses that misinformation and erroneous beliefs however can cause adolescents to use ineffective methods of contraception or no method at all .Some teenagers think they cannot become pregnant the first time they have intercourse. Others think. They must have an orgasm or must have menstruation a certain length of time. Pregnancy, however, can result from any intercourse near ovulation. Although many adolescent have anovulatory menstrual cycles during the early months after menarchy, they cannot depend on anovulation to prevent pregnancy because some will ovulate before their first menses. Teenagers and older women tend to douche (insert a solution into the vagina) after intercourse to prevent pregnancy. Douching however, is ineffective because sperm may enter the cervix soon after ejaculation. Coitus interruptus (withdrawal) is another is another unreliable method used by teenagers. It requires more control over timing of ejaculation than the most adolescent boys have. In addition, semen and pre ejaculatory fluid spilled near the vagina can enter and cause pregnancy even without penetration by the penis. The nurses role in family planning is that of counselor and educator. To fulfill this role, nurses need current, correct information about contraceptive methods. Nurses must also feel comfortable discussing contraception and be sensitive to the womans concerns and feelings. Nurses must be careful not to introduce their own biases toward or against specific methods. The nurses personal experiences and choices regarding contraception are not pertinent. The need and feelings of a

woman and her partner must be the focus of counseling, and their preferences take precedence. Many women who do not wish to become pregnant do not use any contraceptive during the month before they become pregnant. Women are more likely to use contraception if they have received counseling that is directed to their own needs instead of general information about contraception (Weisman, Maccannon, Henderson, Shortridge, & Orso, 2002). Therefore the nurse must provide individualized family planning information to the women in every situation where it would be appropriate. Local The overall goal of family planning program as stated in the book of (Cuevas, F.P., Reyala, J., Bonito, S., et.al.,2007.) is to provide universal access to family planning information and services wherever these are in need. This aimed to contribute to reduce infant deaths, neonatal deaths, under-five deaths and maternal deaths. Addressing the need to help couples and individual achieve their desired family size within the context of responsible parenthood, improve their reproductive health to attain sustainable development and ensuring that the quality Family Planning services are available in DOH retained hospitals, LGU managed health facilities, NGOs and private sectors are the main objectives of the program. There are different strategies adopted to achieve goal and objectives such as; focus service delivery to the urban and rural poor, reestablishing the FP outreach programs, strengthening the FP provision in regions with high unmet needs, promoting frontline participation of hospitals, mainstream modern natural family planning and promoting and implementing CSR strategy. The family planning program includes the family planning methods. There are different types of family planning methods and is divided into two groups, the artificial and natural methods. Under the artificial methods first is the Female Sterilization; this method is safe and simple procedure which

provides permanent contraception, also known as the Bilateral Tubal Ligation it involves cutting or blocking the fallopian tubes. The prime advantages of this method are that it provides a permanent contraception, it does not affect with sexual intercourse and there are no known side effects. While the disadvantages includes occurrence of uncommon complications such as infection, bleeding in the incision site and injury to internal organs might occur. It doesnt protect against sexually transmitted diseases too and most likely irreversible since reversal surgery might be difficult, expensive and might not be available. Second method is the Male Sterilization, it is a permanent method wherein the vas deferens (passage of sperm) is tied and cut or blocked through a small opening on the scrotal skin, also known as vasectomy. The most advantage of this method is that it is permanent, safe and effective and the men will never loses his sexual ability and ejaculation. While the disadvantages are it is irreversible or difficult to be reverse since it will be expensive, pain, bleeding and hematoma might occur in the area nonetheless it is said to be very effective. pill is also included under the artificial method it contain hormones like estrogen and progesterone and must be taken daily to prevent contraception. The most advantages of this method is that it is convenient and easy to use, it doesnt interfere with sexual intercourse, makes menses regular and predictable it also reduces the risk for ovarian and other gynecologic symptoms such as painful menses and endometriosis, it is reversible and most of all easy to use. Though there are great advantages there are also disadvantages like side effects may occur like nausea, dizziness or breast tenderness it also suppress lactation and when not use regularly its effectiveness might reduce so it must be taken regularly. It is taken orally or per mouth. Male condom is another method it is a sheath rubber made to fit on mans erect penis to prevent the passage of sperm cells and sexually transmitted disease into the vagina. It can protect against microorganism causing HIV or STD and easily to

use are its main advantages. Though there are some disadvantages like decrease sensation during sex and interruption of sexual act still this method is find to be one of the most accessible and easy to use. The last artificial method is the injectables, it contains a synthetic hormone which suppresses ovulation, thickens cervical mucus making it difficult for the sperm to pass through and changes uterine lining. It is reversible, doesnt affect lactation, does not interfere with sexual intercourse and does not need for daily intake. Natural methods includes Lactating Amenorrhea Method, it is temporary method of pregnancy during the post partum. Using LAM would be beneficial to mothers because it is easily available to all breastfeeding women. This could also protect from unplanned pregnancies immediately postpartum and at the same time theres no need for other commodities. This could also contribute to maternal and child health and nutrition. Only for the disadvantage is that it is only effective for 6 months postpartum. Its effectiveness is decreased if the mother and child are separated for extended periods of time especially if the mother is working. This would also be difficult to maintain for up to 6 months due to a variety of social circumstances. Mucus / Billing/ Ovulation is a method wherein it is done through abstaining from sexual intercourse during fertile (wet) days prevents pregnancy. as for its advantage, it can be used by any woman of reproductive age as long as she is not suffering from unusual disease or condition that results in extraordinary vaginal discharge that makes observation difficult. But some women who have medical conditions that would endanger pregnancy, this method is not used. Another method is Basal Body Temperature wherein it is done by identifying the fertile and infertile period of a womans cycle by daily taking and recording of the rise in the body temperature during and after ovulation. It is very effective but it requires time to record the temperature and at the same time couples would practice abstinence during fertile periods. The Symptom-thermal Method is identifying the fertile and infertile days

of the menstrual cycle as determined through a combination of observations made on the cervical mucus, basal body temperature recording and other signs of ovulation. This would accurate for the reason that it uses both the basal body temperature and the observation of the mucus. The Two Day Method is a simple fertility awareness based method of Family Planning that involves the cervical secretions as an indicator of fertility and it requires women to check presence of secretions every day. This method is useful to women with any cycle length and with no health related side effects associated, it incurs very little or no cost, it is immediately reversible; it enhances self discipline mutual respect cooperation communication and shared responsibility of the couple for the Family Planning. Acceptable to couples regardless of culture, religion, socioeconomic status and education. As to the disadvantage, it needs cooperation with the husband, can become unreliable for women who have conditions that cause abnormal cervical secretions, it doesnt protect the client from HIV/AIDS. Last method would be the Standard Days Method which is a new method of natural family planning in which all users with menstrual cycles between 26 and 32 days are counseled to abstain from sexual intercourse on days 8-19 to avoid pregnancy. The couples use color coded cycle beads to mark the fertile and infertile days of the menstrual cycle. Good thing about this method is that it has no related side effects associated with its use, it increases self awareness and knowledge of human reproduction and can lead to a diagnosis of some gynecologic problems, no need for counting or charting since the standard days method makes use of beads for tracking the cycle days, very little cost and promotes male partner involvement in family planning, it enhances self discipline and mutual respect, enhances couples sexual life, acceptable to couples regardless of culture, religion, socioeconomic status and education. This method is not useful to those women who usually have menstrual cycle between 26 and 32 days long.

Synthesis This chapter discusses the different concepts and relevant facts on the Natural Birth Control Methods as well as the different natural contraceptive methods. This also includes the significant results of previous researches which could be of big help in formulating the framework of the present scientific inquiry and were used in enhancing the presentation of findings and interpretation of statistical results. Foreign researchers such as in the works of Oyeridan, K., Isiugo-Abanihe,U., Bankole, A. (2006) have cited the willingness of spouse to discuss matters on contraceptive use maybe influence by socio-cultural and demographic characteristics. These two factors significantly influence spousal communication about family size and family planning. As a result of the study, marital partners are likely to increasingly express and discuss their reproductive goals and thereby reach some agreement on a desirable family size with the use of contraceptive method to achieve it. Meanwhile, in the study conducted in Iran by Larsen (2003), the government has identified overpopulation as an obstacle to the development of the country, thus programs on family planning were revitalized. This discourages childbearing for females younger than 18 years old or older than 35 years old to limit family size to three children. Three to four years gap between pregnancies was also emphasized. Population stability was achieved by the state through Ministries of education. Thus in 30 years, the literacy rate for adult males nearly doubled from 48% in 1970 to 84% in 2000. From 25% in 1970 to more than 70% today, female literacy climbed even faster. Among the natural methods of family planning, withdrawal method was the most preferred method of mothers in the study conducted by Macam, F., Mapa, R., Porol, J., et al. (2010), and they concluded that There was no significant difference in terms of the level of awareness in family planning methods when mothers in the area were grouped according to age

and number of children. The same study was conducted by Sumande, D., Saputalo, A., Sipe, J., et al. (1994) that the natural methods of contraceptives that has the most or the highest degree of preference of most wives is rhythm, one can draw out the conclusion that wives have the previous knowledge that using the method will not cause them any emotional or psychological effect which could be bad for their health. However, foreign authors Decherney, A.H., Goodwin, T.M., Nathan, L., and Laufer, N. (2007) strongly believed that Contraception is practiced by most couples for personal reasons. Many couples use contraception to space their children or to limit their family size. In the book of Rosenberg (2006), analysis of the health survey revealed withdrawal and periodic abstinence prevails mostly in 16 countries located in Sub-Saharan Africa. Furthermore, (US department of health and human services [USDHHS], 2000) concluded that those who wish to control the timing of pregnancies cannot live contraception to chance. A healthy people 2010 goal is to increase the number of pregnancies that are intended to 70%. There were lots of causes why incidence of increasing number of pregnancies are remarkably increasing as tackled in the separate works of (Paukku,Quan, Darney, and Raine, 2003) and (Peterson, Gazmararian, Clark, & Green, 2001). Local authors (Cuevas, F.P., Reyala, J., Bonito, S., et.al.,2007.) provides overall information on family planning and discuss in detail the different methods. Indeed, these related literatures are informative and could directly relate to the study of the level of awareness of couples on natural birth control methods and how does it affect the family size.