Contraceptive choice and acceptability: the future for STI risk in Kelantan,Malaysia

Abstract

More than 150 million women become pregnant in developing countries annually and an estimated 287,000 die from pregnancy-related causes. Contraception is vital to prevent unnecessary maternal deaths, as well as sexually transmitted infections. The objective of this study was to investigate preferred contraceptive methods and the factors that influence contraceptive choice among women in Kelantan, Malaysia. A cross-sectional study using interview-based questionnaires was conducted, during July and August 2009, in local family planning clinics in Kelantan. The questionnaire was administered to adult women (age 20–50). Prevalence of unplanned pregnancies was high (48%). Contraceptive preference was Depo contraceptive injection (32%), oral contraceptive pills (27%), intrauterine devices (15%) and contraceptive implants (12%); 9% used condoms. Only 2% used contraception to protect against sexually transmitted infections or HIV/AIDS. Younger women (OR 0.90; 95% CI 0.807–0.993) were more likely to use contraception. In conclusion, non-interrupted contraceptive methods were preferred. More than 60% would stop using contraception if it interrupted intercourse. From both a public health and infectious disease perspective, this is extremely worrying.

Keywords

Contraception sexually transmitted infections women sexual and reproductive health family planning services contraceptive choice prevention Malaysia

Background

More than 150 million women become pregnant in developing countries each year and an estimated 287,000 of these women die from pregnancy-related causes such as haemorrhage, unsafe abortion, hypertension disorder, sepsis and obstructed labour.¹ The World Health Organization (WHO) estimates that 1440 women die each day (an average of one a minute) because of complications during pregnancy or childbirth, and about one million people die each year from reproductive tract infections including sexually transmitted infections (STIs) other than HIV/AIDS.² Malaysia, a country with a population of over 22 million people, is no different.

There are 13 states in Malaysia including the peninsular state, Kelantan, which consists of approximately 5% of the total population (Figure 1). In 2000, there were 40,061 live births in Kelantan. The maternal, neonatal and infant mortality rate in the same year was 0.2, 3.9 and 10.5, respectively.³ STIs also occur in all sectors of Malaysia’s population, including the sex industry which is not regulated. There are no effective prevention efforts to control the spread of STIs in the sex industry.⁴ In 2003, a total of 58,012 HIV infections were estimated to exist,⁵ with more than 70% of infections acquired by intravenous drug users (IDUs), 20% by sexual intercourse and 1.7% by perinatal infection.^6,7 However, the actual mode of transmission among IDUs is unclear due to the high prevalence of unprotected sex amongst this population.⁸ The true nature of STI prevalence in Malaysia is difficult to evaluate due to under-reporting of cases⁹ and most studies were not designed systematically to collect STI data.¹⁰ Several studies show that these public health issues, STI acquisition and unwanted pregnancy can be prevented with effective family planning (FP) services. In addition, maternal mortality may be reduced by reducing the number of potentially dangerous pregnancies.¹¹ Barrier contraceptive methods (specifically male condoms), when used consistently and correctly, are most effective in preventing STIs, including HIV.^12,13

Figure 1.

Kelantan, West Malaysia.

FP became official policy in Malaysia in 1966 with the launch of the National Planning Program. The National Family Planning Board (NFPB), subsequently renamed the National Population and Family Development Board (NPFDB), was also established to plan, execute and coordinate all FP activities in the country.¹⁴ The initial programme served urban areas mainly but subsequently, the National Program was expanded to the rural areas through the integration of FP with the Primary Health Care and Maternal and Child Health Services of the Ministry of Health (MOH) in 1971.^14,15 A third agency providing contraceptive services and provision is the Federation of Reproductive Health Association of Malaysia (FRHAM). This is the leading voluntary family planning, sexual and reproductive health organization in Malaysia and consists of 13 FP Associations from 13 states in Malaysia.¹⁶

A partnership and collaboration system is in place between the NPFDB, MOH and FRHAM in providing FP and other reproductive health services. The MOH integrates FP services with the rural health services while the NPFDB and the FRHAM and private sectors provide for FP in urban areas primarily.¹⁴ All three agencies have their own system/supply chain from procuring and distributing/disseminating to the usage of FP commodities. The services are widely accessible, affordable and acceptable to all, and are provided on the basis of health benefits to the mother, child and family. There is no coercion or discrimination and individual couples are free to choose the most suitable contraceptive method based on the timing, spacing and numbers of their children.¹⁵ Reproductive rights recognised the basic rights of couples or individuals to decide freely on the number, spacing and timing of their child; however, in the Malaysian context, unmarried women or unmarried pregnant women are not condoned as it is against ethics, values, morality and the official national religion Islam (approximately 59% of the population).¹⁷ While adolescents in Malaysia (age 10 to 19) have the right to reproductive health information, knowledge, counseling and education, they have no right to contraceptive services.¹⁵

Sovereignty of decision-making allows individuals to exercise their sexual life effectively and achieve their reproductive goal. However, the conceptuality does not reflect the reality. Based on a meta analysis study on contraception, one’s freedom over decision making can possibly be impelled by race, culture, religious belief, economic and education status, fear of side effects, accessibility and accuracy of information or influence of family members and friends.^7,18,19

In this study, we investigate the choice, accessibility, affordability and availability of contraceptive methods in Malaysia, specifically in Kelantan, a state of Western Malaysia (Figure 1). The aim of this study is to investigate preferred contraception methods and the different factors that influence contraceptive choice among women. The results of this study are beneficial for government and health service providers to achieve a better understanding of women’s perception and attitude to contraception. The results also provide a broad picture of the current FP services in Kelantan.

Methods

Study area

This cross-sectional survey was conducted in Kelantan, Malaysia. The population of Kelantan is approximately 1.3 million people; 92.5% of the population is Malay. There are 261 family planning clinics (FPCs) in the region provided jointly by the three key agencies, NPFDB, MOH and FRHAM.

Study population

The sampling frame consisted of all clinics under FRHAM governance. This included clinics in four different towns within Kelantan; Kota Bharu (state capital), Pasir Puteh, Machang and Tanah Merah, from July to August 2009. The four towns are located in North Eastern Kelantan and the distance between the towns varies from 48 km to 16 km. All are within a 48 km radius. Permission to conduct the study in the FRHAM clinics was granted subject to ethical approval by the Ethics Committee in Hospital University Sains Malaysia (HUSM) in Kelantan, Malaysia. Due to time limitations in Malaysia, it was not possible to attain permission for access to the MOH or NPFDB clinics. The questionnaires were given to all contraceptive users within the study age group who attended these clinics during the study period. The exclusion criteria were male, females younger than 20 (because the national programme does not provide contraceptive services to teenagers) or older than 50 years (as they are past childbearing, for the most part) and non-contraceptive users.

Data collection

Data were collected using a self-administrated questionnaire that was adapted from several studies and internet resources before being reviewed and approved by both the Clinical Research Ethics Committee of the Cork Teaching Hospitals (English version) and the Ethics Committee in Hospital University Sains Malaysia (HUSM) in Kelantan, Malaysia (Malay version).^20–22 The study protocol was approved by both committees. The questionnaire was forward translated to Malay language by a medical professional who is a Malay native language speaker but also competent in English. It was piloted to 20 sample clients consisting of Malay language teachers, students, contraceptive users and medical staff for further fine-tuning on the appropriateness and suitability of the questions and language used. Back translation was conducted by the same person who conducted the forward translation.

The questionnaire was divided into three parts; background, social history and contraception history. Information was sought on age, race, religion, socio-economic characteristics, education status, fertility and family size preference, contraceptive history, reason for contraceptive used, spousal communication, accessibility of information on FP, attitude of client to FP and decision making on contraception. Each of the volunteers completed the questionnaire in an interview room. A trained member of the clinic was available to help those who could not read or to clarify any vagueness that they found in the questionnaire. This session took place while they were waiting for their appointment with the provider.

Statistical methods

Data obtained were coded and analysed in SPSS (v15.0); 150 clients attended four different local FPCs in Kelantan during the data collection period. All of them received the questionnaire and gave their consent for participation in the study; 93% of questionnaires were complete (n = 139). Incomplete questionnaires were due to time constraints. Descriptive statistics were obtained. Statistical differences between the groups were tested using χ²-test at the 5% significance level. Binary logistic regression was used to investigate the association between ‘always’ contraception use (dependent) and each independent factor that influences consistent contraceptive use among women.

Results

Demographic characteristics of respondents

The demographic characteristics of respondents are illustrated in Table 1. The majority of respondents were married (>85%) and between age 30 and 39 years (53%). The mean age was 34.55 ± 6.47; 69% of respondents were Malay, followed by Chinese (27%) and others (4%). This pattern reflects the ethnicity breakdown of the Malaysian population. In 2010, Malays represented 60.3%, Chinese 22.9% and Indians 7.1% of the total population. Higher proportions of Chinese and Indians are found in urban locations;²³ 69% of respondents were Muslims and the remainder was Buddhist (25%), Christian (4%) and others. There were no significant differences by age, race, religion, marital status, income and occupation among respondents in rural and urban areas. There was a significant difference in education background (p < 0.05). The majority of respondents received secondary school education in both areas; however, the proportion of primary school only education was twice as high in rural areas compared to urban areas. There was no postgraduate education in rural areas. The ‘poor’ level in Kelantan is defined as individual income less than RM340 per month²⁴ and the average monthly income level is RM1829.²⁵ Therefore, approximately 40% of respondents fall within the ‘poor’ levels in both areas, and more than 65% of respondents from both areas were below the state’s average income. In all, 45% of respondents in rural areas were unemployed compared to 39% in urban areas.

Table 1.

Demographic background of women attending family planning clinics (FPCs) in Kelantan.

Characteristics	Urban (n = 88)		Rural (n = 62)		Total		p Value
Characteristics	No	%	No	%	No	%	p Value
Age	0.342
20–24	10	11.4	4	6.5	14	9.3
25–29	10	11.4	10	16.1	20	13.3
30–34	22	25.0	15	24.2	37	24.7
35–39	26	29.5	16	25.8	42	28.0
40–44	14	15.9	16	25.8	30	20.0
45–49	6	6.8	1	1.6	7	4.7
Race	0.052
Malay	67	76.1	37	59.7	104	69.3
Chinese	20	22.7	20	32.3	40	26.7
India	1	1.1	2	3.2	3	2.0
Other	–	–	3	4.8	3	2.0
Religion	0.116
Islam	67	76.1	37	59.7	104	69.3
Christian	3	3.4	3	4.8	6	4.0
Buddhist	18	20.5	19	30.6	37	24.7
Hindu	–	–	2	3.2	2	1.3
Other	–	–	1	1.6	1	0.7
Education	0.046
Primary	5	5.7	10	16.1	15	10.0
Secondary	45	51.1	29	46.8	74	49.3
Certificate	8	9.1	11	17.7	19	12.7
Diploma	9	10.2	6	9.7	15	10.0
Degree	17	19.3	6	9.7	23	15.3
Postgraduate	4	4.5	–	–	4	2.7
Marital Status	0.472
Single/never married	4	4.5	4	6.5	8	5.3
Widowed	–	–	1	1.6	1	0.7
Married–monogamous	80	90.9	52	83.9	132	88.0
Married–polygamous	2	2.3	1	1.6	3	2.0
Divorced	2	2.3	4	6.5	6	4.0

Sexual and obstetric characteristics of respondent

The sexual and obstetric characteristics of the respondents are presented in Table 2. Chi-square tests revealed no significant differences among these characteristics between rural and urban areas. There were some findings of importance; 45% of respondents in rural areas had more than four children compared to 37% in urban areas. A higher proportion of urban residents than rural residents would prefer 4–6 children though this was not statistically significant. The mean number of desired children for both areas was 4.07 ± 1.59. The number of unplanned pregnancies was high (48%) in both areas; 16% of rural respondents had experienced up to three unplanned pregnancies compared to 10% of those in urban areas. They also admitted that an unintended pregnancy affected their financial status more than personal emotions, while the opposite was true for urban respondents. Forty percent of respondents reported sexual intercourse more than four times per month and only 1.3% of respondents admitted to having more than one sex partner.

Table 2.

Sexual and obstetric background of women attending family planning clinics (FPCs) in Kelantan.

Characteristics	No	%
Frequency of sexual intercourse
Less than two times per week	79	53.0
More than three times per week	34	22.8
Less than two times per month	10	6.7
More than four times per month	26	17.4
More than one sex partner
Yes	2	1.3
No	147	98.7
No. of children
0 children	4	2.7
1–3	85	57.0
4–6	48	32.2
≥7	12	8.1
Desired no. of children
1–3	65	43.9
4–6	71	48.0
≥7	12	8.1
Unplanned pregnancy
Yes	72	48.3
No	77	51.7
No. of unplanned pregnancies
0	75	50.3
1–2	65	43.6
3–4	7	4.7
>5	2	1.3
Did unplanned pregnancy affect your
Personal emotions	24	16.1
Family	6	4.0
Financial status	22	14.8
Others	19	12.8
No effect	78	52.3

Contraceptive background

Both urban and rural respondents received contraceptive information from local FPCs (49%) and general practitioners (17%). More than 85% admitted that the information obtained was sufficient. The top four contraceptives used among the respondents were Depo contraceptive injection (32%), oral contraceptive pill (OCP) (27%) intrauterine device (IUD) (15%) and contraceptive implant (12%) (Figure 2). Only 9% used condoms; 64% of respondents reported that they always use contraception and only 3% of respondents reported that they never used any contraceptive method before. A total of 61% of respondents were using contraception for three years and 9% for more than 10 years. The primary objective for contraceptive use was to avoid pregnancy (52%) and secondly to space the children (36%). Only 1.6% of respondents used contraception due to concern about STIs or HIV/AIDS; 29% of respondents in rural areas admitted that FP had affected their financial status compared to 18% in urban areas. Approximately 15% of respondents admitted that FP had an effect on their marriage and sexual relationship and 26% admitted that it has an effect on agreement of the family size. Most of the respondents discussed FP with their partners (73%) and any decisions taken were made by both of them (72%). Only 7% sought counseling advice to solve any problems related to FP on their marriage, sexual relationship, agreement of family size and financial status. However, more than 60% of respondents admitted to discontinuing with contraception if the method used caused an interruption in sexual intercourse.

Figure 2.

Method of contraception used by women attending family planning clinics (FPCs) in Kelantan.

Women’s attitude towards FP services in Malaysia

More than 82% of respondents agreed that the quality of FP services was good in terms of doctors’ services, accessibility of preferred contraceptive methods, availability and accuracy of information given and effectiveness of current contraceptive used. However, 11.4% agreed that the availability of contraceptive methods at their current residence was poor and 12.8% said it was neither poor nor good.

More than 95% of respondents are satisfied with current FP services in Malaysia. However, there were some barriers to accessing contraceptive methods. The main barrier for respondents in both urban and rural areas was a fear of side effects, 58% and 42% in each area, respectively. Other prominent worries for both urban and rural respondents were the fear of side effects on the foetus if pregnant (31% and 30%, respectively) and the cost (14% and 18%, respectively). However, those in urban areas had more difficulties with clinics or pharmacy hours (12%) compared to just 4% in rural areas. There was a significant difference in the difficulties of transportation among respondents in both areas (p < 0.05), with those in rural areas having more difficulty, as expected.

When asked about suggestions to improve the quality of FP services in Malaysia, approximately 50% of respondents agreed that an increase in education, clarifying erroneous preconceptions, giving information to the general population and incorporating FP into counseling may be helpful to improve the services. Approximately 30% agreed that reducing cost and provision of over-the-counter contraceptive methods (i.e. condom/spermicide/OCP) and easy access to contraception may be beneficial as well.

Factors that influence contraceptive use

Respondents were asked to rate each of eight factors that influenced their contraceptive use (no influence, moderate influence, high influence) (Table 3). Opinion was considerably divided. While 46% felt cultural and religious beliefs had no influence on decision making, 31% felt it had a high influence. Economic and financial status was a high influence for 39% of people. Availability of FP services was a high influence for more than 41% of people.

Table 3.

Factors that influence decision making process of contraception use amongst women attending family planning clinics (FPCs) in Kelantan, Malaysia.

Total (n = 150)
No	%
Cultural and religious belief
No influence	65	46.4
Moderate influence	32	22.9
High influence	43	30.7
Personal opinion
No influence	31	22.1
Moderate influence	39	27.9
High influence	70	50.0
Economic/financial status
No influence	37	26.4
Moderate influence	48	34.3
High influence	55	39.3
Family planning counseling
No influence	50	35.7
Moderate influence	36	25.7
High influence	54	38.6
Previous usage of contraceptive methods
No influence	58	41.4
Moderate influence	27	19.3
High influence	55	39.3
Fear of side effects
No influence	59	42.1
Moderate influence	31	22.1
High influence	50	35.7
Influence of others (for e.g. husband, mother, elders, friends, etc.)
No influence	64	45.7
Moderate influence	38	27.1
High influence	38	27.1
Availability of the family planning services
No influence	47	33.6
Moderate influence	35	25.0
High influence	58	41.4

Determinants of consistent contraceptive use

A binary logistic regression model was conducted to examine the factors influencing consistent contraceptive use (always users) versus sometimes/never users. Variables that were included in the model were age (continuous), race (Malay, Chinese, Indian, other), religion (Islam, Christian, Buddhist, Hindu, other), marital status (single/never married, married monogamous, married polygamous, widowed/divorced), education (none/primary/secondary, certificate/diploma, degree, postgraduate), living area (urban, rural), income (below RM500, RM500-RM1000, >RM1000-RM2500, >RM2500), employment (homemaker, unemployed, student, working), responsibility for contraceptive decision making (male, female, both) and unplanned pregnancy (yes, no).

The variables retained in the final model were age (OR 0.90; 95% CI 0.807, 0.993; p = 0.036), area and education, though the latter two were not statistically significant at the 5% level. As age increases, those using contraception are likely to decrease.

Discussion

Although Malaysia is a multiracial country, the predominant race in Kelantan is Malay and the majority of the population is Muslim.²³ The percentage of new contraceptive users is below the national average. The majority of respondents in this study were between the ages of 30 to 39 and used Depo contraceptive injections, different to the preferred OCP for contraceptive users within the 20–29 year age group according to the NPFDB report in 2004.³

The low proportion of condom users (especially in rural areas) and low number of respondents who used contraception as a method of STIs/HIV infection prevention is extremely worrying. This finding supports previous studies regarding STI awareness in Malaysia.^26–28 Although the majority of the women surveyed were married, some of them admitted to being in a married polygamous relationship, thereby increasing their risk of STI. Also, we know that worldwide, the burden of STIs rests with those aged less than 29 years, and nearly 25% of our survey respondents were in this category. Our finding suggests a low level of awareness and knowledge of STIs and would suggest future education work is needed to bridge this gap. More than 60% are willing to stop using contraception if it interferes with sexual intercourse and this likely contributes to the low level of condom use, which will naturally interrupt intercourse. It also accounts for the high preference for non-interrupted methods including the Depo injection, OCPs, IUDs and contraceptive implants. This finding suggests that the risk of acquiring and transmitting an STI is high in Malaysia, particularly if one of the partners has multiple partners. The school curriculum in Malaysia does not focus on sex education.²⁷ The National Program does not provide contraceptive services to those ≤19 years. The 2004 Malaysian Population and Family Survey found that less than half of the young people aged 13 to 24 had heard of at least one FP method and only one in four had heard of condoms, despite their availability in pharmacies and provision shops.¹⁴ Sex education is such a controversial issue among different groups of people, especially among the ulama (Islamic religious leaders) that no definite policy has been formulated.^27,29

Existing literature highlights that socio-demographic characteristics, cultural and religious beliefs and the education level of women are believed to affect not only the decision to use contraception but also the contraceptive choice.^7,18,19,30 However, this study showed that age was the most important factor affecting contraceptive decision making.

It is important for each woman to access information and gain more education on any preferable contraceptive methods based on their needs and desirable characteristics. This will involve a multi-disciplinary approach. Respect for clients’ wishes and perception with regard to their cultural and social background should be incorporated into the quality of services, to ensure the integrity of the client-provider relationship. Given the low level of condom use, and the increase in STIs in Malaysia, and worldwide, including sex education on the school syllabus is important. Focus should also be given to high-risk groups, such as IDUs, given the high rate of HIV amongst this group in Malaysia.^27,28

As the number of contraceptive methods increases in availability and variability, the prevalence of contraceptive use may also increase.^13,31 Therefore, it is crucial to ensure the flexibility of contraceptive accessibility and availability via community-based settings, especially in areas with limited services. This group of women are generally satisfied with the contraceptive services provided, but it is clear they lack knowledge on the side effects etc. A simple education programme, nationally and through the schools, could mitigate these issues and improve the uptake of contraception use. In addition, education around STIs and the danger of not using barrier methods is necessary if Malaysia wishes to curb the transmission of STIs including HIV. These women find the counseling approach reassuring. By counseling, we mean information/education by the providers. Counseling is beneficial to implant confidence and avoid discontinuity of contraception particularly in methods with high demand on users’ compliance. Counseling also provides the opportunity to negate any fears about side effects. Finally, an improvement in public transportation especially in rural areas could also be a vital means of improving access to FP services but would also contribute to the reduction in the maternal mortality ratio.³²

Study limitations

This study was limited to one state in Malaysia, Kelantan. The findings may not be representative of the whole country. The study was also conducted in an FP clinic and may not be generalizable to the general population. The sample size did not include adolescents and therefore the results cannot be extrapolated to this population. This study can only provide suggestions of associations without proving the actual degree of influence of each potential factor in the decision-making process of contraceptive choice. Further studies using large sample sizes are needed to confirm our findings.

Footnotes

Concluding remarks

Methods of contraception that do not interrupt sexual intercourse are the preferred methods of contraception for women in Kelantan, Malaysia. Only 2% used contraception for the prevention of STIs. Only 9% use condoms. There is also a low level of awareness and knowledge of STIs amongst this group. Given the continuing increase in STIs, including HIV, worldwide this is extremely worrying from a public health perspective. Trends from individual STI clinics in Malaysia show that the incidence of STIs, particularly early syphilis, genital herpes, genital warts and HIV, is on the rise, especially among women.¹⁴ Sex education for both males and females is vital to alter this statistic. A change of policy in Malaysia to allow the National Program to provide contraceptive services to the unmarried and to teenagers (≤19) is also necessary to combat the rising number of teenage pregnancies and abandoned babies.¹⁴

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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