Knowledge and factors determining choice of contraception among Singaporean women

INTRODUCTION

Contraceptive use is the cornerstone of prevention for unintended pregnancy.(1) In Singapore, about one in five pregnancies are terminated,(2,3) with unintended pregnancies accounting for most of the terminations.(4,5) This indicates an unmet need for contraception. Termination of pregnancy (TOP) is associated with significant risks. Vacuum aspiration involves short-term risks (e.g. associated with general anaesthesia, uterine haemorrhage, perforation and infection) and long-term risks (e.g. increased risk of subsequent preterm birth),(6) while medical TOP comes with adverse effects (e.g. lower abdominal pain, fever and diarrhoea) and the need for surgical intervention should TOP fail.(7) Hence, prevention of unintended pregnancies is a long-term healthcare goal with significance for public health; this has been outlined in the Millennium Development Goals Report by the United Nations.(8) Prevention of unintended pregnancies can also lead to reductions in healthcare costs.(9) Good knowledge of contraception has been associated with increased contraceptive use, which in turn reduces the incidence of abortion.(10)

While a wide variety of contraceptive methods are available in Singapore, there is no robust data about the level of awareness and knowledge of contraception among women in Singapore. It is thus unclear whether current measures to educate women on contraception are effective. Women consider many factors when choosing a method of contraception.(11-14) Although there are previous studies on contraceptive knowledge and factors determining choice of contraception, most of them were conducted on North American and European populations, and may not reflect the situation in Singapore due to differences in socioeconomic and cultural factors. Hence, the primary aim of the present study was to ascertain the level of awareness and knowledge of contraception among women in Singapore. The secondary aim was to identify factors that influence the women’s choice of contraception.

METHODS

A cross-sectional survey of female patients, aged 21–49 years, who presented to the Obstetrics and Gynaecology Clinic at National University Hospital, Singapore, was conducted from 19 February 2013 to 14 January 2014. Ethics approval was obtained from the Domain Specific Review Board of the National Healthcare Group, Singapore. Written informed consent was obtained from all participants before they answered the survey. The survey was administered by a trained interviewer in a private room to maintain privacy and confidentiality. The answers given were verbally reviewed with the participant after each question. No financial compensation was given to the participants and no funding was obtained for this study.

An original questionnaire was developed for the purpose of this study. It was designed to assess awareness and knowledge of nine methods of contraception that are available in Singapore, namely the oral contraceptive pill (OCP), implant, patch, copper intrauterine device (IUD), levonorgestrel-releasing intrauterine system (LNG-IUS, also known as hormonal IUD), injectable contraceptive, condom, tubal ligation and vaginal ring. For each of these nine methods, we assessed the participant’s level of awareness by asking her if she had heard of the method before. If she had heard of it, we asked her four true/false questions that assessed various knowledge aspects and myths about the method (e.g. how it is used, efficacy, side effects, duration of action, reversibility and protection against sexually transmitted infections). The questionnaire was developed after we conducted a thorough search on existing literature and obtained expert opinion about contraceptive methods. Participants who had ≥ 2 correct answers for a method (out of four questions) were considered to have good knowledge of that method, while those who had one or no correct answers were deemed to have poor knowledge of the method.

The demographic information of the participants (i.e. age, marital status, years of marriage, highest education level, ethnicity, religion, parity and fertility intention) was collected. Information about their current and previous contraceptive use was also collected. To identify reasons for the adoption or non-adoption of contraceptive methods, intrinsic factors (i.e. properties of the contraceptive methods) and extrinsic factors (i.e. sociocultural influences) that could affect contraceptive choice were studied. Participants were asked to rate each factor as important or not important in their choice of contraception.

All statistical analyses were performed using IBM SPSS Statistics for Windows version 21.0 (IBM Corp, Armonk, NY, USA). Univariate descriptive statistics were used for all study variables. Fisher’s exact test was used to identify the predictors of good knowledge of each method of contraception. A p-value < 0.05 was considered statistically significant.

RESULTS

A total of 275 women were approached, but 16 declined to participate. Hence, 259 questionnaires were completed, yielding a response rate of 94.2%. The mean age of the participants was 32.2 ± 7.5 years (Table I). Most of the participants were married (78.0%) and most had post-secondary education (66.8%). The majority were Chinese (51.0%), followed by Malays (24.7%), Indians (15.4%) and others (8.9%). Among the study group, 55.6% were parous and 21.6% had a previous abortion. In terms of fertility intention, the proportions of women who intended to delay, space or stop pregnancy were 36.7%, 31.7% and 31.7%, respectively.

Table I

Sociodemographic characteristics of the participants (n = 259).

Table II shows the number of women who were aware or had good knowledge of the nine contraceptive methods. All of the 259 women were aware of the condom as a contraceptive method and more than half of them were aware of OCP, tubal ligation and copper IUD. Less than half of the women were aware of the other five methods, with hormonal IUD/LNG-IUS ranking the lowest (24.3%). In terms of knowledge about the contraceptive methods, 89.2% of the women had good knowledge of the condom (the highest among the nine methods). On the other hand, only 46.0% of those who were aware of hormonal IUD/LNG-IUS had good knowledge of it.

Table II

Awareness and knowledge of contraceptive methods among the participants (n = 259).

Table III shows the pattern of contraceptive use among the 259 participants. Despite their mean age of 32.2 years, 59.8% were not currently using contraception. The most commonly used method was the condom (60.6% of the 104 women who were currently using contraception). Although 48.3% of the women were aware of the implant as a contraceptive method and 86.4% of those who were aware had good knowledge about it, the uptake of this method was low (only 4.8% of the 104 women currently using contraception). Methods that the participants had poor awareness and knowledge of, such as hormonal IUD/LNG-IUS, the patch and the vaginal ring, had correspondingly negligible uptake.

Table III

Pattern of contraception use among the participants (n = 259).

Table IV shows the association between awareness of contraceptive methods and selected characteristics. Parity was found to be significantly associated with greater awareness of contraceptive methods; 56.2% of the parous women were aware of > 5 methods, compared to only 33.0% of the nulliparous women (odds ratio [OR] 2.61, 95% confidence interval [CI] 1.57–4.34). Previous abortion was also significantly associated with greater awareness of contraceptive methods. 60.7% of women with ≥ 1 abortion were aware of > 5 methods as compared to 41.9% of the women who had no previous abortions (OR 2.15, 95% CI 1.17–3.93). Stoppers and spacers were also more likely to be aware of > 5 contraceptive methods as compared to delayers (56.1%, 47.6% and 35.8%, respectively; p = 0.024). Women who had used contraception before were more likely to be aware of > 5 contraceptive methods as compared to those who had no experience with contraception (53.7% vs. 24.6%; OR 3.55, 95% CI 1.91–6.57).

Table IV

Association between awareness of contraceptive methods and selected characteristics (n = 259).

Table V shows the association between good knowledge of individual contraceptive methods and selected characteristics. A higher proportion of nulliparous women had good knowledge of OCP as compared to parous women (p = 0.031). On the other hand, a higher proportion of parous women had good knowledge of condoms as compared to nulliparous women (p = 0.009). For all nine contraceptive methods, there was no significant association between a previous abortion and good knowledge of the method. A higher proportion of women who had previously used contraception had good knowledge of condoms as compared to those who had never used contraception (p < 0.001). When the associations between education level and good knowledge of the various contraceptive methods were studied, only OCP (p = 0.011) and tubal ligation (p = 0.006) showed a significant association.

Table V

Association between good knowledge of a contraceptive method and selected characteristics.

We also analysed the relationship between experience in using a specific contraceptive method and having good knowledge of that method (Table VI). We found that those who had experience using hormonal IUD/LNG-IUS (p = 0.042) and the condom (p < 0.001) were more likely to have good knowledge of those methods. No association between experience and good knowledge was found for the other methods.

Table VI

Association between previous use of a particular contraceptive method and good knowledge of the method.

Table VII shows the intrinsic and extrinsic factors that the participants rated as important in their choice of contraception. Seven participants declined to answer this segment of the questionnaire, as they had never used and did not intend to use contraception. In terms of intrinsic factors, efficacy was rated as important by most of the participants (90.5%); a substantial proportion were concerned about side effects (86.1%), while only 46.8% thought that non-contraceptive benefits such as reducing menstrual flow or acne were important. In terms of extrinsic factors, 90.1% and 77.8% of the participants, respectively, considered the advice of a healthcare professional and their partner’s opinion to be important. Few rated peer influence (21.0%) and cultural practices (16.3%) as important.

Table VII

Factors of importance in participants’ choice of contraception (n = 252).

DISCUSSION

Global trends over the last two decades highlight the need for increased investments in interventions aimed at managing the surge in demand for contraception.(15) This is the first survey study to assess the awareness and knowledge of available methods of contraception in Singapore among Singaporean women. Although most of the women in the study were highly educated (i.e. had post-secondary education), most had poor awareness and knowledge of long-acting reversible methods of contraception and newer combined hormonal methods. These results are similar to those of previous studies on contraceptive knowledge conducted in developed countries.(16-19) In our study, the uptake of long-acting reversible methods of contraception and newer combined hormonal methods was also very low. This is despite the fact that long-acting reversible methods are highly recommended due to their high efficacy, low side-effect profile, high satisfaction and high continuation rates (even in adolescents and young women).(20-22) The cost-effectiveness of long-acting reversible methods has also been well established.(23)

In the present study, participants scored highest in awareness and good knowledge of the condom, which was similar to the finding of a study conducted on European and American women.(24) This is likely due to condoms being widely available and highly publicised in safe sex campaigns. Poor publicity by doctors, limited availability and patient discomfort with invasive methods are possible reasons for the poor awareness and knowledge of methods such as LNG-IUS, the patch and the vaginal ring among Singaporean women.

While OCP is the most commonly used contraceptive method in countries like the United States, the United Kingdom, Italy and Germany,(24) the condom was the method with the highest uptake in our study. This is in keeping with the finding that the participants had the highest level of awareness and knowledge of condoms. Low uptake of the implant, which was observed in this study and in studies conducted in other countries,(24) could be due to the invasive nature of this method, the greater one-time cost and the necessity for visits to a doctor.

Positive associations between increased awareness of contraceptive methods and both parity and a history of abortion suggest that current postnatal and pre-abortion contraception counselling practices may be effective in promoting awareness. However, these counselling sessions may not be effective in promoting good knowledge of contraceptive methods, as no association was found between good knowledge of doctor-dependent contraceptive methods and parity or a history of abortion. Moreover, we found that participants who had used a particular method were not more likely to have good knowledge of that method (with the exception of LNG-IUS), suggesting that the women were not properly educated about the methods that were prescribed to them.

Education level was generally not associated with greater awareness or good knowledge of contraceptive methods among our participants; even those who had post-secondary education did not have good knowledge about long-acting contraceptives. The sex education that is conducted in Singapore schools (up to the pre-university level) promotes abstinence, with little focus on contraception. As such, women have to obtain information on contraceptives from other sources such as healthcare professionals or the Internet. Thus, doctors and nurses play a crucial role in educating women about contraception and making recommendations on methods that best meet their needs.(24-26)

Similar to the findings of other studies,(13,14) efficacy was the biggest concern among the women in the present study when choosing a method of contraception. Thus, more emphasis should be placed on imparting information on the efficacy, side effects and reversibility of various types of contraceptives. As the women’s choice of contraception was also found to be heavily influenced by their partner’s opinion, we believe that partner education is equally important. Although previous studies found that the religious factor has a significant effect on contraceptive choice,(27,28) this was not found to be a major influence in our study.

This study was not without limitations. For one, it was conducted in a subsidised specialist clinic of a restructured hospital and hence, the results may not be representative of the general population. The cross-sectional nature of the study was also a limitation, as it precluded us from studying the changes in contraceptive choice over the life course of these women. In addition, our criterion for good knowledge of contraception was arbitrarily set at ≥ 2 correct answers out of four questions, which is a fairly lenient standard. A stricter criterion would have led to results that showed poorer knowledge of contraception among the women.

There is a need for a nationwide, multicentre, longitudinal study involving a large group of women, with follow-up at regular intervals over an extended period of time. As age and reproductive experiences have been shown to impact contraceptive decisions,(29,30) such a large longitudinal study could also investigate factors affecting the actual use of contraceptives. Previous studies have demonstrated the presence of knowledge gaps and misconceptions about contraception among physicians, which affect their ability to recommend the use of contraception.(31-33) Thus, research could also be conducted to evaluate the knowledge, attitudes and practices of healthcare professionals in relation to contraception. Structured training of healthcare professionals can then be undertaken to overcome the barrier.(34) Factors affecting compliance to and continuation of contraception can also be studied in order to improve the management of women who are already using reliable methods of contraception.

The results of the present study can provide insights into available opportunities for improving contraception services in Singapore. We recommend that nurses who are specially trained in contraception counselling be stationed at postnatal wards, obstetrics and gynaecology specialist clinics, and contraception booths at primary healthcare facilities, to provide comprehensive counselling on contraception for couples. Such counselling has been shown to be effective in some centres.(35) Dedicated services by community workers, antenatal contraceptive counselling(36) and theory-based interventions (e.g. the use of motivational interviews and social cognitive theory) have been found to be clinically effective in increasing the uptake of IUD.(37) Well-designed leaflets and other audiovisual aids can be used to complement the personal interaction couples have with the healthcare provider during counselling sessions.(38) An online contraception advice service could also be set up to provide easy access to reliable and accurate information about contraception. We also recommend that opportunistic contraception education be offered to all women of child-bearing age during their general visits to healthcare facilities. Efforts to raise awareness on contraceptive methods may be better targeted at nulliparous women, as this group of women tends to have lower awareness of contraceptive methods.

To study the effectiveness of our recommended interventions in improving awareness and knowledge on contraception, and ultimately in reducing abortion rates, prospective trials would need to be carried out. Although we did not include teenagers in the present study, we would like to highlight the importance of contraception education for this age group, as teenagers were found to be more likely to not use contraception and present late for abortion.(4,5)

In conclusion, the present study provides evidence that women in Singapore have poor knowledge of a few contraceptive methods, such as hormonal IUD and vaginal ring. More effective ways of educating women on contraception are needed in order to increase the uptake of reliable methods of contraception and improve the reproductive health of Singaporean women.