الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Egypt has achieved a remarkable success in promoting CP. FP use has increased steadily over years. CP use levels rose rapidly reaching nearly 59% in 2014 and the percentage increased in urban governorates to nearly 63%. But unmet need remains a challenging indicator over decades. It is useful for tracking progress towards the target of achieving universal access to reproductive health services.
The three most commonly used methods in Egypt were IUD, pills and injectables. The unmet need prevalence in Egypt was nearly 13 % in 2014. About one third of this unmet need reflected a desire to space the next birth and the remainder represented an interest in limiting births. FPPs are considered role models for CP use but their rate and pattern of use, and unmet need have not yet been studied in Egypt.
The aim of the study was to estimate current level and identify types and reasons for unmet need for FP among providers (physicians, nurses and CHWs (Raedate Refeyate)) working in FP clinics of the MOHP in Alexandria health facilities (maternal and child health centers, Urban Health Centers, Rural Health Units and Hospitals).Study design: A cross sectional study.
Study setting:The study was conducted in FP clinics belonging to the MOHP in Alexandria governorate. The following health facilities were included:1)Urban Health Centers.
2) Family Health Units / Maternal Child Health Centers / and Health Offices.3)Rural Health Units.4) Hospitals.A total of 139 FP clinics distributed all over the eight health districts were included.
Study population: participant including physicians, nurses and CHWs (Raedate Refeyate), fulfilling the inclusion criteria were included.
Inclusion criteria: Currently married FPPs, in their child bearing age and received at least one FP training course.Sampling: The total target participants fulfilling the inclusion criteria were included.The total number of FPPs was 436 distributed as: FP physicians were 129, nurses were 173 and CHWs (Raedate Refeyate) were 134. After exclusion due to different reasons, the final number of participants was 398.Data collection: A predesigned self-administered electronic Google form questionnaire was used to collect the data about sociodemographic characteristics, reproductive profile, pattern of contraceptive use and unmet need types and reasons.
The main results of this study could be summarized as follows:1.The present study estimated that the current contraceptive prevalence among FPPs working in FP clinics in Alexandria was 62.6%, with 51.8% of them used it for limiting.2.The estimated unmet need prevalence among providers was 18.8%, 2.2% of this need reflected a desire to space the next birth, and the remainder represented an interest in limiting births. The unmet need prevalence presented the highest among CHWs (Raedate Refeyate) (21،1%) while the lowest percentage was among physicians (15.7%).3.The majority of participants (79.9%) reported no current desire for having another child.
4. There has been continuous training courses for FPPs, 56.3% of them reported a range of training from 5-15 times with a mean of 6.38 3.77 times, and 47 % reported having their last training course within a year from the time of the study.5.The fertility preferences of the provider was consistent with her husband as regard both the desired number of children and the spacing duration. The highest percentage of both reported having the desire for 1-3 children (78.6% & 59.8%, respectively) and both of them reported a preferred spacing duration of 1-3 years (75.1% & 83.9%) respectively.
6. The most commonly used methods by providers were IUD (82.3%), mainly used for limiting, followed by pills (67.5%), condom (34.9%), and injectables (27.7%), which were mainly used for spacing.7.The least commonly used methods were vaginal suppositories, gelly or diaphragm (3.6%), vaginal ring (0.8%) and female sterilization (0.3%) (Only one provider).8.The most important reasons for limiting, were having enough number of children (88.4%) and to raise them well (80.1%). While husband desire (21.6%) and history of complications during pregnancy or birth (18.6%) were the least important reasons. Higher percentages of nurses (50.6%) and CHWs (Raedate Refeyate) (51.3%) reported financial reasons for limiting than physicians (38.8%).
9. The most important reasons for method choice by providers were being effective and safe to use (77.9%), having enough information about advantages and disadvantages (63.1%) and its long acting effect (61.4%). While having no effect on fertility (16.9%), everyone the provider knew were comfortable using it (15.3%) and being chosen for her by the doctor (6.8%) were the least important reasons.10.The higher percentage of providers obtained their contraceptive methods from governmental sources (88.2 %(. Physicians mostly obtained their method from non-governmental sources (84.3%), while nurses and CHWs (Raedate Refeyate) obtained their method mostly from governmental sources (90.9% and 97.4% respectively).11.The most commonly used contraceptive methods by currently pregnant providers were IUD (45.2%), condom (33.3%) and pills (29 %).12.Fertility related reasons were the most important reason for never using a method (97.9%). The desire to have another child (83.3%) and fatalistic beliefs (up to God) (56.3%) were the most important fertility-related reasons.
13. None of the studied participants stated self-opposition or religious prohibition either by the provider herself or her husband.
14. Fertility-related reasons (97 %) and method related reasons (25.7%) were the most important reasons for discontinuation.
15. Unmet need increased with age (30.2 %) with increased providers age (40+ years old). It was highest among providers whose work experience from >25 years (42.6%), provider whose husband was illiterate (47.1%) and who had experienced health problems during last pregnancy or labor (33.1%).
16. The most important reasons for unmet need for FP in female clients from FPPs point of view were lack of information about FP methods (85.9%), fear of side effects (70.6%), amenorrhea with breastfeeding (56.3%) and husband refusal (55.3%).
17. In relation to the decision maker in FP method choice, 82.7% of FPPs reported that clients usually have joint decision with their husbands.
18.More than half (56.3%) of FPPs reported that they think social media affects clients’ satisfaction of FP methods, while 35.7% reported that it sometimes happens.
19.With regard to rumors about FP methods, 48.5% of FPPs reported not being affected with rumors, while 22.6% reported that it affects them.
20. Availability of information about FP methods regarding side effects and complications significantly affected FPPs decision to personally use the method in 58.3% of providers (p = 0.025).
21. FPPs reported that their personal use of methods significantly affects their counseling (66.1%, p=0.033), while 28.4% of them reported that counseling was sometimes affected.
22. With regard to FPPs communication with any religious figures or searching religious issues related to FP methods, 47% of them reported they never done it, while 46.5% reported that they sometimes communicated with religious figures.
23. Unmet need for FP was frequently associated with age of the provider, years of work from graduation and husband education as sociodemographic determinants. And was frequently associated with history of health problems during last pregnancy or labor, desired number of children for the provider and her husband as reproductive profile determinants. And was also frequently associated with fear of side effects and husband refusal as provider’s opinion about reasons for unmet need in female clients. Availability of a lot of information about method side effects and complications affected FPPs decision to use the method and the effect of personal use of a method on counseling the client about it were also significantly associated with unmet need for FP.
6.2. Conclusion
This study demonstrated a high percentage of contraceptive prevalence rate among FPPs in Alexandria, reflecting good knowledge and favorable attitudes towards FP practices among providers. All FPPs have received training courses, relevant to their occupation and on regular basis to keep providers updated about FP methods and counseling approaches, giving much credit for that to the FP sector at the MOHP.
About two thirds of providers had from 1-3 children, which was mostly concomitant with the provider and her husband’s desired number. Unlike the general population, neither the provider nor her husband had gender preference.
FPPs mainly used CP methods for limiting, and for that IUD was their number one choice from LARCs. Subdermal implants as a LARC has been considered one of the finest available methods in the public sector, yet only a small percentage of providers were using it. Most providers obtained the CP methods from governmental sources except for physicians who mostly obtained them from non-governmental sources. The most important reasons for method choice by providers were being effective and safe to use, having enough information about advantages and disadvantages, and its long- acting effect. Fertility related reasons were the most important reasons for never using a method or for discontinuation among providers especially desire to have another child.
On the contrary to what was expected, the unmet need prevalence among providers (18.8%) was higher than the national prevalence rate. The highest proportion was contributed by nurses and CHWs (Raedate Refeyate). Unmet need for limiting was consistently higher than unmet need for spacing in all types of providers.
The significant predictors of unmet need among the FPP were husband education, history of health problems at last pregnancy, the desired number of children, fear of side effects, and the effect of provider’s personal use of CP on counseling.
6.3. Recommendations
1. FP programs should overcome the barriers of FP uptake experienced by the FPPs by tailoring FP programs to the specific needs of service providers where they can be followed up and regularly checked with their needs and demands, possibly by tertiary level care. Because experiencing of health problems during the last pregnancy or birth was an important reason for unmet need expressed by providers, adequate pre-pregnancy and antenatal health care should be ensured.
2. FP programs should provide more FP options specific for providers to be for example partially funded in order to expand their choices, like providing them with other pill generations, other types of IUDs, or condoms. Expanding the range of methods that are readily available and acceptable would decrease the discontinuation and inadequate switching.
3. Tailored training courses for CHWs (Raedate Refeyate) and nurses should be designed and implemented to emphasize on effectiveness of FP methods through provision of convenient, accessible, high-quality services offering a range of methods to facilitate switching. The training should discuss different effective alternatives of methods in cases of infrequent sexual activity.
4. More frequent clinical training courses especially for physicians and nurses should be design and implemented to discuss methods’ side effects and complications along with associated health problems (This clinical training should focus on the medical eligibility criteria). The training should also include innovative tactics and approaches to break down the myths and misconceptions that scare providers away, while at the same time respond to the very real side effects that the methods can cause.
5. Involve religious leaders in FP training programs in order to provide the FPP with sufficient knowledge that help them to improve their counseling skills and resolve religious misconceptions about FP among their social networks.
6. Enable couple counseling policy on the provider’s level as a start to encourage public acceptance in a way of generalizing male involvement in FP decision making and stopping the dealing with FP as a female matter.
7. Conducted further studies covering FPPs in other areas in Egypt should be done to explore the status of unmet need.
8. Conduct in-depth qualitative studies to better understand the reasons of unmet need among FPPs and therefore to identify and tackle modifiable and non-modifiable reasons in order to tailor specific programs to decrease its rate.
9. Qualitative research on CHWs (Raedate Refeyate) is also needed to further assess the relationship between their fertility preferences, beliefs, and contraceptive use. Providers’ fatalistic beliefs and misbeliefs about benefits of large families, peer pressure, and boys’ preference should be openly expressed and analyzed. Providers’ desire for children and fear of side effects as main reasons for discontinuation of method use should be properly explored using in-depth questions.
10. Improving the income level of providers, especially nurses and CHW (Raedate Refeyate) should be considered in order to avoid the financial burden expressed by them as a motive for use of methods for limiting and spacing births.