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KNOWLEDGE, ATTITUDE AND PRACTICE OF HUSBANDS TOWARD S MODERN FAMILY PLANNING IN MUKALLA, YEMEN
YAHYA KHAMIS AHMED ALMUALM
UNIVERSITI SAINS MALAYSIA
2007
2
KNOWLEDGE, ATTITUDE AND PRACTICE OF HUSBANDS TOWARD S MODERN FAMILY PLANNING IN MUKALLA, YEMEN
by
YAHYA KHAMIS AHMED ALMUALM
Thesis submitted in fulfillment of the requirements for the degree of
Master of Science (Family Health)
May 2007
ACKNOWLEDGEMENTS
Bismillahirrahmanirrahim
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First of all I am thankful and very grateful to the dearest, most beneficial and the
most sincere entity to me which is the one and only my Allah subhano talla.
Thanks to Allah to give me so caring and loving mother and all my family for
whom I really don’t have any words to thank. I wish to express my gratitude to
the following persons for their cooperation and commitment in the conduction of
this study and writing up of this thesis;
My supervisor, Prof Dr Zulkifli b Ahmad, the Head of Department, Department of
Community Medicine. Really obligated to Allah for giving me this most important
figure and I would like to dedicate this study to him. The dedication is all about
his valuable drawings on my ground breaking brain, my research behavior and
his very respecting, friendly dealing with me that I will never ever forget during
my life insyalla.
Secondly, Dr Nors’aadah Bachok, my co-supervisor for her useful suggestions
as to how the research could be improved and her help in the statistical analysis.
My field co-supervisor Associate Prof Dr Abdulla b Gouth for his agreement to be
my field co-supervisor and his help and useful suggestions during my collection
data stage in Yemen.
This research would not be possible without the financial assistance which was
provided by Benevolent Fund, I would like to acknowledge the project manager
of this association, Dr. Omer Abdullah ba Mahsoon and his colleagues and all
others, too many to name who were sponsoring this charity association directly
or indirectly, all staffs in Saudi and Yemen offices, my older brother Idrees bin
Sloom, who was always helping and inspiring for me and support me in pre
research era.
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I would like to thank all my colleagues and respected teachers and lecturers in
my department and most importantly Associate Prof Dr Tengku Ariff, Dr.Hashim,
Dr Kamarul, Dr Ayub, Dr. Naeem, Azwan, colleagues of Master students either
by course work or research mode specially Dr Anees, Dr Raja, Dr Rahim and all
staffs in Department of Community Medicine, specially Ayu, Nurul, Lailani,
Kartini . I would like to extend my grateful appreciation, love and respect to all my
friends, for their friendship, even lasting support and sincerity specially,
Associate Prof Dr Ali Batrfi, Deputy Dean of College of Medicine, University of
Hadhramaut for Science and Technology, Guru Enikartini b Daud, Atif Amin, Dr.
Otta, Dr Abdulla Alyamani and his wife Dr Fozia, Dr Salim Ganim, Mah’d
Bazahdih, Abdulla Alhanshi, Abdelrub bin Nasser, Msubah Alnamori, Omer
almasri, Dr saeed Alfadly, Dr Hassan Alfadly, Dr Agel, Dr Adel Bahmeed, Dr
Sami Alshwal, Dr Osama, Dr Ahmed Alarhbi, Dr Abdulla, Dr EZat, Nassar,
Ahmed, Dr Ebrahim, Dr Shadi, Mah’d Algaml, Dr Noorazman,Dr Sohaimi,Dr
Shafee, Dr Zinol, Hilmi, Fadly, Zaeem, Ahmed, Omer, Zaki, Abdulla, Saeed,
Moh,d, Abduaziz, Abdulgader, Bajoban, Ali, Bagerwan, Moneera, Zinab, Zhoor,
Ekhlas, Wfa, abood, Mah’d, Salim, Awad, Fuad b matrif, Miss Linda, Assistant
Registrar of Medical School and Mr Amir assistant registrar of IPS this is all
about their care and sincere thoughts and affection for me and my research.
.I owes an immense debt to my best friend EdiMansyah for his support.
My deepest thanks go to staff in Ministry of Public Health and Population and
Central Statistical organization, Hadhramaut branch.
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A special thanks goes to my loving mother, my dearest wife and my lovable
children and siblings and all near and dear ones in the family who missed me in
this time of my stay in Malaysia and were always praying for me.
Yahya Khamis Ahmed Almualm
E.MAIL [email protected]
Post Box No 50629
Contact No. 00967-353436, 00967- 71986478
Mukalla (Yemen)
TABLE OF CONTENTS
Page
6
Acknowledgements ii
Table of contents v
List of tables viii
List of figures ix
List of appendices x
List of abbreviations xi
Abstrak xii
Abstract xv
CHAPTER ONE: INTRODUCTION 1
CHAPTER TWO : LITERATURE REVIEW
2.1 Over view of family planning 6
2.2 Situation of family planning in the world 7
2.3 Family planning in the Arab region 9
2.4 Family planning methods 10
2.5 Family planning services in Yemen 17
2.6 Factors associated with family planning practice 19
2.7 Role of husbands towards family planning 23
2.8 Role of Islam 27
CHAPTER THREE:
OBJECTIVES AND RESEARCH QUESTIONS
3.1 Objectives 31
3.1.1 General objectives 31
3.1.2 Specific objectives 31
3.2 Research questions 31
CHAPTER FOUR : METHODOLOGY
4.1 Study design 32
4.2 Study area 32
4.3 Study preparation 33
4.4 Reference population 33
4.5 Source population 33
4.6 Study population 33
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4.7 Criteria for selection of husbands 34
4.7.1 Inclusion criteria 34
4.7.2 Exclusion criteria 35
4.8 Sample size calculation 35
4.9 Study instrument 36
4.9.1 Questionnaire 36
4.10 Pilot study 37
4.11 Data collection 38
4.12 Data entry and analysis 40
CHAPTER FIVE : RESULTS
5.1 Socio-demographic characteristics of husbands and wives 42
5.2 Practice of family planning methods among husbands and
wives
46
5.3 Types of modern family planning methods used by
husbands and wives
47
5.4 Decision maker regarding the use of family planning in the
family
50
5.5 Husbands allowing of wife to visit Health Centers, MCH
Clinic
50
5.6 Opinion of husbands regarding Islam and family planning 51
5.7 Experience of unplanned pregnancies 51
5.8 Knowledge of husbands for family planning methods 53
5.9 Attitude of the husbands towards modern family planning
methods
56
5.10 Scores for attitude of husbands regarding family planning
methods
58
5.11 Factors associated with total knowledge score among
husbands
59
5.12 Factors associated with total attitude score among
husbands
62
CHAPTER SIX: DISCUSSION
6.1 Practice of family planning 64
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6.2 Factors affecting family planning practice 67
6.3 Knowledge of husbands on family planning 72
6.4 Attitude of the husbands 75
6.5 Limitations of the study 92
CHAPTER SEVEN: CONCLUSIONS AND
RECOMMENDATIONS
7.1 Conclusions 94
7.2 Recommendations 96
REFERENCES 98
APPENDICES 113
LIST OF TABLES
Page
Table 5.1 The socio-demographic characteristics of husbands and
their wives
44
9
Table 5.2 Number of living children and practice of modern family
planning methods by husbands
48
Table 5.3 Number of living children and practice of modern family
planning methods by wives
49
Table 5.4 Reported reasons by husbands for couples not using
family planning.
51
Table 5.5 The distribution of husbands by their awareness of family
planning methods
52
Table 5.6 Knowledge of mechanism of family planning methods by
husbands
54
Table 5.7 Awareness of the husbands about where the family
planning services are available in Mukalla
55
Table 5.8 Husband’s opinion on appropriate number of children for
a family
55
Table 5.9 Attitude of husbands towards modern family planning
methods
57
Table 5.10 Factors associated with total knowledge score among
husbands
61
Table 5.11 Factors associated with total attitude score among
husbands
63
LIST OF FIGURES
Page
2.1 Conceptual frame work of the study 30
3.1 Flow chart of the study 39
10
5.1 Prevalence of family planning practice by husband 46
5.2 Prevalence of family planning practice by wife 47
5.3 Attitude scores for husbands regarding family planning 59
LIST OF APPENDICES
Page
A Questionnaire in English language 113
B Questionnaire in Arabic language 121
C Photo graphs of field work in Mukalla 126
11
D Approval letter from IPS for consideration of Feld
Supervisor in Yemen
130
E Final report of Field Supervisor after completing data
collection stage in Yemen
131
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LIST OF ABBREVIATIONS
WHO World Health Organization
SD Standard deviation
IUCD Intra Uterine Contraceptive Device
95% CI: 95% Confidence Interval
SPSS Statistical Package for Social Sciences
UN United Nations.
KAP Knowledge, attitudes and practices
YDMCHS Yemen Demographic and Maternal and Child
Health Survey
CSOY Central Statistical Organization Yemen
UNDP United Nations Development Program
DFID: UK Department for international development, United
Kingdom
UNFPA United Nations Population Fund
USM Universiti Sains Malaysia
UNICEF United Nations Children Fund
WB World Bank
CDC Center For Disease Control , United States of
America
PHC Primary Health Care
NPFPP National Population and Family Planning Program
STD Sexual Transmitted Diseases
IPPF International Planned Parenthood Federation
ICPD International Conference on Population and
Development
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PENGETAHUAN, SIKAP DAN AMALAN SUAMI TERHADAP PERANC ANGAN
KELUARGA MODEN DI MUKALLA, YEMEN
ABSTRAK
Tujuan kajian ini adalah untuk menilai tahap pengetahuan, sikap dan amalan
kaedah perancang keluarga moden di kalangan suami di Mukalla, Yemen. Kajian
keratan rentas ini melibatkan 400 orang suami yang menetap di kuarters Alamol
dan Almustagbal di Mukalla. Golongan suami telah dipilih secara rawak daripada
isirumah di dua buah kuaters tersebut. Suami yang tidak memenuhi beberapa
kriteria yang ditetapkan telah digantikan dengan jiran yang berhampiran. Mereka
yang dipilih telah ditemuduga mengunakan soalselidik berstruktur. Prevalens
amalan kaedah perancang keluarga di kalangan suami adalah sebanyak 39.0%
and 44.3% di kalangan isteri. Hanya 44 orang suami (11.0%) dan 83 orang isteri
(20.8%) sahaja yang mengamalkan kaedah moden perancang keluarga.
Terdapat 77 pasangan (19.3%) dimana masing-masing suami dan isteri telah
mengamalkan kaedah perancang keluarga, 79 pasangan lagi (19.8%) dimana
hanya suami sahaja yang mengamalkannya tapi tidak bagi isteri, 100 pasangan
(25.0%) dimana hanya isteri sahaja yang mengamalkannya tapi tidak bagi suami
dan 144 pasangan (36.0%) dimana kedua-dua suami dan isteri tidak
mengamalkan apa-apa kaedah perancang keluarga. Di kalangan penguna
kaedah moden perancang keluarga, kondom merupakan kaedah yang biasa
digunakan oleh suami (88.6%), manakala pil (54.2%) diikuti alat-alat intra-uterine
(43.4%) bagi isteri. Lebih daripada 90% suami mengetahui tentang pil-pil, alat-
alat intra-uterine dan kondom. Kebanyakan suami (89%) mempunyai sikap yang
positif terhadap kaedah perancang keluarga dan bersetuju bahawa kaedah
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moden perancang keluarga lebih efektif daripada kaedah tradisional. Majoriti
suami (51.3%) bersetuju bahawa golongan suami juga perlu mengamalkan
kaedah perancang keluarga. Walau bagaimanapun, terdapat 172 orang suami
(43.0%) merasakan bahawa kaedah perancang keluarga hanya sesuai
diamalkan oleh golongan isteri sahaja. Lebih kurang 282 orang suami (70.5%)
percaya bahawa keputusan untuk mengamalkan kaedah perancang keluarga
perlu diputuskan oleh suami dan 225 orang lagi (56.3%) merasakan hanya
wanita sahaja yang sepatutnya memutuskan pengunaan kaedah tersebut. Hasil
kajian menunjukkan tidak semua suami bersetuju bahawa golongan suami
sebagai pembuat keputusan utama bagi amalan perancang keluarga.
Hampir semua suami (>90%) menyedari akan kewujudan pelbagai jenis kaedah
perancang keluarga kecuali kaedah pemandulan lelaki (51.0%). Dari segi sikap,
kaedah pemandulan lelaki merupakan kaedah yang tidak popular di dalam kajian
ini berbanding kaedah pemandulan perempuan, mengambarkan kurangnya
kesedaran pengunaan kaedah ini. Amat sedikit suami (2.0%) yang mempunyai
skor sikap yang rendah terhadap kaedah perancang keluarga. Di kalangan
suami yang bersikap positif, 132 (33.0%) orang mempunyai skor yang sederhana
manakala 247 (61.8%) orang mempunyai skor yang baik dan hanya 13 (3.3%)
daripada suami yang mempunyai skor yang sangat baik, menunjukkan golongan
suami secara umumnya mempunyai sikap yang positif terhadap kaedah
perancang keluarga.
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Analisis regresi berganda terhadap skor pengetahuan mendapati wujudnya
hubungan yang bererti di antara tahap skor pengetahuan dengan jumlan tahun
pengajian suami,jumlan tahun pengajian isteri dan anak-anak. Bagi skor sikap,
analisis regresi berganda mendapati wujudnya hubungan yang bererti diantara
skor sikap dengan jumlan tahun pengajian suami, jumlan anak-anak yang tinggal
bersama dan gaji bulanan isteri.
Program perancang keluarga di Yemen perlu memfokuskan golongan suami
supaya terlibat bersama sebagai pembuat keputusan dalam pengamalan kaedah
perancang keluarga. Usaha ini boleh tercapai melalui penumpuan program
promosi dan pendidikan perancang keluarga terhadap golongan suami. Ketua
agama mesti melibatkan diri dalam mengenalpasti dan mengupas isu-isu agama
berkaitan perancang keluarga.
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KNOWLEDGE, ATTITUDE AND PRACTICE OF HUSBANDS TOWARD S
MODERN FAMILY PLANNING IN MUKALLA, YEMEN
ABSTRACT
The aim of this study is to asses the knowledge, attitude and practice of modern
family planning among husbands in Mukalla, Yemen. This study was a cross-
sectional study involving 400 husbands living in Alamol and Almustagbal quarters
in Mukalla. These husbands were selected from households randomly selected
from the two quarters. Husbands who do not meet pre-determined criteria were
replaced with those from the nearest house. The selected husbands were
interviewed using a structured questionnaire. The prevalence of family planning
practice among the husbands were 39.0% and 44.3% among their wives. Only
44 (11.0%) of the husbands and 83 (20.8%) of the wives were currently
practicing modern family planning. There were only 77 couples (19.3%) where
both husbands and wives have practiced family planning, 79 (19.8%) of couples
where husbands practice but their wives do not, 100 (25.0%) of couples where
husbands do not practice but wives do and 144 (36.0%) where both husbands
and wives do not practice any family planning. Among users, the condom was
the most common method used by the husbands (88.6%), while the pill was the
most common method used by wives (54.2%) followed closely by intra-uterine
devices (43.4%). More than 90% of husbands knew about pills, intra-uterine
devices and condoms. Most of the husbands (89.3%) have positive attitudes
towards family planning and agreed that modern methods are more effective
than traditional methods. The majority of husbands (51.3%) agree that husbands
should also practice family planning. However, 172 husbands (43.0%) felt that
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family planning should be practiced only by the wife. About 282 husbands
(70.5%) believed that the decision regarding practice of family planning should
be decided by husbands and 225 (56.3%) felt the wife only should decide on
practicing family planning. The results indicate ambivalence by some husbands
on the main decision maker for family planning practice.
Nearly all husbands (>90%) were aware of the common types of family planning
except for male sterilization (51.0%). Male sterilization is uncommon in this study
compared to female sterilization, which may explain the lower level of
awareness. Very few husbands (2.0%) had poor attitude scores towards family
planning. Among the positive attitude husbands, 132 (33.0%) had moderate
scores while 247 (61.8%) had good scores and only 13 (3.3%) of the husbands
had very good scores indicating that the husbands generally have positive
attitudes towards family planning.
Multiple regression analysis of the total knowledge score revealed significant
association with years completed education of husband, years completed
education of wife and the number of living children. For the attitude score,
multiple linear regression analysis revealed a significant association with years
completed education of husbands, the number of living children and monthly
income of the wives.
Family planning programs in Yemen should also focus on Yemeni husbands to
participate as joint decision makers in modern family planning practice. This can
18
be achieved through targeted family planning education and promotion programs
to Yemeni husbands. Religious leaders must be involved in clarifying religious
issues regarding family planning.
CHAPTER 1
INTRODUCTION
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A rapid population growth is a burden on the resources of many developing
countries. Unregulated fertility, which contributes to such situations, compromise
the economic development and political stability of these countries. Therefore,
many countries consider limiting population growth as an important component of
their overall developmental goal to improve living standards and the quality of life
of the people. This strategy is now enhanced by the availability of effective
modern contraceptive methods since the 1960s. Many international institutions
and organisations such as the World Health Organisation (WHO), World Bank
(WB), United Nations Population Fund (UNFPA) and United Nations Children’s
Fund (UNICEF) have strongly advocated family planning as a means to space
children and limit family size and should be one of the essential primary health
care services provided. Family planning has also been a key component of the
WHO-UNICEF Child Survival Strategy which goes under the acronym – GOBI-
FFF (growth monitoring, oral rehydrating salts, breastfeeding, immunization,
female education, supplementary feeding and fertility control.
Between the mid-1960s and 1990, the percentage of couples in the developing
world using contraception went up from an average of 9% to 53% (Hamilton,
1997). Still, disparities occur between developed and developing countries and
within countries. Scarcity of resources and information, falling donor support,
cultural and political barriers, societal attitudes or misconceptions still contribute
to the high level of unmet needs for contraception in many developing countries.
In 1996, the number of women in the world with unmet need for contraception
20
was estimated to be around 100 million, or about one in every five married
women (Robey et al, 1996).
The unmet need for contraception is often translated into a heavy health burden
for many developing countries. There are about 30 million unwanted pregnancies
each year in developing countries (Kumar, 2001). About 19 million unsafe
abortions take place worldwide each year, where approximately one in ten
pregnancies ended in an unsafe abortion (Ahman & Shah, 2002). Nearly 80,000
women are estimated to die each year from unsafe abortions (Hwang et al,
2004). Although maternal deaths are rare events in developed countries, they
remain common events in many developing countries. Estimates of maternal
mortality indicates that every year, about 515,000 women die from causes
related to pregnancy and childbirth, a rate of over 1,400 maternal deaths each
day, and a little short of one death every minute (WHO, 2001). Another estimated
62,000,000 acute morbidities per year occur during pregnancy, childbirth or in the
postpartum period worldwide, and these estimates might well be twice as high
(Varkevisser, 1995).
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Various strategies and initiatives have been carried out to reduce many of these
burdens. The Safe Motherhood Initiative started in 1987 focused on decreasing
pregnancy related morbidity and mortality. The International Conference on
Population and Development (ICPD), Cairo, 1994 expanded maternal health to a
broader scope of reproductive health and endorsed a range of major goals for
countries to achieve. Two of the goals are a 75% reduction in the maternal
mortality ratios by 2015 and that all couples and individuals should have the full
opportunity to exercise their right to have children by choice
(Tangcharoensathien, 2002; Rosenfield & Schwartz, 2005). The Millenium
Development Goals, adopted by the United Nations in 2000 require member
countries to achieve a set of goals, of which Goal 5 is to improve maternal health
by reducing three quarters of the ratio of women dying in childbirth by 2015. In all
these programs, contraception and family planning play a central role in the
strategies to achieve the goals set.
Studies on family planning in developing countries have long focused on women
as the subject of interest. Very little work in this area has focused on men. It is
now increasingly recognized that the actions required to achieve improvements
in reproductive health outcomes in general and maternal health in particular
should also encourage men’s active participation (Roth & Mbizva, 2001). The
biological and social interdependence between husbands and wives in their plan
for the family and practice of contraception makes the importance of including
men in this area of research (Edwards, 1994). Exploring the role of husbands in
their and their spouse contraceptive practices is particularly important in
22
countries such as Yemen, where women have relatively limited personal control
over their lives and are dependent on their husbands for many decisions.
In Yemen, poverty, illiteracy, high mortality, beliefs, low women empowerment
and poor health services together with the high population growth rate of around
3.5% poses great challenges in promoting the practice of family planning. The
contraceptive prevalence rate in Yemen was only about 10% in the 1991-92
survey compared to 42% in Morocco and 46 % in Egypt. Maternal mortality rate
is still very high at 114 maternal deaths per 10,000 live births and the infant
mortality rate at 75 per 1000 in 1991. The total fertility rate in Yemen is still high
as well, despite a decrease from 7.7 births per women in 1991-1992 to 6.5 in the
1994 census, and reached 8.4 births per women which was considered to be the
highest in world (CSOY,1998).
Since the introduction of National Family Population and Planning Program in
Yemen in 1984, no provision has been made to include men in the motivation
campaign or to involve them in the program. In 1997, a study conducted by the
Central Statistical Organization Yemen (CSOY), found that family planning
prevalence in Sana’a was 22% when both husband and wife approved of it, and
in 12% of couples when the wife approves but the husband does not and in 4%
when the husband approve but the wife doesn’t (CSOY, 1998). There are many
Yemeni women with unmet needs for family planning because the husband is still
a significant barrier to family planning practice (CSOY 1998). A study on the
knowledge, attitudes and practices of Yemeni husbands in family planning will be
23
useful for policy makers to improve family planning services and practices in
Yemen.
CHAPTER 2
LITERATURE REVIEW
2.1 Overview of Family Planning
Family planning is defined as birth spacing, preventing unwanted pregnancies or
secure wanted pregnancy (WHO, 1995). Family planning is adopted voluntarily
through the practice of contraception or other methods of birth control on the
basis of knowledge, attitude and responsible decision by individuals and couples,
in order to promote the health welfare of the family and contribute to the social
and economic development of the country.
Family planning has been identified by the World Health Organisation (WHO) as
24
one of the six essential health interventions needed to achieve safe motherhood
and by United Nations Children Fund (UNICEF) as one of seven strategies for
child survival. Both women and men’s use of contraception have been going on
for centuries. Traditional methods such as coitus interruptus is described in
Bible, periodic abstinence was used in ancient India and the precursor to the
condom was used by the Egyptians back in 1350 BC (Edwards, 1994).
The practices of modern contraceptive methods offer many advantages in health
and economy of the couple and the country. The primary aim of family planning
enables women and men to plan their families and space their children through
the use of modern contraceptives. However, family planning also embraces
activities such as infertility and genetic counseling, contraception, abortion and
sterilization. Family planning programs, policies and methods have become
increasingly important in the last decade as a result of the socio-economic
problems influencing rapid population growth, as well as public health problems,
especially control of sexually transmitted diseases (STDs) such as AIDS (UN,
1994). There is evidence based on many studies which show that these
programs are jointly responsible for improvement in the quality of family life,
directly benefiting the health of women and children and is the most cost effective
intervention to lowering fertility (Maguire, 1994).
2.2 Situation of family planning in the world
The era of modern contraception began in 1960s, when both the birth control pill
and intrauterine contraceptive device (IUCD) became available. These effective
25
and convenient contraceptive methods resulted in widespread changes in birth,
fertility and demography in the United States. Between 1800 and 1900, the family
size in the United States declined from 7.0 to 3.5 children, and by 1933, the
average family size had declined to 2.3 children (CDC, 2000). Since 1972, the
average family size had leveled off at approximately two children, with increasing
safety, efficacy, diversity, accessibility and use of contraceptive methods
(Forrest, 1994).
Between 1990 and 1994, the global average contraceptive use by married
women of reproductive age rose from 57% to 60% (Hamilton, 1997). The
introduction of combined oral contraceptive pill also brought about the sexual
revolution in the West, where it was possible for sex without any fear of
pregnancy. Worldwide, however, there are still unmet needs especially in
developing countries, where a scarcity of resources and information, cultural and
political barriers, and societal attitudes or misconceptions, conspire to exact a
heavy toll on all women’s health, with unwanted pregnancies, unsafe abortions,
maternal mortality and HIV-1 infection still leading causes of death in women.
Even in developed countries, the situation is far from ideal and policies and
provision of services vary considerably within each country. Unwanted side
effects, inconvenience of the chosen method, and media scares about safety of
modern contraceptives are some of the issues that limit their acceptability. Poor
contraceptive use is further compounded by ignorance among users and
providers of wide range of methods available now and likely to be so in the
future. Giving women reproductive autonomy through comprehensive and up-to-
26
date information about all methods is vital for successful and long-term use of
contraception (Kubba et al, 2000).
2.3 Family planning in the Arab region
The region’s population growth rate currently stands at about 3% per year, and
the population of the Arab world is expected to reach 400 million by 2010. The
mean age at first marriage ranges from 17 years in Yemen to 24 years in Tunisia
and has been slowly rising in all eight countries in the region (Egypt, Jordan,
Mauritania, Morocco, Sudan, Syria, Tunisia, and Yemen). The current fertility
level in the Arab region is 2-3 times those required for generational replacement.
Completed fertility of ever- married women 45-49 years of age ranges from over
six children in Mauritania and Sudan, about seven children in Egypt, Morocco,
Tunisia and Yemen: and about eight children in Syria to almost nine in Jordan.
Examination of total fertility rate trends reveals little change in Mauritania, the
Sudan, and Syria, and decline in total fertility of about one child per woman in
Jordan, 1.5-1.8 children per woman in Egypt, Morocco, and Tunisia, and an
increase in Yemen (Farid S,1986).
The percentage of ever-married women who have ever used contraception
ranges from only 2-3% in Mauritania and Yemen to 40-46% in Egypt, Jordan,
and Tunisia. Current contraceptive use is highest (36%) in Tunisia. The following
factors seem to be associated with greater use of contraception: urban
27
residence, higher educational level, three or more children already in the family,
and more sons than daughters. Only 32-38% of women in Egypt, Jordan and
Tunisia indicated they would never use contraception compared to 92-97% in
Yemen and Mauritania. An increasing age at marriage and decreasing child
mortality have promoted the transition from a high to a moderate fertility level in
the Arab world (Farid S, 1986).
2.4 Family planning methods
About 85% of couples will become pregnant within one year without
contraception (Cleland et al,2006). Thus, even the least effective form of
contraception is considerably better than using nothing. There are a number of
family planning methods available to the couple. These methods can be divided
based on several criteria such as natural/artificial, traditional/modern,
temporary/permanent, male/female and oral/injectables/IUCDs. Natural family
planning means abstinence from sexual intercourse during fertile period to
prevent pregnancy. This includes the rhythm method (the calendar method),
mucus method, basal body temperature method or a combination of these
methods. This method has no systemic or long-term side-effects. However, these
methods are based on the timing of the women’s fertile period, which can be
highly unpredictable, even if their cycles are regular. The timing is even less
predictable for women with irregular menstrual cycles. The fertile period occurred
during a broad range of days in the menstrual cycle. On every day between day
6 and 21, women have at minimum a 10% probability of being in their fertile
28
period. Only about 30% of women had their fertile period entirely within the days
of the menstrual cycle identified by the clinical guidelines, which is between day
10 and 17 and only 10 percent of women ovulate exactly 14 days before the next
menses. Most women reach their fertile period earlier and others much later
(Wilcox et al, 2000).
In Malaysia, abstinence during fertile period is the third most popular
contraceptive methods used among all ethnic groups (Rohani, 1988). Some
couples find that abstinence during the fertile period is difficult to practice
consistently as it produce undesirable tension in their relationship. Other
traditional methods include coitus interruptus or male withdrawal, which is one
the oldest method of contraception. The husband withdraws the penis just before
ejaculation to ensure that all sperms are deposited outside the vagina. It is a
simple method, moderately effective, widely acceptable by well-adjusted and
motivated couples and does not require any professional supervision. It is the
commonest traditional method used among all three ethnic groups in Malaysia
(Rohani, 1988).
Lactational amenorrhea method (LAM) is a contraceptive method that relies on,
or uses, the state of infertility which results from exclusive breastfeeding. Other
criteria necessary are that the woman is still having lactational amenorrhea and
up to six months post partum. When these criteria are met, LAM can be more
than 98% effective in preventing pregnancy (Hight-Laukaran V et al, 1996). As
presently defined, the method is effective for a maximum of six months, yet a
29
large proportion of women remain protected from pregnancy beyond this time.
Only about 5% (3-10%) of breastfeeding women have been known to conceive
during amenorrhoea during the first year postpartum.
Barrier methods of contraception prevent sperm in the ejaculate from entering
either the vagina or the cervical os, by either mechanical or chemical means, or
both. It includes male condoms, female condoms, diaphragms and cervical
caps. It creates a barrier that prevents sperm from reaching the ovum. Male
condoms are one of the most commonly used contraceptives. It is one of the
oldest methods used to prevent pregnancy and sexual transmission of diseases.
They were initially made from animal skins but most modern condoms are made
from latex or polyurethrane. Use of condoms is advocated as an effective primary
prevention for HIV/AIDS in the fight to control of the current epidemic.
Spermicides can be used as a primary birth control method or, more commonly,
as an adjunct to the barrier methods. They are chemical barriers that kill or
inactivate sperm in the vagina before they can move in to the upper genital tract.
The spermicides are surfactants – surface – active compounds that can destroy
sperm – cell membranes. These barrier methods are safe and fairly effective if
used consistently and correctly. It also can be used as a back up method in
cases of failure by the barrier methods.
Hormonal methods are the most popular family planning methods used
worldwide. Ludwig Haber Landt, a physiologist in 1921, suggested that extracts
of ovaries could be used as oral contraceptive. There are several types of
30
hormonal contraception available. These include oral contraceptive pills, which
include combined oral contraceptive pills, progestogen only pills and post coital
contraceptive pills, injectables and implants
The first oral contraceptive, Enovid was marketed in the USA in 1960. Since
then, many different steroidal contraceptives have been developed, progressively
containing lower doses of estrogen and progestogen/progestin. More than 200
million women have used these preparations world wide since 1960. By 1965,
the pill had become the most popular birth control method used in the United
States. Combined oral contraceptive pills contain two hormones, an estrogen and
a progestin that come in packets of either 21 or 28 pills. The 21 pills pack
contains only active pills and requires women to take a seven days break in
between packs. The 28- pills pack contains 21 active pills and 7 inactive or
hormone free pills. There are three types of combined pills, which are
monophasic pill, where the hormone content is constant in all 21 active pills,
biphasic pills and triphasic pills, where the ratio of estrogen to progestin varies
among the active pills. Progestogen only pills contain only progestin and no
estrogen. They are especially suitable for women who are breastfeeding since
this type of pills does not affect milk supply and quality.
The oral contraceptive pill is the best – known modern method and the
commonest family planning method used in Yemen (CSOY, 1998). The Yemen
Demographic, Maternal and Child Health Survey (1997) reported that 84% of
currently married women have heard of at least one family planning method and
31
slightly less than 80% reported knowing a modern method and oral contraceptive
pill was the most widely known modern method at more than 75% of currently
married women (CSOY, 1998).
Post-coital contraceptive pills are intended for emergency use and must be taken
within 72 hours of a single episode of unprotected coitus and repeated exactly 12
hours later to prevent pregnancy. This method is indicated in a woman who is
exposed to unexpected and / or unprotected sexual intercourse such as cases of
rape. World wide, this emergency post-coital contraception has been used
extensively for over two decades.The options currently available include
progestin alone (levonorgestrel, 750 mcg (Prostinor), an estrogen -progestin
combination, which comprises of combination of 100 mcg ethinyl oestradiol and
500 mcg levonorgestrel, which is called yuzpe regimen. The pregnancy rate in
these treated women varies from 1 % to 4 %, depending on the stage in the cycle
when coitus occurred and also depends on the timing of the pill used. A recent
analysis of the timing of pill use suggests an inverse linear relationship between
efficacy and the time from intercourse to treatment. The earlier the pills were
used, the more effective they were during the 72 hours period studied. Delaying
the first dose by 12 hours increased the odds of pregnancy by almost 50 %
(Piaggio et al, 1999).
Injectable forms of hormonal contraception are considered safe, very effective,
simple to use and easy to administer. Injectable contraceptives are among the
most effective reversible contraceptive available, with a failure rate less than one
32
percent after a year of use. It is particularly suited to the needs of young women,
providing very high efficacy rate and less complication. The disadvantages
include irregular bleeding, weight gain and delayed return to fertility. Injectable
contraceptives work in several ways to prevent pregnancy. The primary action is
the inhibition of ovulation. Besides that, it also increases the viscosity or
thickness of the cervical mucus, making it less permeable to sperm penetration
to the uterine cavity.
Another type of hormonal contraception is the contraceptive implant. It is an
effective, long acting, reversible, low dose progestogen-only product, suitable for
use in family planning programs along with other currently available
contraceptive preparations and devices. It offers long term contraception and is
an alternative to the irreversible methods of contraception. Implant is inserted
subdermally in the first seven days of menstrual cycle and once in place, it
requires no further attention by the user. However, it must be inserted or
removed by a specially trained health professional. The mode of actions includes
inhibitions of ovulation, suppression of endometrium and increase the viscosity or
thickness of the cervical mucus. The effectiveness of this method is comparable
to combined oral contraceptive pills and intrauterine device. Amenorrhea is
common after insertion of implants, reported by 20% of users at any time in the
first two years (Kubba et al, 2000).
Intrauterine contraceptive devices (IUCDs) are small plastic devices that come in
different sizes and shapes and have a life span ranging from one to five years. It
33
prevents pregnancy primarily by preventing fertilization. Fertilisation is prevented
by a foreign body sterile inflammatory reaction in the endometrium that prevents
sperm from reaching the fallopian tubes. In the past, there were objections to
IUCDs as it believed to function primarily as an abortifacient, preventing
implantation of the fertilized egg. The IUCD is inserted in to the uterus through
the cervix by a trained health professional at any time convenient to the user,
normally within the first seven days after normal menses, or within the first seven
days post abortion, or six to eight weeks post delivery, or within five days of
unprotected sexual intercourse. Grimes et al (2000) noted that the insertion of an
IUCD immediately after abortion, either induced or spontaneous abortion was
both safe and practical. O’ Hanley & Huber (1992) also found that insertion of an
IUCD in the post-menstrual and immediate post-partum periods was convenient,
efficient, safe and have a low incidence of infection.
Sterilization is a permanent contraceptive option available to couples that have
decided to end bearing child. Female sterilization involves occlusion or
transaction of the fallopian tubes, commonly referred to as ‘tubal ligation’. Male
sterilization is performed by vasectomy. In many developed countries, this
remains the most popular method in couples over 35 years. Female sterilization
is the most common birth control method at 30% worldwide for married couples,
followed by intrauterine devices at 20% and contraceptive pills at 14% (Hamilton,
1997).
Despite calls for increased involvement of men in contraception, only the
34
traditional methods of withdrawal and condoms are available (Kubba et al, 2000).
The male condom is a essentially a sheath worn over the penis during
intercourse. It is the most harmless form of modern contraceptives with a failure
rate of about 12%. It prevents pregnancy by acting as a barrier preventing the
sperm from reaching the ovum. The use of condom allows males to have an
active part in preventing pregnancy. It is suitable in couples who have infrequent
sexual relationship and is only delaying pregnancy. Condoms also protect males
and females from contracting a sexually transmitted disease, including AIDS.
They act as a barrier to organisms transmitting sexually transmitted disease.
Some condom contain spermicidal to improve their effectiveness. Side effects
are mainly allergy to latex rubber or to the lubricant. However, non rubber-based
condoms are available for such situations.
Studies on family planning programs, policies and methods have increased
drastically in the last decade as a result of the socio-economic problems
influencing population growth, as well as public health problems, especially STD
(sexually transmitted diseases) such as AIDS, using contraception as one of the
means for family planning (United Nations, 1994).
2.5 Family planning services in Yemen
Yemen adopted the primary health care (PHC) approach in 1978, the year of the
Alma Ata Conference. This approach emphasizes preventive and promotive
health programs and first level curative care. To implement this approach,
Yemen has utilized a traditional three-tier system consisting of health units,
35
health centers, and hospitals. Ideally, within this system, health units provide the
most basic curative and preventive care to all villages within their catchment
areas, with each area consisting of a population of 3,000 – 5,000. These units
are backed up by PHC centers staffed by a physician and equipped with a
laboratory and x-ray facilities. At the secondary level are district and governorate
hospitals providing inpatient care and offer more sophisticated diagnostic and
curative services.
The National Population and Family Planning Program, Yemen (NPFPP) was
established in 1984 to strengthen the government’s capacity to implement
population policy in North Yemen. After the unification of North and South Yemen
in May 1990, the government established the National Population Council (NPC)
to oversee implementation of a national population and family planning policy
adopted in October 1991.
The stated objectives of the family planning program in Yemen are to:
i. increase the use of contraception to 35% among women of reproductive age,
and expand family planning services to men, and
ii. Make family planning a free choice for couples, a basic human right as well as
a factor for social change. Family planning must also include the treatment for
Infertility.
There are several methods of family planning available in Yemen. The methods
include natural family planning methods or fertility awareness-based method,
traditional methods, barrier methods, hormonal methods, intrauterine device and
36
permanent methods. In Yemen family planning services are provided by several
sources such as:
A. Public sector B. Private sector
1- Central hospitals 1- Private dispensaries
2- MCH clinics 2- Private hospital
3- Primary health care centers 3- Private doctor
4- Mobile clinics 4- Public field worker clinics
5-Yemen family care association clinics 5- Private Pharmacies
Family planning services by the Ministry of Health are provided through it’s
extensive network of facilities available through out the country. Most Yemeni
women go alone to the health centers and MCH clinics to seek family planning.
Occasionally, some of them are accompanied by their husbands or other family
members with permission from their husbands. Family planning are usually
prescribed by midwives to the people at a nominal price in the centers and
clinics.
2.6 Factors associated with family planning practic e
The factors associated with family planning practice can be divided into personal,
demographic, socio-cultural, religion, economic, and health services. Among the
personal factors associated with family planning practice are knowledge of family
planning methods and influence of family members and friends, especially those
who have experience in family planning methods. Demographic factors such as
37
parity, age, marital status, religion, husband’s education, husband’s occupation,
monthly family income, and woman’s occupation are also know to be associated
with family planning practice. However, a study in Mexico by Romero-Gutierrez
et al (2003) found that many of these factors which have previously been
considered to affect family planning acceptance were not significant. He found
the reasons were the women accepted family planning mainly for personal
reasons and their decision was only influenced by the family size desired. Al-
Riyami et al (2004) found that Oman women’s autonomy. education and
employment were influential in their contraceptive practice. Approval of husbands
was an important factor for women noted in many studies in developing countries
(Kamal, 2000; Sahin & Sahin, 2003; Al-Riyami, 2004)
In Yemen, about 42% of women said they had not talked to their husbands about
family planning in the year preceding the survey while 26% had discussed it once
or twice and 32% had discussed it more often (CSOY, 1998). Women in the
oldest and youngest cohorts were least likely to have discussed family planning
with their husbands. In 40% of couples, both husband and wife approved of
family planning; in 22% both disapprove. In 12% of couples, the wife approved
but the husbands did not, while in 4%, the husband approved but the wife did
not. There were marked differential by level of education: the higher the wife's
level of education, the more likely it is the couple approves family planning. Partly
for this reason, couples in urban areas are twice as likely to approve of family
planning as those in rural areas. Couples' approval of family planning is highest
38
in the Plateau and Desert region (48%) and lowest in the Mountainous region
(29%) (CSOY, 1998)
A national survey of men conducted in the United States 1991 found that about
12% of married men aged 20-39 years have had a vasectomy and about 13%
were married to a woman who is sterilized. Sterilization rises with the husband’s
age, wife’s age, duration of marriage and number of children. Black couples were
significantly less likely than white couples to rely on sterilization, and interracial
couples were less likely than same-race couples to be sterilized. Use of male
sterilization is also strongly associated with having had recent contraceptive
failure while using a male method (Tanfer et al ., 1995).
Mass media campaigns and advertisements and social marketing will influence
both men and women to “legitimizing contraception in their minds”. In 1994, a
study of Kenyan rural male attitudes to contraception showed that the most
(93.2%) approved of family planning. Although 63.9% of the respondents felt that
family size decision making should be a couple’s responsibility and 78.6% of
respondents preferred a husband and wife approach to the family planning
counseling, 56.9% said that the women should be the one to actually use the
contraceptive, and 88.7% approved of female sterilization while 64.5%
disapproved of vasectomy (Were & Karanja, 1994). In a survey conducted in an
inner city sexually transmitted disease clinic in Newton, Massachusetts, USA,
men who were given coupons to redeem for condoms at a neighborhood
pharmacy show that only 22% of the sample did so (O’Donnell L et al, 1995).
39
Gender, ethnicity, marital status and education were not significant predictors of
whether study participants redeemed their coupons.
A multimedia communication campaign was conducted in Zimbabwe between
1988 and 1989 to promote family planning among men. Among married men, the
use of modern contraceptive methods increased from about 56% to 59% during
the campaign, condom use increased from 5% to 10%. Men exposed to the
campaign were significantly more likely than other men to make the decision to
use family planning and to say that both spouses should decide how many
children to have (Piotrow et al., 1992). In Ethiopia, a study was undertaken from
1990 to 1991 to determine the relative efficacy of home visitation with and
without husband participation on the use of modern contraception. The aim of the
study was to initiate and sustain modern contraception use among married
couple. A greater proportion of couples in the experimental group were practicing
modern contraception at 2 months (25% vs15%) and 12 months (33% vs17%)
following the home visit intervention. By 12 months following the home visit,
experimental subjects were less likely to have defaulted and more likely to have
started using modern contraception following an initial delay (Terefe &
Larson,1993).
In Ghana, two plausible explanations for why individual’s characteristics may
affect partner’s beliefs and behavior were provided. Spousal influence, rather
than being mutual or reciprocal, is an exclusive right exercised only by the
husbands. The study also attributed the limited impact of family planning
40
programs in Ghana and most of Sub-Saharan Africa to the continued neglect of
men as equal targets of such programs. It also showed that the wives of
educated men behaved significantly different from the wives of uneducated men
(Ezeh,1993). Involvement of men and women in using contraception is
influenced by a number of factors, mostly lack of knowledge, cultural barriers,
education, socio-economic pressure, and service of family planning providers
and economic pressures. The Bangladesh Demographic and Health Survey
(BDHS) 1993-94 estimated 92% of husbands approve of family planning and in
the BDHS 1996- 97 report, 96% of respondents (males and females) said their
spouse approved of family planning (Kamal, 2000).
Religious and cultural pressures also influence the family planning programs in
Arab countries. In Jordan, nearly 40% of married men do not believe in practicing
contraception and more than half believe that family size should be left up to
God. (Warren et al, 1990) According to the 1985 Jordan Husband’s Fertility
Survey (JHFS), the proportion that was illiterate to 20.8% these with at least
secondary schooling and the proportion who said that both the husband and wife
should decide on using family planning methods together increased from 12% to
57% respectively. These barriers should be overcome is by encouraging,
providing on-site orientations to staff about family planning, posting sign,
establishing committees, which pay attention to these issues, and providing more
educational materials for husbands (Warren et al., 1990).
41
2.7 Role of husbands towards family planning :
Women’s roles in family planning are well known as they are the primary career
of the child during and after pregnancy. What is less clear is the role and level of
husband’s involvement. Birth control methods involving men such as coitus
interruptus, periodic abstinence and condoms cannot be used without the
complete cooperation of men. With the availability of modern methods (the pill
and IUCD) in the 1960s, women gained reliable control of their reproductive
capability (Edwards, 1994). In many societies, men are the primary decision
makers regarding the family and family planning practice (Kamal, 2000; Sahin &
Sahin, 2003; Al-Riyami, 2004) However, decisions about family planning are
sometimes not discussed or made without sufficient communication between
husbands and wives. Efforts to improve couples’ communication can help lead to
decisions about family planning that reflect the needs of both women and men.
Husbands will need relevant information to participate responsibly in making
decisions on family planning. The family planning services should also be
relevant for husbands to participate. Husbands can learn more about family
planning by accompanying their wives on clinic visits and by taking advantage of
special clinics hours for men, where available. Husbands also can participate in
family planning by helping their wives to remember to take a pill every day or to
return to the clinic for regular injections. Husbands also can help their wives by
organizing transportation to the clinic, paying for family planning methods and
services, and taking care of children during clinic visits (WHO, 2004).
42
The aim of family planning is to enable couples to decide freely and responsibly
the spacing of their children, to have the information and means to do so, to
ensure informed choices and to make available a full range of and effective
methods (UN, 1994). A survey done in United States in 1993 of publicly funded
family planning clinics found that in only 13% of clinics do male patients comprise
more than 10% of the total clientele; just 6% of all family planning clients are
men. This is due to the fact that these clinics are staffed with females and most
of these patients are women and their messages address their perspectives and
needs of women. Statistics show that the number of male clients had increased
over the last five years (Schulte & Sonenstein, 1995). Male involvement in
contraception and their attitudes differ between the developed and developing
societies. Their attitude towards family planning program also varies according to
their religion, culture and education. Although their attitude towards such a matter
does affect their involvement, some studies show that using contraceptives (for
different reasons) in the developing world is governed by the male dominance in
these cultures (Commack & Heaton, 1993). Changes in both men’s and women’s
knowledge, attitudes and behaviors are essential to the harmonious relationship
between them, as men play a role in bringing about gender equality (Brindis et
al., 1998). In Sudan, a high proportion of men oppose contraception and it was
suggested that family planning programs “should increase the availability of male
methods, include men in educational programs about population, health and
contraception, and/or target younger men, who already have more positive
attitude towards family planning (Taha, 1993). It also was generally believed that
refusal by husbands and family leaders were the main obstacle in women’s
43
practice of contraception. A study conducted in Eastern Turkey showed that men
are the dominant decision makers in this region. Husband’s approval for
contraceptive usage among women reported a 45.2% rate of not practicing family
planning and the main reason was disapproval of the husband or family leaders
(38%) (Sahin & Sahin, 2003). It is necessary to discover the knowledge,
perception, attitudes and contraceptive practice of men to increase their
involvement in reproductive health needs of families. Improving the status of
woman will change male-dominant decision-making. Higher levels of education
and wider employment opportunities for women as well as higher family
socioeconomics status may directly influence decision making in family life,
leading in turn to more effective contraceptive use. Improvement of the status of
women in the family and society in general would make Turkey’s family planning
program more effective and successful. There is contraception for both men and
women, but studies showed that common methods are usually female ones. The
indicator of lack of male involvement in family planning in the developing world is
the low use of male methods of contraception in comparison with the female
methods, while others refer it to the dominant role of the man in other societies
(Sahin & Sahin, 2003). There are other countries such as in Ethiopia, Ghana
and Gaza where husband’s approval are generally needed (Ezeh, 1993. Terefe
& Larson, 1993. Donati et al., 2000). However, in Bangladesh, husbands support
their wives by obtaining the contraceptive supplies (Kamal, 2000).
Contraceptive practice also has an important implication for sexually transmitted
diseases (STDs). Patterns of contraceptive use may have changed because
44
there are now other reasons for contraception besides avoiding pregnancies.
Data on contraceptive use in the 1984 Canadian fertility survey and from 1995
general social survey found a decline in contraceptive use over the last decade
has left Canada’s overall contraceptive prevalence among the lowest in the
industrialized world while the rate of sterilization is among the highest. These
changes in contraceptive behavior complicate efforts to plan for social and health
needs, particularly policy decision focusing on reducing infections with STDs
(Martin & Wu., 2000).
2.8 Role of Islam
Muslim jurists have differences in opinion on the question of birth prevention, on
its lawfulness, on conditions for practice and on methods that may be used.
Muslim jurists determine the lawfulness of an act on the basis of a method which
comprises four principles or sources (usul). Two of these (Qur’an and Sunnah)
are religious sources. The other two principles include (qiyas) and consensus of
the ulama (ijma’).
A companion of the rophet (PBUH), Jabir reported that he practiced al-azl (coitus
interruptus) during the time of the Prophet (PBUH) who knew about this, but did
not forbid Jabir from doing it. In 1980, Dr. Yusuf Al-Qardhawi issued a Fatwa
(opinion) on family planning. The preservation of the human species is
unquestionably the primary objective of marriage. And such preservation of
species requires continued reproduction. Accordingly Islam encourages having
many children and blessed both male and female progeny. However, it allows the
45
Muslim to plan his family due to valid reasons and recognized necessities. The
common method of contraception at the time of the prophet was coitus
interruptus (withdrawal). The companions of the prophet engaged in this practice
during the period when the Quran was being revealed to him.
According to Dr Yusuf Al-Qardhawi, modern contraceptives are similar in
purpose to coitus interruptus and are allowed by analogy (qiyas). He also quoted
Ahmad ibn Hanbal as requiring the consent of the wife. As regards to abortion,
he objects to it especially after the fetus is completely formed. However, Sheikh’
Ali Jad al-Haq, the Grand Mufti of Egypt, commented that family planning as a
distrust in the popular belief that Allah will take care of the family’s needs
regardless of how big it grows. From the Islamic perspective, children are a gift
and blessing from Allah. Allah mentioned some of the bounties that He has
bestowed upon mankind in the following verse; “And Allah has made for you
spouses of your own kind and has made for you, from your wives, sons and
grandsons, and has bestowed upon you good provisions.” (al-Nahl 72).The
institution of marriage and the desire for children was the custom of the best
creation of Prophets and Messengers chosen by Allah. Allah says about them
“And indeed we sent messengers before you and made for them wives and
offspring” (al-Raad 38). The best example for the believers is the example of the
Prophet Muhammad (pbuh), who married and had children. These prophets and
messengers are the people whom Muslims should look to emulate. Allah says”
They are those whom Allah has guided. So follow their guidance” (al-Anaam 90).
46
Birth control is allowed in Islam when necessary, provided its aim is not to
prohibit pregnancy permanently, unless indicated for medical reasons. One good
reason for using contraception exists when one fears that the pregnancy or
delivery might endanger the life of the baby or of the mother (Harlina, 2005).
47
(KAP) of husbands in MukallaTowards modern family
PlanningKnowledge :
Knowledge of modern family planning methodsAttitude:
Attitude of husbands towards family planningPractice:
Practice of family planning methods byhusbands and wife
demographic factors.*Age, *No children, Race, *Occupation, *Education
Culture beliefsHabits,
Mass education,Main decision maker
.Community awareness
Conceptual frame work of study
Social factors*Income, Religion,
Early marriage age, Poverty
Health Service1. Availability2. Quality3. Accessibility4. Acceptability 5. staffing
Good KAP Poor KAP
Low growth rate1.Low fertility rate2.Low maternal mortality, Morbidity rate3.Low infant mortality. Morbidity rate.4.Decrease low birth Weight.5. Low risk pregnancies.6. Fully breast – fed infant.7.Low illiteracy rate8. High socio-economic level
High growth rate1 High fertility rate 2.High maternal mortality, Morbidity rate3.High infant mortality. Morbidity rate.4.Increase low birth Weight.5. High risk pregnancies.6.No fully breast – fed infant.7.High illiteracy rate8. Low socio-economic Level
Figure No 4.2
Figure. 2.1
Conceptual work frame of the study
48
CHAPTER 3
OBJECTIVES AND RESEARCH QUESTION
3.1 Objectives
3.1.1 General objectives
1. To determine the practice and types of modern family planning among
couples in Mukalla, Yemen.
2. To determine the husband’s knowledge and attitude towards modern
family planning and factors influencing them.
3.1.2 Specific objectives
1. To determine the prevalence and types of modern family planning used by
Yemeni couples in Mukalla.
2. To determine the knowledge and attitude of husbands in Mukalla regarding
modern family planning.
3. To determine factors associated with the husband’s attitude towards
modern family planning in Mukalla.
3.2 Research questions
1- What is the prevalence and types of family planning use among Yemeni
families?
2 - What is the attitude of Yemeni husbands on modern family planning?
3 - What is the knowledge of Yemeni husbands on modern family planning?
4 - What factors influence the knowledge and attitude of Yemeni husbands
towards modern family planning?
49
CHAPTER 4
METHODOLOGY
4.1 Study design
This is a cross-sectional study of Yemeni husbands in Mukalla district in the
governorate of Hadhramaut, Yemen on their knowledge, attitude and practices of
modern family planning practices.
4.2 Study area
This study was carried out in Mukalla, Hadhramaut. Hadhramaut is located in
southern Yemen, situated between 14 – 19 degrees latitudes north and 48 – 51
degrees longitudes east. Hadhramaut, is the largest governorate in the Republic
of Yemen. Hadhramaut comprises an area of about 161,749sq.kms, which is
about 36% of Yemen. Hadhramaut has an estimated total population of
1,029,000, in which all are Muslims. Administratively, Hadharamaut consists of
30 districts. Mukalla is the capital city of Hadhramaut and is situated on the coast
facing the Indian Ocean. Mukalla has a population of 165,587, living in ten
quarters. The main occupations in Mukalla are petty traders, farmers,
government employees and fishermen.
50
4.3 Study preparation
The study protocol was initially prepared in Malaysia after discussion with my
supervisors and presentation to the Department of Community Medicine, School
of Medical Sciences, Universiti Sains Malaysia. Communication with the field
supervisor in Yemen was regularly done to determine the feasibility of the study.
Prior to starting the fieldwork for this study, permission from the local health
department in Mukalla was obtained after presentation and discussion of the
proposed study with the relevant health officers.
4.4 Reference population
The reference population for this study was all Yemeni husbands living in
Mukalla, Yemen
4.5 Source population
The source population for this study was all Yemeni husbands living in
Allmostagbal and alomal quarters.
4.6 Study population
Mukalla is administratively divided into ten quarters. Two quarters were randomly
selected for the study because of logistic, time and financial constraints. The
study population was husbands selected from the two selected quarters. The
husbands were selected based on a random selection of houses in each quarter.
The number of houses selected for each quarter was based on proportionate
sampling based on total number of houses in each quarter. The sampling frames
51
for the houses at each quarter were obtained from the Central Statistical
Organisation Yemen.
The researcher visited all the selected houses in the two quarters. At each
house, the husbands were identified and interviewed using a standard
questionnaire. In houses where there were more than one husbands, only one
was randomly selected. In houses where the husbands were not available, an
appointment was made and a repeat visit was done to carry out the interview. If
at the repeat visit, the husbands were still not available, the house was excluded
from the study and the nearest house with an available husband was chosen as
a replacement. In houses where the husband did not meet the pre-determined
inclusion and exclusion selection criteria, a replacement was immediately made
from the nearest house.
4.7 Criteria for selection of husbands
4.7.1. Inclusion criteria
1. Husbands must be living together with their wife in the house.
2. Have at least one surviving child.
4.7.2. Exclusion criteria
1. Husbands who are not from Yemen
2. Husband’s age must be > 60 years.
3- Husbands without any children
4- Husbands who are unable to be interviewed because of chronic illness
52
5- Husbands with wives who are currently pregnant
4.8 Sample size calculation
Objective 1: To determine the prevalence of modern family planning practice by
Yemeni couples in Mukalla, Hadhramaut.
The sample size was calculated using the single proportion formula;
N = Z2* P ( 1- P)
∆2
N = minimum required sample size
Z = 95 % confidence interval (CI) = 1.96
∆ = precision = 0.05
P = estimated proportion of husbands practicing contraceptive
Based on 60.9% of husbands in Jordan practicing family planning methods
(Warren et al, 1985), the calculated minimum sample size required was 400
subjects.
4.9 Study instrument
4.9.1 Questionnaire
A questionnaire was initially constructed in English in order for discussions on the
scope and relevance of the questions to be done to have a high degree of
content validity. This was done by reviewing the literature and discussing with
lecturers from the Department of Community Medicine, School of Medical
Sciences, Universiti Sains Malaysia. The finalized questionnaire was then
53
translated by the researcher into Arabic for interviewing husbands in Yemen. No
back translation was done as there were no experts in Arabic available.
The questionnaires include the following areas:
A. Socio- demographic background of the husbands and their wife;
B. Knowledge of husband on modern family planning
There were 20 questions on knowledge of modern family planning methods that
were available in Mukalla. The questions focused on the husband’s awareness,
mechanism, and places where it was available in Mukalla with responses being
yes, no and uncertain. A score was given for each answer, with the appropriate
answer given a score of three, uncertain answer given a score of two and the
inappropriate answer given a score of one. A total score of knowledge was
determined for each husband.
C. Attitude on husbands on modern family planning
There were 12 statements on attitudes to the use of modern family planning. The
attitude was measured using a five-point Likert scale; strongly agree, agree,
unsure, disagree and strongly disagree. A score of one to five were given to the
husband’s response, with positive responses given higher scores.
D. Practice of family planning by husbands and their wives:
This section determined the family planning practice and methods of husbands
and their wives. Reasons for not currently practicing family planning in the couple
were determined. The decision maker for family planning in the couple and the
54
experience of unplanned pregnancies were also determined.
4.10 Pilot study
A pilot study was carried out in Malaysia to pre-test the questionnaire in Arabic in
order to determine problems related to the questions and to estimate the length
of time required completing the questionnaire. This study was conducted among
all available married Arab male postgraduate students (N=35) in Universiti Sains
Malaysia Health Campus. Changes were made accordingly on unclear questions
or statements. The statements under the attitude domain were tested for internal
consistency and the Cronbachs alpha obtained was 0.73
4.11 Data collection
Announcements were made through the local clinics and mosques in the
selected quarters in Mukalla about the study and for husbands to cooperate and
participate. The houses were selected randomly as stated above. A visit was
done by the researcher to each house and an introduction and briefing on the
study was done. A quick assessment was made to check that the husband met
all the inclusion and exclusion criteria. For each household selected but the
husband excluded based on selection criteria, the nearest house was chosen
and the husband was selected as a replacement. Consent was obtained from the
husbands to conduct the study. A personal one-to-one interview using the
structured questionnaire was carried out with the husbands. In situations where
the husband was busy or not available, an appointment was made for the
researcher to return and interview the husbands.
55
At the end of the interview, the questionnaire was checked to ensure that all
questions were asked and completed. All completed questionnaires were given
the appropriate ID number and compiled in a file. The husband was thanked for
his cooperation and participation.
56
Flow Chart of the Study
Mukalla District (10 Quarters)2 Quarters selected
(Randomly)
1. Alomal - N= 6210 houses 2. Allmostagbal –N=6350 houses
200 houses selected per quarter based on probablity proportional to size
400 husbandsInclusion/Exclusion criteria
Excluded husbands (No=40) 1.No child/ pregnantwife-352.Husbands refused to
cooperate- 5Excluded husbands replaced
by neighboring N=40
QuarterAlomall
N=200 husbands
Quarter Almostagba
N=200 husbands
Total sample (N= 400 houses)by simple random sampling
Sampling Frame:List of households, Hadhramaut Statistical Department,2004
Interview of Husband, Questionnaire-KAP
Data Entry and Report Writing
Required sample size 400 husbands
Included husbands(N=360)
Figure 3.1. Flow chart of the study.
57
4.12 Data entry and analysis
A data file was created based on the questionnaire using the Statistical Package
for Social Sciences (SPSS) Version 11.0 software. The raw data was entered
into the SPSS data file. Preliminary data checking was done to detect data entry
errors. Outliers were identified by plotting histograms and checked for possibility
of data entry errors. Any data entry error found was then cleaned.
The distribution and frequencies were examined. All continuous variables were
expressed as means and standard deviations. Some continuous variables were
categorized based on the need for presentation or further analysis. Descriptive
analysis using frequencies and percentages for categorical variables were
obtained.
For practice of family planning, the percentage of the husbands who practice
family planning, the percentage of the wives practicing family planning and the
types of methods used were determined. The percentage for common reasons
for not currently practicing family planning in the couple was also determined.
The decision maker for family planning in the couple and the experience of
unplanned pregnancies in the coupled were also determined. All the results was
presented as percentages of the total number of husbands studied.
For knowledge on family planning, the percentages of the husbands giving the
correct or positive response for each question were also determined and
58
presented The total knowledge score were also determined for further analysis.
For attitude to family planning, the researcher categorized the total attitude
scores into four categories based on the total score obtained by the husbands.
The possible range of total scores was 12 – 60. The mid-point of 36 was taken as
cut-off score for poor and satisfactory attitude. The satisfactory attitude category
was further categorized equally into three sub-categories; moderate, good and
very good. The final four categories used in the descriptive analysis were:
1. Poor attitude if the score was 12 – 36
2. Moderate attitude if the score was 37 – 43
3. Good attitude if the score was 44 – 51
4. Very good attitude if the score was 52 - 60
Associations between the husband’s total knowledge and attitude score with a
number of socio-demographic factors were determined by both simple and
multiple linear regressions and presented.
59
CHAPTER 5
RESULTS
A total of 400 husbands in Mukalla were interviewed using the study
questionnaire about their knowledge, attitude and the practice of family planning
during the period from 1/12/05 until 30/5/06. There were 40 husbands who were
excluded based on the inclusion and exclusion criteria. There were 22 husbands
whose wife were currently pregnant, 13 husbands who did not have any children
yet and 5 husbands who were away at work during the first visit and were not
keen to participate with a follow-up appointment. As stipulated in the
Methodology, all 40 husbands were replaced with a husband from one of the
nearest houses.
5.1 Socio-demographic characteristics of husbands a nd wives
Table 5.1 shows the characteristics of the husbands regarding age, level of
education occupation, number of children and monthly income. There were 301
husbands (75.3%) who were between 31–50 years while only a minority of
husbands 52 (13.0%) were 30 years old and less while 47 (11.8%) were aged 51
years and more. However, none of the husbands were adolescents, aged less
than 20 years.
60
The results also showed that 165 husbands (41.3%) were educated up to
secondary school level. There were 146 husbands (36.5%) who had a university
education while only four husbands (1.0%) did not have any schooling.
Regarding the monthly income of the husbands, 180 husbands (45.5%) were
living on monthly income of between 20000–30000YR (USD 106-160). All the
400 husbands were employed, with 82 (20.5%) of them being self-employed.
The majority of the wives - 223 (55.8%) were between 31-50 years old. Only
eight wives (2.0%) were aged 51 years or older and 46 wives (11.5%) were
adolescents, between 15 -20 years old. The educational status of nearly half of
the wives - 168 (42.0 %) were only till primary school level while only a minority
of them - 27 (6.75%) had no schooling. Most of the wives (80.5%) were
housewives with the remainder working, with monthly incomes of between 10000
- 20000 YR. However, all working wives had lower monthly income compared to
the husbands.
There were 119 families (29.8%) with 1-2 children while 179 families (44.8%)
with 3-4 children. There were 102 families (35.5%) with at least 4 children. The
maximum number of children found in a family was ten.
61
Table 5.1: The socio-demographic characteristics of husbands and their wives (N=400) Characteristic
N % Mean SD
Age of husband (years) 41.1 (8.8) 1. ≤ 30 52 (13.0) 2. 31 – 40 144 (36.0) 3. 41 – 50 157 (39.3 4. ≥ 51
47 (11.8
Years education (husband) 12.2 (3.6) 1. No schooling 4 (1.0) 2. Primary school 85 (21.3) 3. Secondary school 165 (41.3) 4. University 146
(36.5)
Income of husband (YR/month) 31231.1 (14113.5)
1. ≤ 10000 3 (0.8) 2. 10001 – 20000 40 (10.0) 3. 20001 – 30000 180 (45.0) 4. 30001 – 40000 125 (31.3) 5. 40001- 50000 40 (10.0) 6. 50001 – 60000 9 (2.3) 7. ≥ 60001 3
(0.8)
Husband’s occupation 1. Unemployed 0 (0.0) 2. Government 254 (63.5 3. Semi-government 30 (7.5) 4. Self employee 82 (20.5) 5. Private 34
(8.5)
Age of wife ( years) 33.2 (8.9) 1. 15-20 46 (11.5) 2. 21 - 30 123 (30.8) 3. 31- 40 150 (37.5) 4. 41- 50 73 (18.3) 5. ≥ 51 8 (2.0)
62
Table 5.1: The socio-demographic characteristics of husbands and their wives (N=400) (continued)
Characteristic
N % Mean SD
Years of education (wife) 1. No schooling 27 (6.8) 2. Primary school 168 (42.0) 3. Secondary school 161 (40.3) 4. University 44 (11.0)
Income of wife (YR/month) 20610.3 (5437.3) 1. Not working 322 ( 80.5) 2. 10000-20000 39 (9.8) 3. 200001-30000 36 (9.0) 4. ≥ 300001 3 (0.8)
Wife’s occupation 1. Unemployed 322 ( 80.5) 2. Government 45 (11.0) 3. Semi government 5 (1.3) 4. Self employed 27 (6.8) 5. Private 1 (0.3)
No of children 3.5 (1.8) 1. 1 – 2 119 (29.8) 2. 3 – 4 179 ( 44.8) 3. 5 – 6 74 (18.5) 4. 7 – 8 22 ( 5.5) 5. 9 – 10 6 ( 1.5)
63
5.2 Practice of family planning methods among hu sbands and wives
The prevalence of ever practicing modern family planning among husbands in
Mukalla was 39.0% (156 husbands), while 244 husbands (61.0%) have never
practiced any modern family planning (Fig 5.1).
.
Current use, 44, 11.0%
Previous use, 112, 28.0%
Never use, 244, 61.0%
Figure 5.1: Prevalence of family planning practice by husbands
(N= 400).
A total of 177 wives (44.3%) practiced modern family planning, with 83 wives
(20.8%) currently practicing and 94 wives (23.5%) had previously practiced.
There were 223 wives (55.8%) who had never practiced any modern family
planning (Fig 5.2).
64
Current use, 83, 20.8%
Previous use, 94, 23.5%
Never use, 223, 55.8%
Figure 5.2: Prevalence of family planning practic e by wives
(N= 400).
There were 77 husband-wife couples (19.3%) where both husbands and wives
use modern family planning methods, 79 couples (19.8%) where only husbands
use but their wives do not, 100 couples (25.0%) where the husbands do not use
but their wives use and 144 couples (36.0%) where both the husbands and their
wives do not practice any modern family planning.
5.3 Types of modern family planning methods used by husband and wife
In this study, among the wives currently practicing family planning, the most
common method was contraceptive pills - 45 (54.2%) followed by intrauterine
contraceptive devices (IUCDs) - 36 (43.4 %) respectively, while vaginal cup
were reported in only two wives (2.4 %) and none of the wives had female
sterilization.
65
Among the 44 husbands currently practicing family planning, all were using
condoms. No husbands had undergone sterilization. Among 112 husbands who
had previously practiced family planning, again all of them used condom.
Table 5.2: Number of living children and practice o f modern family planning
methods by husbands (N=400)
No of children
Current use
N (%)
Previous use
N (%)
Never use
N (%)
1-2 8 (2.0) 35 (8.8) 76 (19.0)
3-4 24 (6.0) 52 (13.0) 110 (27.5)
5-6 8 (2.0) 20 (5.0) 46 (11.5)
7-8 3 (0.8) 3 (0.8) 16 (4.0)
9-10 1 (0.3) 2 (0.5) 3 (0.8)
Total 44 (11.0) 112 (28.0) 244 (61.0)
Table 5.2 showed that only 11.0% of husbands currently practice family planning
while 28.0% of husbands had previously used family planning. There were more
husbands who either currently or previously use family planning methods among
those with lesser children (1 – 4 children) compared to those with more than four
children. Overall, there were 244 husbands who have never used modern family
planning methods
66
Table 5.3: Number of living children and practice o f modern family planning
methods by wives (N=400)
No of children
Current use
N (%)
Previous use
N (%)
Never use
N (%)
1-2 20 (5.1) 26 (6.6) 73 (18.3)
3-4 43 (10.8) 40 (10.1) 96 (24.1)
5-6 16 (4.1) 21 (5.3) 37 (9.3)
7-8 4 (1.0) 4 (1.0) 14 (3.6)
9-10 0 (0.0) 3 (0.8) 3 (0.8)
Total 83 (20.8) 94 (23.5) 223 (55.8)
Table 5.3 shows that only 20.8 % of wives currently practice family planning
while 23.5 % of wives had previously used family planning. There were more
wives who either currently or previously use family planning methods among
those with 1 –6 children compared to those with more than six children. Overall,
there were 223 wives who have never used modern family planning methods
67
5.4 Decision maker regarding the use of family plan ning in the family
In this study, most husbands (93.0%) believed that both the husband and the
wife should make joint decisions regarding family planning practices while only
the remaining husbands (7.0%) believed that the husband was the sole decision
maker.
However, when asked about the main decision maker, nearly all husbands
(98.3%) who responded that both husband and wife should be joint decision
maker in family planning practice felt that the husband should be the main
decision maker. Only the six husbands (1.6%) felt the wife should be the main
decision maker about family planning in the family.
5.5 Husbands allowing of wife to visit Health cente rs/ MCH clinics
In this study, the majority of husbands (77.3%) allowed their wives to visit Health
centers MCH clinics alone without being accompanied. There were 84 husbands
(21.0%) only allowed their wives to visit with accompanied by their child or other
family members while seven husbands (1.9%) will not allow their wives to visit
Health / MCH clinics.
68
5.6 Opinion of husbands regarding Islam and family planning
In this study, 209 (52.3%) of husbands were not aware whether Islam is against
family planning practice. There were 179 husbands (44.8%) who believed that
Islam allows family planning practice only in certain situations. Very few
husbands (2.3%) felt that Islam is against the use of family planning while only
three husbands (0.8%) disagreed that family planning practice is against Islam.
5.7 Experience of unplanned pregnancies
The husbands were asked about whether they have any experience of
unplanned pregnancies of their wives. About 44 husbands (11.0%) have
experienced unplanned pregnancies in the family.
Table 5.4: Reported reasons by husbands for couples not using family planning (N =144).
Reasons
Yes
(%)
No
( %)
Family planning methods forbidden in Islam 77 (53.4) 67 (46.6)
Wish to have male child 61 (42.3) 83 (57.7)
Wife is lactating 16 (11.1) 128 (88.9)
Scared of complications 13 (9.1) 131 (90.9)
Wish to have female child 10 (6.9) 134 (93.1)
Believe contraceptive not effective 4 (2.7) 140 (97.3)
Wife do not know about family planning 4 (2.7) 140 (97.3)
Husband old 4 (2.7) 140 (97.3)
Wife is not healthy 2 (1.3) 142 (98.7)
Traditional believe 2 (1.3) 142 (98.7)
Husband is not healthy 1 (0.6) 143 (99.4)
69
Wish to have more children 1 (0.6) 143 (99.4)
Not having sex 0 (0.0) 144(100.0)
Cultural belief 0 (0.0) 144(100.0)
Table 5.4 showed that144 Yemeni husbands (36.0%) in Mukalla were not
practicing family planning. The main reasons given were that it was forbidden in
Islam (53.4%), followed by wish to have a male child (42.3%), wife is lactating
(11.1%), (9.1%) were scared of complications and (6.9%) Wished to have a
female child.
Table 5.5: The distribution of husbands by their aw areness of family
planning methods (N=400)
Types of family planning methods
Aware about method (%)
Unaware about method (%)
Pills 372 (93.0)
28 (7.0)
IUCD 371 (92.8)
29 (7.3)
Condom 369 (92.3)
31 (7.8)
Sterilization of wife 352 (88.0)
48 (12.0)
Sterilization of husband
204 (51.0)
196 (49.0)
Table 5.5 showed that most Yemeni husbands in Mukalla were aware and knew
about the common methods of modern family planning, especially the reversible
methods The most common modern family planning method knew by the
husbands were contraceptive pills - 372 (93.0 %) followed by intrauterine devices
(IUCDs) - 371 (92.75 %) respectively, while condom - 369 (92.3%). For
70
irreversible methods of family planning, 352 (88.0%) husbands knew about
female sterilization while only 204 (51.0%) husbands knew about male
sterilization.
5.8 Knowledge of husbands for family planning metho ds
The husbands were further asked about their knowledge regarding mechanism of
family planning methods (Table 5.7). Their knowledge was generally poor. Only
176 husbands (44.0%) knew that contraceptive pills contain hormones and only
221 husbands (55.3%) knew that IUDs are small devices used to prevent
fertilization by a foreign body response in the endometrium, preventing the
sperm from reaching the fallopian tubes but does not affect implantation of the
fertilized egg. Husbands were more knowledgeable regarding condoms, with 356
husbands (89.0%) knowing that the condom acts as a barrier to prevent sperm
from entering the vagina.
71
Table 5.6: Knowledge of mechanism of family plannin g methods by
husbands (N=400)
Mechanism of family planning methods
Know of mechanism (%)
Do not know of mechanism (%)
Condom blocks sperm from entering the uterus
356 (89.0) 44 (11.0)
Female sterilization is a permanent method
334 (83.5) 66 (16.5)
Effective life span of IUD about 3-5 years
221 (55.3) 179 (44.75)
Male sterilization is a permanent method
184 (46.0) 216 (54.0)
Contraceptive pills contain hormones
176 (44.0) 224 (56.0)
Vaginal cup is a barrier to from entering the uterus
25 (6.3) 375 (93.8)
The husbands were further asked about their awareness of places in Mukalla
where family planning services are available. Table 5.7 showed that 390 (97.5%)
Yemeni husbands were aware about the places where family planning services
were provided. The most known source of family planning services in Mukalla
city were the pharmacies (95.5%) followed by public hospitals (85.8%).
72
Table 5.7: Awareness of the husband about where the family planning
services are available in Mukalla (N=400).
Family planning services N (%)
A. Aware 390 (97.5)
Pharmacies 382 (95.5)
Public hospital 343 (85.8)
MCH centers 236 (59.0)
Private hospitals 159 (39.8)
Charity association clinics 126 (31.5)
B. Not aware 10 ( 2.5)
Table 5.8: Husband’s opinion on appropriate number of children for a
family (N=400)
No of children N %
3-4 54 13.5
5-6 131 32.8
7-8 128 32.0
9-10 74 18.5
11-12 7 1.8
13-14 3 0.8
15 3 0.8
73
Table 5.9 showed the majority Yemeni husbands (32.8%) felt that the appropriate
number for their family should be 5-6 children (32.8%) and 7-8 children (32.0%).
There were no husbands who felt that 1-2 children were ideal.
5.9 Attitude of the husbands towards modern family planning methods
The majority of husbands - 205 (51.3 %) agreed that they should themselves
practice family planning methods to space their children. Only 14 husbands
(3.5%) disagreed with three of them (0.8 %) strongly disagreed (Table 5.9).
Around 172 (43.0%) strongly agreed that the wife should practice family planning
while 25 (6.3%) were strongly disagreed. Most husbands - 356 (89.3%) agreed
that modern family planning methods are more effective than traditional methods
of planning. Very few husbands - 13 (3.3%) were uncertain of the effectiveness
with only one of them (0.3%) strongly disagreeing that modern family planning
methods are more effective than traditional methods.
The majority of husbands - 310 (77.5%) also agreed that they should discuss
with their wives about choice of family planning methods. Only 9 (2.8 %) of the
husbands strongly disagreed that they should discuss with their wives the choice
of family planning methods.
There were 294 (73.5%) husbands who felt that they have more influence than
their wives in deciding whether to have another child. Only eight husbands
(2.0%) disagreed. Most husbands 282 (70.5%) felt that husbands only should
74
decide on whether to practice family planning. Only 50 husbands (12.5%)
disagreed while another four husbands were uncertain. About 225 (56.3%) of
husbands felt that family planning methods should be used only by wife, while 91
(23.0 %) were disagreed that family planning methods should be used only by
wife, and another four husbands were uncertain.
Table 5.9: Attitude of husbands towards modern fam ily planning methods
(N=400)
Attitude of husbands (%) Statements Strongly
disagree Disagree
Uncertain Agree
Strongly agree
Mean score
Modern more effective than traditional methods
1 (0.3)
0 (0.0)
13 (3.3)
29 (7.3)
357 (89.3)
4.8
Husband should discuss with wife choice of methods
9 (2.3)
0 (0.0)
2 (0.5)
79 (19.8)
310 (77.5)
4.7
Husband should know more about family planning
2 (0.5)
2 (0.5)
1 (0.3)
166 (41.4)
229 (57.3)
4.6
Wife only should decide on family planning practice
8 (2. 0)
5 (1.3)
7 (1.8)
155 (38.8)
225 (56.3)
4.5
Husband should practice family planning
3 (0.8)
14 (3.5)
4 (1.0)
174 (43.5)
205 (51.3)
4.4
Wife should know more about family planning
9 (2.3)
7 (1.8)
7 (1.8)
195 (48.8)
182 (45.5)
4.3
75
Wife should practice family planning
25 (6.3)
5 (1.3)
8 (2.0)
190 (47.5)
172 (43.0)
4.2
Wife more influential than husband whether to have another child
101 (25.3)
263 (65.8)
9 (2.3)
19 (4.8)
8 (2.0)
4.0
Family planning should be practiced only by husband
80 (20.0)
269 (67.3)
5 (1.3)
18 (4.5)
28 (7.0)
3.9
Family planning should be practiced only by wife
67 (16.8)
25 (6.3)
4 (1.0)
79 (19.8)
225 (56.3)
2.0
Husband only should decide on family planning practice
27 (6.8)
23 (5.8)
4 (1.0 )
64 (16.0)
282 (70.5)
1.6
Husband more influential than wife whether to have another child
5 (1.3)
3 (0.8)
3 (0.8)
95 (23.8)
294 (73.5)
1.3
5.10 Scores for attitude of husbands regarding fam ily planning methods
The minimum total score based on the 12 attitude statements is 12 and the
maximum total score is 60. The total attitude scores obtained by the husbands
ranged from 33 to 58 with a mean score of 44.5 (SD 3.6). Based on a mid-score
of 36 (50%) as a cutoff for a poor or satisfactory attitude, there were only eight
husbands (2.0%) with poor scores (< 36) indicating their poor attitude towards
family planning. For husbands with satisfactory total attitude scores, the score
76
was further categorized into three equal parts, with 36-43 denoting a moderate
score, 44-51 as a good score and 52- 60 as a very good score. Out of the total
400 husbands, 132 husbands (33.0%) had moderate score, 247 husbands
(61.8%) had good scores and only 13 husbands (3.3%) had very good scores.
This result suggests that the overall attitudes of most Yemeni husbands in
Mukalla towards family planning were good.
5.7 Factors associated with total knowledge score among husbands
Table 5.10 shows the results of both univariate and multivariate analyses of
husband’s knowledge with five demographic factors using simple and multiple
linear regression respectively. In the univariate analysis, there were significant
associations with years of completed education of husband, years of completed
education of wife. However, the multivariate analysis revealed that the significant
associated factors of Yemeni husband’s knowledge were years of completed
Figure 5.3 Attitude scores for husbands regarding f amily planning (N=400)
Poor attitude
Moderate attitude
2.0% 3.3%
33.0%
61.8%
0
50
100
150
200
250
300
Poor attitude Moderate attitude Good attitude Very good attitude
8
133
247
13
FRE
QU
EN
CY
OF
HU
SBA
ND
S
77
5.11 Factors associated with total knowledge score among husbands
Table 5.11 show the results of both simple and multiple linear regression analysis
of husband’s total knowledge score with five demographic factors. In the
univariate analysis, the, total knowledge score was significantly associated with
years of education of husband, years of education of wife and monthly income of
wife. However, in the multiple linear regression analysis significant factors
associated with Yemeni husband’s knowledge were years of education of
husband, years of education of wife and monthly income of wife. This means that
when either the wife or husband are more educated, the knowledge score of the
husband will be higher. The income of wife was also found to be associated with
the level of knowledge of the husband. However, the husband’s monthly income
was not found to be significantly associate with his knowledge score.
78
Table 5.10: Factors associated with total knowledge score among husbands (N=400)
SLR
MLR Factor β 95% CI P Adj, β 95% CI P
Age of husband
.0000368 -0.066, 0.066 0.999 -.008 -0.124, 0.108 0.896
Years of completed education of husband
0.361 0.196, 0.5250 < 0.01 0.339 0.157, 0.521 <0.001
Years of completed education of wife
0.310 0.162, 0.458 < 0.01 0.237 0.068, 0.406 <0.001
No of living children with current wife
0.063 -.0.274, -0.399 0.715 0.550 0.104, 0.995 0.016
Husband monthly income
0.025 -0.018, 0.068 0.247 0.029 -0.011, 0.069 0.158
Wife monthly income
0.185 0.116, 0.253 <0.001 0.183 0.115, 0,259 <0.001
---------------------------------------------------------------------------------------------------------------------------------------------------------------------
---------------
SLR: simple linear regression. MLR : multiple linear regression.
79
5.12 Factors associated with total attitude score among husbands
Table 5.11 shows the results of both univariate and multivariate analyses using
simple and multiple linear regression for the relationship of husband’s attitudes
with five demographic factors in Yemeni husband’s. In the univariate analysis,
there is significance positive linear relationship between total attitude score of
husbands with completed years of education of wife and husband and there is
significant positive linear relationship between number of children living with
current wife and the total score of attitude of husbands. This means that when
both the wife or husband are more educated, the attitude of the husband will be
more positive towards family planning and when there are more children living
with the family, the attitude of the husband will be more positive towards family
planning.
80
Table 5.11: Factors associated with total attitude score among husbands
(N=400)
SLR MLR Factor
Β 95% CI P Adj β 95% CI P Age of husband -0.014 -0.054, 0.026 0.503 0.01 -.061, 0.081 0.780
Age of wife -0.012 -0.052, 0.027 0.547 -0.039 -.122, 0.035 0.295
Years of completed education of husband
0.115 0.017, 0.213 0.021 0.120 0.007,0.231 0.035
Years of completed education of wife
0.092 0.004, 0.181 0.041 0.066 -.038, 0.170 0.210
No of living children with current wife
0.053 -0.144, 0.250 0.598 0.349 -.396, 0.270 0.02
Husband monthly income
-0.007 -0.032, 0.18 0.587 -0.003 -0.028, 0.022 0.814
Wife monthly income 0.077 0.036, 0.118 <0.01 0.079 0.037, 0.170 <0.001
SLR: Simple linear regression MLR: Multiple linear regression
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CHAPTER 6
DISCUSSION
Many countries consider limiting the population size as an important strategy to
achieve the goals of poverty eradication and improve living standards for its
people. Yemen is one of the world’s poorest countries (DFID, 2005), with about
42% of the Yemeni population living below the official poverty line (CSOY, 1998).
Yemen has one of the highest population growth rates in the world at 3.7%,
which is a major hindrance in achieving these goals. The World Health
Organization states that population growth rate is related to the fertility rate of a
country, which is in turn directly related to the prevalence family planning practice
(Chichakli et al, 2000). Thus, family planning is one strategy for Yemen to
optimize in order to move forward in advancing the socio-economic development
of its people.
6.1 Practice of family planning
In this study, the prevalence of family planning practice among husbands in
Mukalla was 39.0%, of which 11.0% are current users and 28.0% are previous
users. The prevalence of family planning practice among their wives was 44.3%,
with current use at 20.8 % and previous use at 23.5%. There were 61.0 % of
husbands and 55.8 % of their wives who have never practiced family planning.
The prevalence of currently practicing modern family planning by husbands in
Mukalla (11.0 %) is much lower than that reported for Jordanian husbands in the
1985 Jordan Husband Fertility Survey (JHFS) at 26.5% (Warren et al, 1990). The
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prevalence rate of wives practicing family planning currently (20.8 %) in Mukalla
is also lower than in Jordan which is 27.1 % This difference may be attributed to
Jordan being relatively more developed than Yemen, and Jordanians being more
modern and more receptive to modern family planning.
In this study, the prevalence of family planning practice by the wives (43.5%) is
higher than the 35.0% prevalence found in the 1997 Yemen Demographic and
Health (DHS) Survey. This indicates an increase in the prevalence of family
planning practice among the women in Yemen. However, there was no study
found on family planning practices of Yemeni men conducted previously in order
to compare with the results of this study. However, It should also be noted that in
this study, the history of family planning practice of the wives were obtained from
the husbands. It is known that many Yemeni husbands do not discuss family
planning with their wives and are therefore unable to truly know the status of their
wife’s family planning practice. It is also conceivable that some wives may
secretly practice family planning without the knowledge of their husbands,
especially those wives who perceived their husbands as not supportive of family
planning.
In this study, among family planning users, the most common modern method
among husbands was using condoms - 88.6%. No husbands had undergone
sterilization. The findings indicate the majority of the husbands and their wives do
not actively plan to limit the number of children or to space their children.
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However, many of the Yemeni couple may be practicing traditional methods of
contraception such as coitus interruptus or safe period. If such situation exists, it
will be easier to get these husbands to support their wives to switch from
traditional methods and practice modern family planning.
The common modern family planning methods currently used by the wives was
contraceptive pills - 54.2%, followed by intrauterine devices (IUD) - 43.4%
respectively. Other modes of family planning were rare with vaginal cup being
reported once (1.2%) and none had undergone female sterilization. This finding
is similar to a previous study in Yemen which also found that oral contraceptive
pills were the commonest family planning method practiced in Yemen (CSOY,
1998). In Bangladesh; 43% of the wives rely on the pill. Pills are the easiest
mode of family planning for the wives as other forms of female methods such as
contraceptive implants and IUDs are procedurally more difficult and requires
them to go to the health clinics, for which will need permission and support from
their husbands.
This is also seen in Bangladesh where the contraceptive pills was also the most
popular female method, a major reason being the pills have been supplied free
to the wives at their doorstep by female health workers since 1978 without a
need for the husband’s participation. Permanent forms of female sterilization are
more heavily dependent on spousal support (Kamal, 2001). In Oman,
contraceptives are also provided free to all married couples in readily accessible
84
primary health care centers (Al-Riyami et al, 2004). In Yemen currently, the
couples pay for contraceptives at the government clinics, although the costs are
less than those charged by the private pharmacies. Poverty is one of the main
obstacles to family planning practice as many Yemeni families cannot afford the
costs (AL-Fotih, 2005). Wives will also need the money and approval from their
husbands in such situations. The role played by Yemeni husbands as a moral
and financial supporter will be crucial to the successful implementation of the
family planning programme. To minimize the role of husbands in family planning,
Yemen will need to emulate countries such as Bangladesh, Iran and Oman by
providing free modern family planning which are easily accessible to the wives.
6.2 Factors affecting family planning practice
Many factors are known to affect family planning knowledge and attitudes of the
husband, which in turn will influence the practice. The educational level of the
wife has been reported by many studies to be proportional to the practice of
family planning. It has been shown that empowerment indices for decision-
making and freedom of movement for Egyptian women increased steadily and
significantly with education (Kishor et al, 1999). According to Shah et al, 1998,
wife’s education has a stronger negative impact than the husband’s on desired
and actual family size in urban areas; while the husband’s educational level is
more important in rural areas in Kuwait. In Iran, educating women has been
shown to improve family size limitation and increased contraceptive use
(Aghajanian & Merhyar, 1999). A study in Pakistan found four ways that
85
education affects fertility – it leads to later marriage, to women marrying men with
higher income, to women entering the formal employment sector and to changes
in the women’s values and interests (Sathar & Mason, 1993). In this study, the
years of education for the wives were generally less than that of their husband.
This can be one area of focus, which is to increase the education level of the
Yemeni women to be on par with the men. The government should be committed
to provide the opportunities and accessibility to education for Yemeni women,
especially in rural areas. The provision of such opportunities for Yemeni women
to be educated has to be well accepted by the community for such strategy to be
successful. Cultural practices such as early marriage of the girl child will deprive
her of adequate education even if opportunities are provided. Yemen has the
lowest mean age at first marriage which is 17 years among the eight Arab
countries participating in World Fertility Surveys in 1976-1982 (Farid, 1986).
Being educated will improve the employment and earning prospect of the Yemeni
women. It will also help empower them in family planning practice. As discussed
above, employment is a proxy for education, and operates in tandem to influence
family planning. In Turkey, Sahin & Sahin, 2003 noted that higher levels of
education and wider employment opportunities for women leads to higher family
socio-economic status, which in turn directly influence the wife’s role in decision-
making in family life, leading in turn to more modern family planning practice. In
Iran, the government promoted greater employment participation for women by
creating gender-segregated environments in some of the workplaces
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(Aghajanian & Merhyar, 1999). In this study, all the husbands were employed
while very few of their wives (19.5%) were employed. This indicate a relatively
limited empowerment of the Yemeni wives as most of them will therefore be
dependent on their husband for financial and decision making support. This
includes family planning practice, making the wife’s decisions in family planning
to be more strongly influenced by their husband's, which will reflect on his
knowledge and attitudes to family planning. This situation is common in the many
poor Arab countries the patriarchal system governing the family has been the
tradition since time immemorial (Fargues, 2003). This was attributed to failings
for women on three fronts; civil and political freedom, knowledge production and
dissemination and empowerment. However, a study by Morgan et al (2002)
comparing Muslim and non-Muslim communities in four Asian countries, found
no relationship between individual autonomy and fertility and one possible
explanation suggested was the political disadvantage leading Muslim
communities to have higher fertility. This is traditionally the situation in many
Arab communities including Yemen, where large families are desired especially
sons, and this is another possible factor limiting family planning practice.
Husband’s role in fertility control is therefore important in many traditional and
religious societies. Many Arab countries are based on tribal and patriarchal
societies with women taking the social role of childbearing and to have many
children especially sons. In Ethiopia, research on male roles in Ethiopia has
87
consistently found that decisions regarding family size and contraception are
dominated by husbands, who expect to have large families (Mengistu & Larson,
1991). Other studies in Bangladesh, Jordan, Iran, Nepal, Ghana, Tanzania and
Zimbabwe also noted the dominant role of husbands in family planning matters
and husband’s approval will improve family planning practice (Kamal, 2000;
Warren et al, 1990; Aghajanian & Merhyar, 1999; Chapagain, 2005; Ezeh, 1993;
Popoola, 1999; Piotrow et al, 1992). In this study, 61% of the husbands have
never practiced family planning, 76.1% felt family planning should be practiced
only by the wife and 86.5% felt only the husband should decide on family
planning practice for the couple. This is not surprising as in many of these
patriarchal societies, family planning practice are decided by men and if
approved, are practiced mainly by women. A more effective strategy for family
planning programmes is to get the husband’s support for their wives to practice
family planning.
In this study, 52.3% of the husbands were unsure whether Islam is against family
planning practice while 44.8% felt family planning is justified in Islam in certain
situations such as spacing the family. For Yemeni husbands who were not
practicing family planning, the main reason given was that it was forbidden in
Islam. There were still considerable uncertainties about the Islamic ruling on
family planning among the Yemeni husbands. In such situations, it will also be
difficult for the husbands to support their wives to practice family planning.
However, in many Islamic countries such as Iran, flexibility is practiced by many
88
religious leaders in that family planning is allowable for health reasons and only
permanent forms of contraception are disallowed unless it is for medical reasons.
In Iran, religious scholars in tandem with health workers, actively participate in
promoting family planning. Male methods of contraceptives accounted for one-
third of all contraceptive users in Iran (Aghajanian & Merhyar, 1999). The
prevalence was higher among men from areas with a higher level of
development based on urbanization, literacy rates, and access to electricity,
piped water, gas and telephone. However, the majority of males still rely on the
traditional method of ‘coitus interruptus (Aghajanian & Merhyar, 1999).
Accessibility to family planning services is an important component of the family
planning services. In Kuwait, women who want to practice family planning have
easy access to modern methods of contraception such as oral pills and IUDs
which are provided free at all government health centers (Shah et al, 2004).
Contraceptive pills can also be bought over the counter in private pharmacies at
nominal prices (Shah et al, 2001). In Bangladesh too, female health workers
deliver free contraceptives to the doorstep (Kamal, 2000). In Yemen, however,
the government does not provide free family planning, which may limit
accessibility to Yemeni women and a possible factor for the lower prevalence of
family planning practice.
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6.3 Knowledge of husbands on family planning
In this study, most husbands (96.0%) knew that pregnancy can be prevented. In
this study, most husbands (88.0%) were aware about modern family planning
methods, especially contraceptive pills (93.0%), intrauterine devices (92.8%) and
condoms (92.3%). About half of the husbands (51.0%) were aware about female
sterilization and very few were aware about female caps. The results are similar
to the 1985 Jordan Husband’s Fertility Survey (JHFS) where both the pill and
intrauterine devices (IUCDs) are well known by both husbands and wives (> 90
%). This study showed that modern family planning methods such as pills, IUDs,
female sterilization and condoms were widely known to the husbands. However,
when comparing husband’s knowledge of family planning in this study (57.8%) to
husbands in Jordan. Jordanian husbands appeared to be more knowledgeable,
which may be due to the comparatively higher level of education and
modernization of the people in Jordan. However, this conclusion is limited by the
different methods in the assessment of knowledge and the different time-frame of
the studies.
The level of Yemeni’s husband’s awareness about family planning methods is
generally high. However, knowledge of the mechanism of these family planning
methods was poor indicating that the knowledge of the husbands regarding
modern family planning in Yemen was only superficial. About 161 husbands
(40.3%) felt their knowledge about family planning was adequate while 94
husbands (23.5%) disagreed. The remaining 145 husbands (36.3%) were
90
uncertain. There is therefore a need address this felt deficiency in knowledge
about family planning among many Yemeni husbands in this study. The family
planning programme in Yemen has to develop health education and promotion
strategies targeted at husbands. A multimedia communication campaign to
promote family planning targeted at Zimbabwe men helped increased awareness
and use of modern contraceptive methods (Piotrow et al, 1992).
In this study, there were positive relationship between the husband’s level of
knowledge on family planning with years of completed education of husbands
and wives. The husband’s knowledge of family planning was higher with more
years of completed education of both husband and wife. This is expected for the
husband as the knowledge should improve with education. However,
interestingly, the husband’s level of knowledge is also positively related to the
wife’s level of education. This may possibly be explained by the better knowledge
communication between more educated wives and their husband or may simply
be because more educated women tend to marry more educated men.
However, for husbands who are poor in their knowledge of family planning
methods and especially if the family is not practicing family planning, efforts
should be made to identify and educate these husbands on family planning and
the concept of birth spacing. This can be done through talks and pre-marital
courses conducted regularly in public institutions such as universities, colleges or
workers organizations to remove any husband’s misconceptions about the use
and side effects of the various modern family planning methods. Using
91
multimedia strategies will help motivate the people to adopt family planning
methods at an early stage of their married life. The role of Yemeni mass media
promoting modern family planning issues to public should be effectively utilized.
In Zimbabwe, multimedia communication campaign targeted at men improved
the use of modern contraceptives among Shona-speaking men (Piotrow, 1992).
In the Philippines, men are required by law to attend an education session,
including family planning prior to marriage (Mello et al, 2006). In Malaysia, pre-
marriage courses, including family planning, must be attended by couples who
wished to get married.
There are very few studies on family planning focusing on men while there are
many studies focusing on women. In 1988, the pill and IUD are well known by
more than 90% Jordanian husbands and wives (Warren et al, 1990). The high
awareness level of Yemeni husbands on modern contraception found in this
study should also indicate a similar awareness situation among their wives. A
previous study in Yemen found that 84% of currently married women have heard
of at least one family planning method and slightly less than 80% reported
knowing one modern method (CSOY, 1998). Al-Gallaf et al (1995) reported that
the oral pill was very widely known among Kuwaiti women. Taha (1993) reported
that the knowledge of family planning methods in Central Sudan was 43.0%
among hospital women and 51.0% among community women. This study was
focused on the husbands and therefore no comparable figures are available for
the Yemeni wives. It is postulated that the level of awareness of Yemeni wives
92
about family planning should be higher than their husbands as family planning
has traditionally been the domain of women, even in traditional societies and they
are the main targets in family planning programmes. What needs to be done in
Yemen is to improve the family planning knowledge of the family, especially the
husbands, beyond the current superficial awareness of types of contraception
available. Improving knowledge to a deeper understanding of family planning
may help change their attitudes and support for family planning practices.
6.4 Attitude of the husbands
In this study, 372 (93.0%) of the husbands agreed that both the husband and
wife should be the decision maker regarding use of family planning methods in
the family. However, when the husbands were asked about the main decision
maker, 394 (98.5%) answered that the husband was the main decision maker.
This indicates the dominant role of the husband in most family decisions and is
expected of husbands from a traditional patriarchal society like Yemen where the
wife follow the opinion of husband based mainly on the cultural and religious
considerations. This situation must be changed to give more autonomy to the
Yemeni women to have more control over decisions which mainly affects her.
This is in line with the ICPD Programme of Action in 1994 where the concept of
just ‘family planning’ has now expanded to ‘reproductive health’ where women
should have freedom to decide if, when and how often to reproduce (Haslegrave,
2004). Based on the results from this study, the situation in Yemen is still a far
distance from the ICPD goal. However, a multi-sectoral approach to improve
93
family planning practice will have to include strategies for increased autonomy
and empowerment for the Yemeni women.
In this study, 77.3% of husbands allow their wives to visit MCH clinic by herself,
21.0% will allow if she is accompanied by her child or other family members and
very few (1.8%) husbands does not allow their wives to visit MCH clinic. Being
able to visit the clinic alone is one of the indicator for female autonomy used in a
study in Egypt (Nawar, 1996). This finding may not be what is actually practiced
by Yemeni men. Their support in terms of travel costs must also be considered.
A strategy to overcome this may be through mobile clinics providing family
planning services.
In this study, 131 (32.8%) of husbands felt that an ideal number of children for a
family was 5-6 and 128 (32.0%) husbands felt it was 7-8, giving a total of 62.8%
of husbands feeling that having 5-8 children in a family was ideal. However, the
average family size desired by Yemeni husbands was only 3.5. The result was
similar to another study where the average number of children wanted by Yemeni
women was 5.4 (Ayad, 1987). This denotes that Yemeni husbands idealized a
high fertility level which is contrary to many developing countries. The transition
from high fertility to low fertility has proceeded throughout the developing
countries, albeit at very different rates with countries in Sub-Saharan Africa still
remaining at the threshold of the transition (Westoff & Bankole, 2000). In other
studies, less than 20% of the women in Mauritania, and Sudan did not want to
94
have another child in the future (Ayad, 1987). The decline in fertility in many of
these countries typically began when couples reached their desired number of
children. It may also reflect the current economic realities of having a large family
in these poor countries. Based on the ideal number of children from the Yemeni
husband’s perspective, it will be more challenging to promote family planning
practice. Still, in such societies, the women who have to bear the burden and
risks of pregnancy, birth and rearing might be more receptive to smaller ideal
number of children. When the husbands asked about unplanned pregnancies in
the couple, only 11.0% of husbands answered positively. From the husband’s
perspective, this finding may indicate that planning for pregnancy was not crucial
and that all pregnancies were welcomed. Again, this may represent the beliefs
and ideals for a Yemeni husband; that children are a gift from God and their
preference for a large family. Again, strategies which focused on the men can
help improve this situation. Economic disincentives of having large families can
be utilized to encourage family planning.
In the Yemen Demographic and Maternal and Child Health Survey 1997, many
women failed to give a definite numerical answer to a question on the total
number of children she would ideally like to have, suggesting either an absence
of conscious consideration of family size, or a belief that god or fate determines
for a couple the number of children they would have (CSOY, 1998). The.1985
Jordan Husband’s Fertility survey reported that even for the highest
socioeconomic status group (secondary or higher education), over 30% of the
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husbands state that God would decide their family size, and nearly 40% of
married men do not believe in practicing contraception (Warren et al, 1990).
Misch (1990) also believed that the rise of Islamic fundamentalism has
significantly and negatively affected the success of family planning programmes
in the Arab world.
In this study, 51.3% of the husbands strongly agreed and 43.5% agreed that
husband should practice family planning to space their children, giving a total of
94.8% of the husbands generally agreeing that they should practice family
planning. However, for them supporting their wife to practice family planning,
43.0% of the husbands strongly agreed and 47.5% agreed that wife should
practice family planning, indicating that most husbands (90.5%) support their
wives to practice family planning. However, this study found that only 43.5% of
the wives have ever practiced modern family planning. In 1998, it was found that
many Yemeni women do not practice family planning as their husbands posed a
significant barrier to family planning practice (CSOY, 1998). This study found a
surprisingly high level of support for family planning from the husbands, although
this does not seem to be translated into practice by their wives.
In Bangladesh, husband's approval of family planning led to the increased family
planning practice by their wives, which is expected as Bangladesh is a traditional
society where women are expected to be guided by their husbands in every
sphere of life (Kamal, 2000). Iranian husbands were the main decision maker
96
about family planning practice (Rakshani et al, 2005). The husband’s
disapproval of family planning is still a major deterrent factor for women’s fertility
control, while their approval facilitates family planning, especially in developing
countries. More effective male targeting to turnover husbands to be proponents
of family planning is necessary to improve the success of the family planning
programs in such situations (Kamal, 2000).
In the Yemen Demographic and Maternal and Child Health Survey 1998, it was
found that about 40% of Yemeni couples, both husband and wife approved of
family planning, in 12% - the wife approved but the husband does not, in 4% - the
husband approved but the wife does not while in 22% both husband and wives
disapproved, (CSOY, 1998). The survey also found that use of family planning in
Yemen is facilitated when both husband and wife approve of its use. In spite of
the 40% approval among Yemeni couples, yet the majority (77%) was found not
to be practicing family planning. This was also the case found in this study. This
may be possibly due to some misconceptions about modern family planning. The
religious reason that family planning is forbidden in Islam was a major reason
given by the husbands not to practice family planning. It may also be due the
support being not communicated well between the couple. The support of the
husband for their wives to practice family planning has to be communicated to
the wives as not doing so may be perceived as not being supportive.
A study in a Kenyan rural population found that husbands believed family size
decision making is a joint responsibility and that family planning counseling
97
should be given to both husbands and the wives together (Were & Karanja,
1994). Contraception practice has traditionally been the responsibility of wives,
while husbands are involved only in decisions about using contraception
(Edwards, 1994). Educational campaigns through the mass media and health
education sessions at clinics can get husbands and wives discussing and
communicating about family planning. This may be an effective strategy for the
family planning programme in Yemen. In some countries, mixed family planning
clinics for both husbands and wives are established to promote family planning
counseling and decision making for both husbands and wives (Lee, 1999; Donati
et al, 2000)
In Kenya, 93.2% of rural males approved of family planning in 1987, compared to
81 % in 1985 (Were & Karanja, 1994). This finding is similar to this study where
90.5% of the husbands in Mukalla support their wives to practice family planning.
However, possible constraints facing the family planning program in Yemen are
poverty, illiteracy, religion, misconception about the methods and poor health
services. The Yemen Demographic and Maternal and Child Health Survey 1997
reported that 26% of couples were not using family planning methods, of which
the two main reasons are that the women felt that modern family planning
methods are forbidden in Islam and because their husbands refused permission
for use family planning methods. These two factors affecting family practice
among women in Muslim countries have been discussed above. Another study
by Morgan et al (2002) comparing Muslim and non- Muslim communities in four
98
Asian countries, found no relationship between individual autonomy and fertility.
One possible explanation given was the political disadvantage of Muslim
communities, leading them to have higher fertility. While this may be true in
Muslim minority countries, it is not the case with Yemen as nearly all the
population is Muslims.
This family planning practice for the couple should ideally be planned jointly
between the husband and wife, especially if there are unmet needs for family
planning. Most husbands (89.3 %) agreed that modern family planning methods
are more effective than traditional methods in preventing pregnancy. In this
study too, most husbands (77.5 %) strongly agreed that husbands should
discuss with their wives the choice of family planning methods before using the
method. Only 9 (2.3%) husbands disagreed with this statement. Traditionally,
Yemeni husbands and wives have poor communication about sexual and
reproductive matters, even in private. This is also the case in the Philippines
where most men think their role is only as an economic provider and see family
planning purely as their wife’s concern (Lee, 1999). Another cited reason in the
Philippines is that many men were even unable to regularly communicate with
their wives because of work demands. The Yemen Demographic and Maternal
and Child Health Survey 1997 reported that lack of discussion may reflect a lack
of personal interest, hostility to the subject, or a customary reticence in talking
about sex-related matters (CSOY, 2002). The survey found that about 42% of
women said they had not talked to their husband about family planning in the
99
year preceding the survey while 26% had discussed it once or twice and 32%
had discussed it more often. The lack of communication can also prevent wives
from disseminating information they received on modern family methods from
health clinics to their husbands, and thus perpetuate whatever misinformation
and misperception of the husband towards modern family planning methods
(CSOY, 2002). A possible strategy is to have provisions for paternity leave for
husbands from work during which time counseling, discussion and decision
making about family planning can be done with the help of health workers during
postnatal home visits. One of strategies attributed to the success of the family
planning program in Indonesia is to have village family planning volunteers
provide counseling and promote discussion in the homes after birth (Utomo et al,
2006)
In this study, 53.4% of husbands who did not practice any family planning
methods believed that modern family planning methods were forbidden in Islam
and 9.1% were concerned about side-effects. Another 42.3 % of the husbands
wished to get a male child while 6.9% of the husbands wished to have a female
child. In Kuwait, the belief that Islam forbade family planning was a significant
factor for unmet need for contraception (Shah et al, 2003). However, the effect of
religion on family planning practices is not restricted to Muslim countries only. In
the Philippines, an explanation for the low rate of modern method contraception
is the strong opposition of the powerful Catholic Church to family planning
programmes (Mello et al, 2006). Rama et al. (1993) in India reported that the
100
main reasons given by husbands who disapproved of family planning were that
family planning is against religion/God and “children are God’s gift” (45.1%).
These studies clearly indicate that practice of family planning has been
hampered because it was believed to be against religion.
In a previous study, 17% of Yemeni women interviewed stated that family
planning methods were forbidden in Islam (CSOY, 1997) Inaoka et al (1999)
reported that religious and cultural factors play a large role in barriers against
family planning acceptance in Yemen. Al-Fotih (2005) felt that there are many
wrong religious perceptions in Yemen such as family planning is forbidden in
Islam and the husband will not allow his wife to go to the hospital or medical
center to seek family planning. In a study in Gezira, Sudan, participation of the
community in debates and lectures on oral contraceptive by religious leaders
helped improve family planning communications and remove and clarify many
religious misconceptions about family planning (Farah & Belhadj-elGhouyel,
1994). In Jordan, approximately 70% of conservative Muslim women had used
contraception, thus indicating that religious leaders may play significant roles in
increase of contraception practice among Muslim women (Sueyoshi et al, 2006).
The varied interpretation from different views (Fatwa) of the Islamic principles
guiding family planning also contributes to the problem of religion being a barrier
to family planning practice. Appropriate action should be needed to overcome
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this in many countries where religion poses a barrier to the uptake of family
planning. This may be done by targeting religious leaders and other influential
community leaders and increase their understanding of family planning programs
Family planning program in Egypt is an example of a successful program
because it has the support and backing of both the government and the religious
community (Chichakli et al, 2000). The Egyptian mass media played an effective
role in propagating family planning to the public. Another successful family
planning programme is in the Islamic Republic of Iran which is seen as a model
for other Muslim countries to emulate. Through a variety of family planning
measures, Iran has managed to check its population growth projected at 108
million to only 70 million in 2006. Religious leaders are incorporated into
educational programmes promoting family planning and advocating
contraception, which are conveyed regularly through the mass media (Bergsjo,
1994).
In other parts of the Middle East such as Iraq, Kuwait, Oman and Saudi Arabia, a
high population growth is viewed as a positive event as it will help reduce the
need for foreign workforce. Many Arab countries are traditionally made up of
tribal societies, which promote procreation and fertility. Traditionally, Arab
husbands like to get many children as soon as possible (Mahfouz et al, 1994).
Members of the tribe are expected to help one another and a family-oriented
society in which extended families support each other in raising children (AL
Riyami et al, 2004). It is also customary in traditional Arab societies that
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preservation of a clan to ensure the family name is sustained. The social
structure in Arab countries is still dominated by strong patriarchal pronatalist
values. This is also the case in Yemen, where the tradition of having large
families is another barrier to family planning practice. In Oman, less than 1% of
newly married women used contraceptives before their first child as women are
traditionally expected to have a child within the first year of marriage. This
tradition is deeply-rooted in the Arab region, including Yemen (Al Riyami et al,
2004). A study in Sudan showed that the prevalence of contraceptive use prior to
current pregnancy was only 13.0 % (Taha, 1993). However, a study in Kuwait
found that the level of current contraceptive use to be higher at about 52% (Shah
et al, 2001a ;Shah et al, 2001b).
However, the tradition of having large families is now weakened with
development and modernization of these countries coupled with the economic
reality of having a large population. In rich Arab countries, family planning
programmes may be deemphasized to encourage births and population growth.
However, in poor Arab countries, such as Yemen, the tradition of having large
families needs to be balanced with the economic realities. This will indirectly
promote family planning practice, especially among the poorer segments of the
population. Such change in values and traditions will also occur with improved
education of the people and development of the country over time. This can be
facilitated by the Government making accessible the modern family planning
103
methods to the people, especially the women by an effective family planning
programme.
In this study, 56.3% of the Yemeni husbands believed that family planning
methods should be used only by the wife. This is similar to the study in Kenya
(Were & Karanja, 1994) which found that 88.4% of the husbands believed that
the wives should take the responsibility for actually practicing family planning. In
Oman, child bearing remains an essential social role for women (Shah, 1998). In
this study, Yemeni husbands generally have good attitudes towards family
planning. A study in Malaysia reported that majority (78.5%) of husbands of
respondents have a good attitude towards family planning and are supportive of
the family planning program (Rahiza, 2002). Posner et al (1989) found that
Senegal men’s acceptance of family planning methods at least for the purpose of
spacing births was substantial even among men from the most conservative
background. Acceptance of family planning methods by the husbands, especially
those from conservative societies, is very important as this will encourage the
wives to use family planning methods. This study found a positive relationship
between attitude of the husbands towards family planning with the education
level of husband, education level of wife and the number of living children.
Yemeni husbands can be called to support family planning through religious and
health related sermons before and after obligatory weekly prayers, during
community gatherings, by health promotion campaigns, health education
104
programmes in schools and multimedia television and radio programmes
promoting family planning.
Action is needed to improve the level of knowledge of Yemeni husbands to
correct any wrong information and beliefs relating to family planning from both
the medical and religious perspectives. The active involvement of husbands,
religious leaders, parents and health care workers together in family planning
education and promotion will increase the effectiveness Health education
initiatives should initially be directed towards religious leaders who are generally
less informed about the details of family planning methods, and who will have an
important influence on the use of family planning methods in their community.
This effort should be led by senior male doctors from family planning
programmes, who can command the respect of the husbands. This should be
done together with national religious authorities such as the ulamas, with support
from the government.
The 1994 Cairo International Conference on Population and Development (ICPD)
found that the single most important component a nation can invest in to improve
its health is the education of girls and women (United Nations, 1994). The 1994
ICPD reflected on the now commonly understood linkages between education,
women’s empowerment and demographic indicators. Education has been shown
to be more susceptible to improvement through policy intervention than more
deeply rooted cultural conventions regarding family size (Martin, 1995). Kishor et
105
al (1999) reported that empowerment of women in combination with education
provided a clearer picture on contraceptive need and use than education alone.
The illiteracy rate of Yemeni women in 1994 was the highest among the Arab
countries which is about 76% among females 10 years and over (CSOY, 1998).
In a later study, the illiteracy rate in Yemen among female age 15 years and over
has remained high (75%) compared with neighboring Arab and African countries
for example, 43% Algeria, 17% Bahrain, 46% Djibouti, 56% Egypt, 16% Jordan,
20% Kuwait, 20% Lebanon, 32% Libya, 64% Morocco, 38% Oman, 17% Qatar,
33% Saudi Arabia, 54% Sudan, 40% Syria, 39% Tunisia and 21% in United Arab
Emirates (UNFPA, 2003). Improving the literacy rate of Yemeni females through
education should be a focus for the national family planning programme.
In a study of Egyptian women, it was found that more empowered women had
fewer children and that her education was the most important factor related to
woman’s autonomy (Nawar, 1996). Angin & Shorter (1998) have questioned the
relationship between education, empowerment and family planning practice and
found that there is now greater evidence which seems to confirm the relationship
that education leads to women being empowered and wanting fewer births. A
study in Pakistan found four ways by which education affects fertility; education
leads to later marriage, to women marrying men with higher income, to women
entering the formal employment sector and to unspecified changes in women’s
values and interests (Sathar & Mason, 1993). However, the study also found that
domestic autonomy failed to predict fertility. Improvement in the status of women
106
in the family and society in general would make Yemen’s family planning
program more effective and successful. Again, this is can be done by the
government’s commitment to improve the education of girls and women in
Yemen.
An effective and efficient family planning services is important in getting family
planning messages and acceptance across to the community. In Sudan, village
midwives were more effective in disseminating family planning messages and
their efforts outweighed the better communication and health services available
to the hospital population (Taha, 1993). In Indonesia, village family planning
volunteers played an effective role in the family planning programme (Utomo et
al, 2006). It is possible that village midwives in the health centers and village
family planning volunteers, unlike settings in the hospital, have more time to
discuss family planning issues with the women and their husbands besides
conducting routine antenatal or postnatal care activities. The government should
encourage antenatal and postnatal care at the hospitals or health centers for
these primary health care workers to have easier access to the mothers and their
husbands. Such similar effort can be done in Yemen where midwives at health
centers will have more time to discuss family planning methods with women and
their husbands, and this should be a routine part of antenatal care. This service
can be extended to outpatient clinics involving male nurses or medical assistants,
who should also use the opportunity to discuss with their married male patients
on family planning at every clinic visit.
107
A study in Bangladesh found that the high rates of modern family planning
acceptance in Bangladesh is due to the strong rational family planning program
(Kamal, 2000). The Yemen Family Planning Programme faced many obstacles
including poverty, illiteracy, lack of awareness about family planning, religion and
misperceptions about family planning, unsupportive husbands, and health
workers having no obligation for human rights towards the patient (Al-Fotih,
2005). In Oman, contraceptives are provided free to all married couples in
primary heath care centers which are readily accessible to a majority of the
population (Al-Riyami, 2004). Iran has made both condoms and contraceptive
pills free and widely available at health clinics around the country. Contraceptive
pills are available at low costs at private pharmacies across Iran (Aghajanian &
Merhyar, 1999). Bangladesh also provide contraceptive pills free at the doorstep
by female health workers since 1978 (Kamal, 2000). Many other countries such
as Kuwait, Turkey and Indonesia also dispense contraceptive pills free to
women. These strategies can be duplicated in Yemen by providing free family
planning methods to married couples which the poverty can be a barrier to family
planning practice.
Legislative control and economic disincentives are known strategies to limit
population growth. In China, the government has enacted legislation allowing
couples to have only one child (Murthi, 2002). In Singapore, couples are allowed
to have only two children in order to control the growth rates. In Iran, certain
108
maternity benefits were terminated for couples who had more than three children
and helped reduce the growth rate (Aghajanian & Merhyar, 1999). Yemen is one
of poorest country in the world with the highest growth rate in the Middle East.
Yemen should consider taking up some of these measures taken by countries
that have succeeded in their family planning programme.
There are other innovative strategies targeting at men in order to get them more
knowledgeable and actively participating in modern family planning practice,
either personally or through their support for their wives. Forming men’s club for
discussing various issues related to reproductive and sexual health can help
sensitize the husbands. In southern India, more than 25,000 barbers have been
trained as community health workers as male villagers say they feel more
comfortable talking to their barbers than to clinic workers (Associated Press,
1997). Experiences in Uganda, Brazil and Colombia suggest that men will accept
information and services from either male or female counselors as long as they
are knowledgeable and respectful (Green et al., 1995). The health workers at
family planning clinics can employ male workers to cater for the males. Possible
key informants for family planning in villages or quarters in the context of Yemen
can be deployed to promote family planning among the Yemeni males. Outlets
frequented by males such barber shops and men clubs can have family planning
posters and may serve as outlets for selling condoms at nominal rates.
109
In many Arab countries, pronatalist policies of the government support the high
growth rate. Many political leaders view a large population as an indication of
strength and hence a cause for celebration. Rich countries such as Kuwait and
Oman provide for child allowance, free education and free health care (Shah et
al, 1998). Traditional preference to having sons is another probable reason
underlying the high population rates. This is a common phenomenon of
preference for sons to carry on the family name among Arab families (Ayad ,
1987). However, in countries where governments have established active family
planning programmes, contraceptive use is higher and fertility is lower. A multi-
sectoral approach involving many agencies will help expedite the change. Better
infrastructure and opportunities for female education and adequate access to
quality family planning services, will improve women’s autonomy and family
planning practice in the country.
110
6.5 Limitations of the study
This study was designed with much thought and cares to obtain results that were
valid as possible. Due consideration was given to the local culture and
environment of the study population. However, there were limitations which were
beyond the control of the author and are discussed below.
:1. In this study, the questionnaire was designed in the local language, pre-tested
and administered by the author only in order to get valid response. However,
there are possibilities of husbands misunderstanding the questionnaire and not
responding truthfully to sensitive questions asked due to various factors such as
being ashamed, embarrassment, religiosity, and confidentiality on the part of the
respondents. This will result in some degree of information bias. Efforts were
taken to minimize the possibility of such effects as stated in the Methodology
section.
2. The questionnaire was designed to elicit the knowledge, attitudes and practice
of Yemeni husbands regarding family planning. This is a general baseline study
for which there is a very limited literature available from the Arab world especially
from the husband’s perspective. As such, the total scores for knowledge and
attitude calculated were deemed valid representation of the actual values.
Comparison of the total knowledge and attitude scores with other similar studies
would be more valid if standard questionnaires were used.
111
3. This study was carried out only on two randomly selected quarters in Mukalla
out of a total of ten quarters. This may limit the representation of the study
findings to the whole of Mukalla is generally less efficient, with relatively larger
sampling errors. Taking all the ten quarters and sampling based on proportion
from each quarter would be more representative of Mukalla. Increasing the
sample size based on a design effect will also limit this problem.These measures
were not possible because of logistic and financial considerations.
4. There were 40 husbands who were excluded based on the inclusion and
exclusion criteria of which five husbands refused to participate. These husbands
were replaced with husbands from a nearby household who agreed to
participate. This may introduce some selection bias as replacement husbands
who agreed to participate may be more favorable to family planning.
5. This study was focused on the husbands and the questionnaire was directed
to them. There were information about the wives which were obtained from the
husbands. It is pertinent that the response from the husbands reflect the true
situation for their wives. This limitation can only be overcome by including the
wives as respondents. However, this was beyond the financial and logistic
limitations of this study.
112
Chapter 7
CONCLUSIONS & RECOMMENDATIONS
7.1 CONCLUSIONS
This study determined the prevalence of family planning practice of Yemeni
husbands and their wives in Mukalla and the husband’s knowledge and attitude
towards family planning.
The conclusions of this study were;
1. Most husbands (>90%) were aware about common modern family
planning methods available such as contraceptive pills, intrauterine
devices and condoms. However, their knowledge were lacking in depth
on the principles and mechanism for these modern family planning
methods.
2. The husband’s knowledge of family planning was positively associated
with the education level of husband, education level of wife, number of
children in the family and their wives monthly income.
3. Most husbands (89.3 %) have positive attitude towards family planning
and agreed that modern methods are more effective than traditional
113
methods. The majority of husbands (51.3%) agreed that husbands should
practice family planning.
4. The husband’s attitude to family planning was associated with education
level of husband, number of children in the family and monthly income of
their wives.
5. Even with their high awareness and positive attitudes to modern family
planning, the practice of family planning by husbands was low (39.0 %).
The practice of family planning by their wives was higher (44.3%).
Husbands who have never practice family planning (61.0%) gave the
reason that family planning is forbidden in Islam (53.4%).
114
7.2 RECOMMENDATIONS
Based on the results of this study, the following recommendations are made;
1- Family planning education activities must also targeted husbands and
effectively focused on a deeper understanding of the principles and
mechanism of modern family planning methods. More effective and
innovative strategies should include use of mass media, incorporation of
religious leaders in campaigns, pre-marital classes, male family planning
clinics and community outreach programmes for husbands. These activities
can help identify and correct husband’s misperceptions about family planning,
especially those based on religion.
2- Family planning counseling should be targeted to both Yemeni husbands and
their wives. Husbands should be encouraged to communicate with their
wives about planning for their family so that decisions are made jointly. Health
workers can serve as family planning counselors during antenatal and
postnatal visits. Village volunteers should be organized especially in rural
areas to improve the coverage for family planning counseling.
3- The social environment in Yemen has to facilitate the autonomy of Yemeni
women by improving their opportunities for education and employment. This
can help enhanced Yemeni’s women family planning practice and control
115
fertility by later marriage, better access to contraception and change in values
of women.
4- Further studies should be conducted on the wives and in other geographic
locations in Yemen to have a better and comprehensive understanding of the
family planning situation in Yemen. A Demograhic and Health Survey (DHS)
conducted at regular intervals will help determine the trend of demographic
and health situations, including family planning, over time.
116
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Appendix A : Questionnaire in English Serial No.
KNOWLEDGE, ATTITUDE AND PRACTICE OF HUSBANDS TOWARDS MODERN FAMILY PLANNING IN MUKALLA, YEMEN
Dear sir; I am Yahya Khamis Ahmed Almualm, student in MSc in (Community
Medicine), School of Medical Sciences, University Sains Malaysia. You have
been chosen randomly to participate in this study about husband’s knowledge,
attitude and practice towards family planning . Please answer the questions as
best as possible. The answers that you give will be kept confidential. Your
answers will help us to understand better family planning in Yemen.
Thank you
Researcher
Yahya Khamis Ahmed Almualm
Department of Community Medicine,
School of Medical Sciences
16150 Kubang Kerian , Kelantan
University Sains Malaysia.
Contact No. 0129281263 , 00967- 71986478 (Yemen)
Supervisor: Prof. Dr. Zulkifli Ahmad Co-Supervisor: Dr. Norsa’ adah Bachok Asso. Prof DR Abdulla Abin Gouth
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Date:
Address__________________________________________ Tel No:
Governorate ______________________________________
City _________________________________________________________
Quarter ______________________________________________________
A: Biodata:
1. Name ___________________________. 2. Date of Birth
________________
3. Age: .Husband________________years
.wife(current)________________years
5. Is your wife currently pregnant? Yes� No�
6.Years of completed education:.Husband______.Wife( current)________
7. No. of living children with the current wife ________________.
8. Occupation.
9.1. Are you employed? 1. Yes € 2. No €
9.2. What is your occupation? Government € Semi government€ .
Unemployed € Self employed € Private €
9.3. What is your average income (per month)?
YR________________________
9.4. Is your wife (current) employed? 1. Yes € 2. No €
9.5. What is her occupation?
Government € . Semi government €.Unemployed € Self employed €
Private €
9.6. How much her average income (per month)?
YR_______________________
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B: Knowledge:
Answer by Yes, No, Uncertain
1- Do you know whether pregnancy can be prevented?
Yes � No � Uncertain �
2- Do you feel your knowledge is adequate on family planning?
Yes � No � Uncertain �
3- Do you know about contraceptive pills ?
Yes � No � Uncertain �
4- Do you know the pills contains hormone?
Yes � No � Uncertain �
5- Do you know about IUD (intrauterine contraceptive device)?
Yes � No � Uncertain �
6- Do you know the effective life span of IUD is a minimum of 3 years?
Yes � No � Uncertain �
7- Do you know about vaginal cup?
Yes � No � Uncertain �
8- Do you know the vaginal cup acting as a barrier to sperm to reach the
women’s ovum?
Yes � No � Uncertain �
9- Do you know about female sterilization?
Yes � No � Uncertain �
10- Do you know the female sterilization is permanent family planning methods?
Yes � No � Uncertain �
11- Do you know about condom?
Yes � No � Uncertain �
12- Do you know the condom is using to prevent the man’s semen from entering
the women’s ovum?
Yes � No � Uncertain �
13- Do you know about male sterilization?
Yes � No � Uncertain �
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14- Do you know male sterilization is a permanent family planning methods?
Yes � No � Uncertain �
15- Do you know the places where can you get family planning methods?
Yes � No � Uncertain �
16- Do you know the pharmacy nearest to you where can you get family
planning methods?
Yes � No � Uncertain �
17- Do you know the public hospital nearest to you where can you get family
planning methods?
Yes � No � Uncertain �
18- Do you know the MCH centers ( maternity child health) nearest to you
where can you get family planning methods?
Yes � No � Uncertain �
19- Do you know the private hospital nearest to you where can you get family
planning methods?
Yes � No � Uncertain �
20- Do you know the charity association clinics nearest to you where can you
get family planning methods?
Yes � No � Uncertain �
C : Attitude :
Please state your response to the following statement
Statements Strongly Disagree
1
Disagree
2
Unsure
3
Agree
4
Strongly Agree
5
24- Husband should practice family planning to space the children.
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25- Wife should practice family planning to space the children.
26- Husband should discuss with his wife the choice of family planning methods.
27- Husband has more
influence than wife in deciding whether to have another child.
28- Wife has more influence than husband in deciding whether to have another child.
29-Husband only should
decide on family planning practice.
30-Wife only should decide
on family planning practice.
31- Family planning
methods should be used only by wife.
32- Family planning
methods should be used only by husband.
33- Husband should know
more about family planning than wife
34- Wife should know more
about family planning than husband
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D. Practice:
36- Do you practice family planning ?
1. Current use � 2. Previous use � 3.Never �
If never go to question No 40
37- Do you use condom?
1. Yes � 2. No �
38- Do you have male sterilization?
1. Yes � 2. No �
39- Does your wife practice family planning?
1. Current use � 2.Previous use � 2. Never �
If never go to question No 44
40- Is she using contraceptive pills?
1. Yes � 2.No �
41- Is she using IUCD?
1. Yes � 2.No �
42- Is she using vaginal cup?
1. Yes � 2.No �
43- Is she using female sterilization ?
1. Yes � 2.No �
44- You and your wife do not use family planning, because believe in
contraceptive not effective ?
1. Yes � 2.No �
45- You and your wife do not use family planning, because your wife not
healthy?
35- Modern family planning methods is more effective than traditional methods
138
1. Yes � 2.No �
46- You and your wife do not use family planning, because you are not healthy ?
1. Yes � 2.No �
47- You and your wife do not use family planning, because you are old ?
1. Yes � 2.No �
48- You and your wife do not use family planning, because you are not having
sex ?
1. Yes � 2.No �
49- You and your wife do not use family planning, because of traditional believe?
1. Yes � 2.No �
50- You and your wife do not use family planning, because you wish to have
more children?
1. Yes � 2.No �
51- You and your wife do not use family planning, because do not know about
family planning methods ?
1. Yes � 2.No �
52- You and your wife do not use family planning, because family planning
forbidden in Islam?
1. Yes � 2.No �
53- You and your wife do not use family planning, because your wife is lactating
now?
1. Yes � 2.No �
54- You and your wife do not use family planning, because scared of
complication?
1. Yes � 2.No �
55- You and your wife do not use family planning, because wish to have male
child?
1. Yes � 2.No �
56- You and your wife do not use family planning, because wish to have female
child?
139
1. Yes � 2.No �
57- You and your wife do not use family planning, because culture believe?
1. Yes � 2.No �
58- Who is the decision maker regarding the use of family planning methods in
your family?
1. Me � 2. My wife �
3. Both � 4. Others �
59- If both who make the main decision?
1. Husband � 2. Wife �
60- Among your children did have any pregnancy was unplanned?
1.Yes � 2.No �
61- Do you allow your wife to visit MCH clinic?
1. Alone � 2. With child or other family members �
3. Not allowed �
62- Do you think that Islam is against the use of family planning methods?
1.Yes � 2. No � 3. Yes, for some methods
�
4. Ido not know �
63- How many children are an appropriate number for a family?
Total ______________
THANK YOU
140
141
Appendix B Questionnaire in Arabic: ��� ا ا���� ا�����
142
143
144
145
146
Appendix C: Photos:
1
2
Photo 1. Husbands concentrate answering the questionnaire.Photo2. Another husband concentrate answering the questionnaire.
1
2
Photo 1. Husbands concentrate answering the questionnaire.Photo2. Another husband concentrate answering the questionnaire.
147
.
Photo 3a. Midwife instructing the wives about family planning methods in clinic..
Photo 3b. Midwife examining and reporting blood pressure of a wife inMCH centre.
3a
3b
148
4
5
Photo 4. Questionnaire after finished answered by husbands.Photo 5. Mukalla city that involving in the study.
4
5
Photo 4. Questionnaire after finished answered by husbands.Photo 5. Mukalla city that involving in the study.
4
5
Photo 4. Questionnaire after finished answered by husbands.Photo 5. Mukalla city that involving in the study.
149
Al M
ukalla
Al S
ana’a
Photo 6.
Map of Y
emen.
Al M
ukalla
Al S
ana’a
Photo 6.
Map of Y
emen.
Sana’a
Al M
ukalla
Al S
ana’a
Photo 6.
Map of Y
emen.
Al M
ukalla
Al S
ana’a
Photo 6.
Map of Y
emen.
Sana’a
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151