INDIAN JOURNAL FOR THE PRACTISING DOCTOR Vol. 5, No. 2 ...

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INDIAN JOURNAL FOR THE PRACTISING DOCTOR Vol. 5, No. 2 (2008-05 - 2008-06) ISSN: 0973-516X Maj Inam Danish Khan Command Hospital (EC), Kolkata 700027. E-mail: [email protected], Mobile: +91 9836569777 Khan ID. KAPB study on contraceptives among married armed forces personnel. Indian Journal for the Practising Doctor. 2008; 5(2):1-10. Original Article KAPB Study on Contraceptives among Married Armed Forces Personnel

Dr (Capt) In`am Danish Khan, MD, is from the Armed Forces Medical College, Pune. Abstract Background: With the advent of RCH Program Family Planning has shifted from target-based approach to a target-free, cafeteria approach. Indian Armed Forces, having launched its FP program long before the official program of the GOI; the study, therefore, aimed at assessing the status of KAPB among the members in the 21st Century. Methods: 100 married Armed Forces personnel in reproductive age group were randomly selected and data collected by ‘Personal Interview technique’. Data was analyzed under a descriptive single crosssectional design using Epi 6 and Microsoft Excel. Results: The studied population revealed good knowledge of contraceptives. Target respondents with a mean age of 32 years, educated for more than 12 years, knew about most of the contraceptives but preferred condoms. The study highlights the Knowledge- Practice gap with regard to contraceptives particularly vasectomy (84:33). Attitudinally vasectomy was being preferred to tubectomy by the majority, it was practised merely by 33% in practice. Conclusion: Despite a good knowledge of contraceptives and acceptance of the two child norm, vasectomy practice remains poor. Focused IEC campaigns and Health Education of male clientele is required. Key Words: Contraceptives, vasectomy


INTRODUCTION The Government of India adopted Family Planning Program way back in 1951 with dependence on a free supply of condoms, jellies, foam tablets, and diaphragms. The emphasis during the First Five Year Plan (FYP) was promotion of Intrauterine Devices (IUDs) which gradually shifted to a target-oriented program recommending the ‘cafeteria approach’, enhanced incentives and a massive publicity drive. Historically, males were the main acceptors of FP (vasectomy and condoms) comprising over half of the clientele. However, forced vasectomies proved a major setback and the orientation of Family Planning program shifted to women (laparoscopic sterilization, mini-lap and IUDs)1. A later innovation, nonscalpel vasectomy (NSV), was a great refinement. Recently, the focus of research is on Emergency Contraception and Male Pill2. The Indian Armed Forces started Family Welfare program long before the official program was introduced in the country3. The service delivery in the forces operates at 3 levels: a. Directorate level – Program Welfare Cell (DGAFMS) b. Command level – Regional Family Welfare Medical Officers c. Station level – Family Welfare Centers. In line with the trends in the field, incentives and increments are offered along with casual leave to motivate the clientele.4

Materials and methods A list of all married males from AFMC, Pune, whose wives were in the reproductive age was prepared. 100 personnel were randomly selected and inducted in the study. Pilot testing was done on 25 persons for any restructuring of the pre-designed questionnaire. The total reference population on which results were intended to be generalized was defined as “all married Indian Armed Forces personnel whose wives are in reproductive age group”. Unmarried/ divorced personnel, those on temporary duty/ leave in Pune were excluded. Data collection was based on ‘Personal Interview Technique’; confidentiality was assured. For analysis, data was programmed into Epi 6. Core indicators were knowledge of contraceptives, attitude towards contraception, and behaviour and practice (acceptance of vasectomy).

Results and Discussions The mean age of respondents was 32.18 yrs; the average for their wives was 29. The Armed Forces personnel usually belong to 20-45 yrs of age when males are sexually most active5. Most of them were Hindus (84), with 3 Muslims, 7 Sikhs and 6 Christians. Most had studied to higher secondary level, 20% were graduates or postgraduates. Most of the wives were educated to senior secondary level; 4% were illiterate. The mean had been working in the forces for more than 7 yrs; their wives were mostly house wives, 9% being employed. Most of the families were earning 5000-10000 per month. Fifty three percent were nuclear and 47% joint families. Majority (86%) of the respondents had been married after the 21st yr, and had been married for 5 yrs or more. Some 13% wives had had teenage marriage (ie below 19 yrs of age). Many followed two child norm; majority had one child, some of them, however, were planning for the second one. The sex ratio was heavily skewed towards males.


More than 98% had knowledge of condoms, safe period, coitus interruptus, IUDs, Mala D, Mala N, vasectomy and tubectomy. Other contraceptives were variably known. The respondents confirmed the availability of family planning services in Government hospitals.


The respondents accepted the concept of ‘Birth Control’, supported spacing with emphasis on health of the mother. Their ideal number of children was 2, one male and one female. 80% wanted at least one male child, 76% at least one female child. The ideal interval between two births was 2 yrs and three fourths believed that Family Planning should be made legally compulsory.

Attitudinally 79% agreed on husband-wife involvement in Family Planning, 13% put the onus on husbands. Condom was the most popular method (46%) followed by safe period 11% and vasectomy (10%). The preferred source of contraceptives was health centre. More than 90% agreed to go for permanent sterilization (70% vasectomy; 21% tubectomy). Eighty four percent were willing to choose vasectomy over other methods. Vasectomy was preferred for being faster (41%) and simple (39%). Of those declining vasectomy 80% feared the operation and 13% the side effects. In actual practice, 49% used condoms and 5% copper-T; others used multiple methods because of dissatisfaction with a single method. Satisfaction rate was 95%; 5% had experienced contraceptive failure or had personal opinions. Forty four percent of the respondents had shifted to permanent methods. Compared to acceptance by 90% (attitude), only 54% actually practised contraception (practice). Those who had discontinued the use of contraceptives quoted dislike of contraceptive (16%), desire for another child (14%), or wife not agreeing (7%). Usage ratio of temporary vs permanent contraceptive was 3:17. Vasectomy was resorted to by 33% though 70% of the respondents expressed its preference to tubectomy. Thus, tubectomy was actually practiced by 67% of the couples though 70% would verbally prefer vasectomy as the permanent method. Satisfaction rate for permanent methods was 97% with a 3% failure.


Discussion WHO has defined Family Planning as a way of thinking and living that is adopted voluntarily upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote health and welfare of the family group and, thus, contribute effectively to the social development of the country5. India was first among the countries that started an official family planning program6. India is the first country to have launched a well-defined Family Planning Program in 1951. The Government of India adopted the Family Welfare Program in the First Five Year plan following which Family Planning Clinics were established in rural and urban India. Due to limited outreach of these clinics especially in remote areas, an extension wing was added. The program again underwent expansion in mid-sixties with the introduction of IntraUterine Contraceptive Device (IUDs). However when the IUD program proved inadequate, a target-oriented, time-bound program involving the cafeteria approach was adopted. The program witnessed a dramatic thrust in the seventies with Mass Vasectomy Camp Approach, enhanced incentives and a massive publicity drive. All these measures culminated with the imposition of ‘emergency’ in June 1975. Forced sterilizations during the emergency- that were contrary to the basic definition of Family Planning ie voluntary participation – presented the program as “a force” which did not find social acceptance. The succeeding Government was forced to clarify that the acceptance of family planning was entirely voluntary. Eminent reproductive biologists and public health specialists have now realized that integration of family planning with maternal and child health issues is the only way to achieve population stabilization. In fact, reproductive health is a holistic concept that includes human health, safe motherhood, women’s development, child health and development, adolescent sexuality, adolescent education and health, reproductive health care of the aged person, effective contraception, and management of reproductive disorders, infertility, STD’s, genetic disorders and. Ironic, as it may sound, even infertility clinics are covered under the services to be rendered by family planning service providers.


As regards contraception, a consensus has been reached that there can be no ideal contraceptive, suitable for everybody5. A careful choice has to be made from among the current available methods, depending upon the gender, country, socio-religious and cultural practices. According to available information, the most accepted methods are the two terminal methods, vasectomy in males and tubectomy in females. In recent decades, the most common means by which couples regulate fertility have changed from methods requiring control or cooperation by men, e.g. condoms, withdrawal and periodic abstinence, to those for which women bear primary responsibility e.g. virtually all reversible modern methods. Male participation in fertility regulation is needed to balance reproductive health care more evenly between men and women and to increase the number of active users of contraception at a time when the rapid rise in reproductive age couples will demand dramatic increase in numbers of users just to maintain current prevalence. UNFPA lists the following reasons for the growing importance of male involvement in initiatives for family planning: • • • •

The advent of the AIDS epidemic has spurred an intense interest in condom promotion. Men are more in favour of general principle of family planning than has been assumed. Male support affects both the adoption and the correct use of female contraceptives. Male involvement programs can be cost– effective if they are highly focused and offer male contraceptive methods directly or by referral.

It is argued that men are partners in reproduction and sexuality, and therefore it is logical that they equally share satisfying sexual lives and the burden of preventing diseases and health complications. This broadening of the concept of ‘male involvement’ to ‘male responsibility’ requires changes in the strategies of educational campaigns and motivational efforts, where men and women need to be educated and informed about gender equality and their reproductive rights and responsibilities, and not only about the adoption of contraception. Available studies show that in many developing countries males often dominate in family decision taking in the family, including those concerned with reproduction, family size and contraceptive use. Male involvement helps not only in accepting a contraceptive, but also in its effective use and continuation. On the other hand, even if the wife wants to use a contraceptive, she may not be able to do so or may be forced to discontinue if the husband disapproves of contraception. Subsequently (in 1992), Family Planning was integrated into the Child Survival and Safe Motherhood (CSSM) program. The new target free, Reproductive and Child Health Program (RCH), funded by the World Bank, came into force in the 9th Five Year Plan. UNFPA emphasizes on male involvement in family planning supported by widespread acceptance and use of condoms, male support affecting adoption and correct use of female contraceptives, and cost effectiveness of male- based programs, thus broadening the concept from ‘male involvement’ to ‘male responsibility’. The Cairo- and Beijing Conferences, focusing on gender equality, earnestly discussed male involvement2. In line with these, Government of India offered incentives to increase male participation. There has been a significant investment in the Family Planning programs, progressively increasing from 15% of overall spending on health during the 6th Plan to 24% and 35% in the 7th and 8th plans respectively. Unfortunately, even this has not prevented the population crossing the ‘one billion mark’. The 10th Plan insists on assessing the unmet needs for contraception and achieving reduction in fertility through programs on reducing IMR/MMR and enable families to meet their reproductive goals.


In India, the role of male in family planning is still a neglected area of study. There is, further, an urgent need to understand the level of knowledge and attitude of males towards FP and the extent to which they perceive their responsibilities in family formation and reproductive health. Our study has shown a reluctant male attitude and practice with regard to family planning. Other Indian studies have showed similar male non-involvement. In the study by Khan and Patel (1997)2 on male involvement in family planning, in Agra concept of spacing was negligible, ideal number of children was 3 (2 sons and 1 daughter). Some 38-52% decisions on family planning were taken by the male alone. Condom usage was only 39%. Tubectomy was preferred over vasectomy for ease of procedure, and because women are generally housewives. Vasectomy, in addition to being time consuming, was believed to cause male weakness. The actual practices revealed a condom usage of 55% and pill use of 13%; the remaining traditional methods mainly comprised of safe period. The share of modern male methods (vasectomy and condoms) was only 37.6%. Reasons for discontinuation were desire for another child (62%), lack of satisfaction for condoms (15%), and lack of privacy in use (8%)2. A series operations research needs to be undertaken to develop and test models on how to better involve males in family planning to make them more responsible in meeting the couple’s reproductive goals.

Recommendations The target areas to be tackled are the education of the Personnel and their wives education through IEC programs and extensive health and family education, promotion of contraception, education of troops in training, personalized counseling, and guidance and follow up, ensuring better quality of services, training of health personnel, specialized nurses for family planning and development of basic behavioural and motivational research.

References 1. Visaria L, Jeejeebhoy H, Merrick T. From Family Planning to Reproductive Health: Challenges Facing India. Proceedings of 23rd General Population Conference of the International Union for the Scientific Study of Population; 1997 Oct 11-17; Beijing, China. 2. Gupta MC, Mahajan BK. Family Planning and Population Policy: Textbook of Preventive and Social Medicine, 3rd Ed. New Delhi: Jaypee Publishers; 2003. 3. Manual of Health for the Armed Forces. Vol2. New Delhi: Directorate General AFMS: 2003. 4. Govt. of India Ministry of Defence. B/33927/AG/PS-2(b)/432/D (AG); DT 19 Feb 97. 5. Park K. Demography and Family Planning: Textbook of Preventive and Social Medicine. 17th Ed. Jabalpur: M/s Banarasidas Bhanot Publishers; 2002. 6. Khan M, Patel E, Bella C: Male Involvement in Family Planning: A KAPB study of Agra district. The Population Council, India. June 1997. Location: SNDT Churchgate. Further Reading • • • • • •

Banerji D. Health and Family Planning Services in India. India: Lok Prakash Publishers; 1985. HIV/AIDS Scenario in Armed Forces (editorial). The AFMC Almanac Sep 2004; Special supplement: 1-3. Imarana Qadeer. Health Care System in Transition- III India, Part I. The Indian Experience. J of Pub Hlth Med 2000; 22:25-32 Kishore J. Reproductive and Child Health: National Health Programmes of India 4th Ed. New Delhi: Century publications; 2002. Ministry of Health and Family Welfare, Department of Health and Family Welfare, Family Welfare Programme in India: Annual Report 1991–92, New Delhi: Government of India, 1993. Mistry, Malika: Role of religion in Fertility and Family Planning Among Muslims in India. Indian Journal of Secularism. 3 (2). July-Sep 1999: 1-33.