Family planning enables populations to achieve the desired number of children and determine spacing of births. Contraception significantly reduces the rate of unintended pregnancies, infant and maternal mortality linked to subsequent complications of maternity, and the transmission of STDs.1

In the United States, birth control pills are the most used reversible method. However, the use of long-acting modern methods, such as intrauterine devices and subcutaneous implants, increased from 6% of all contraceptive users in 2008 to 17.8% in 2016.These methods had failure rates of less than 1% per year.2

Despite these successful results seen with modern methods, they are often disregarded in Haitian society because of religious, educational, social and cultural barriers, particularly among lower class families. According to the 2017 EMMUS VI report, 38% of women have unmet needs in terms of family planning, 25% of births were unwanted, 32% were not desired at the time they occurred, and the maternal mortality rate stood at 529 cases of death per 100,000 births. An increase in infant mortality was also observed among children born less than two years after the previous birth (130%) compared to children born four years or more after the last pregnancy (55%).3

Besides the EMMUS report’s data on public health matters such as surveys on domestic violence and mother/child’s health, there is a notable absence of published research on reproductive health issues and contraception in Haiti. This picture presented above is a public health problem that could be alleviated if a good assessment followed by adequate measures including awareness about contraceptive methods of family planning, were conducted among women of childbearing age. Considering that introducing contraception methods in the post-partum period can be a strategic manner of ensuring proper birth spacing, prevent unwanted pregnancies and improve maternal health,4 we carried out this study to determine level of knowledge and use of contraception directly among post-partum women at Saint-Nicolas Hospital to expose the current situation and raise awareness on the subject.

METHOD

Sample selection

We carried out a prospective cross-sectional study targeting women who gave birth physiologically or surgically in the maternity ward of Saint-Nicolas hospital, still in the immediate postpartum period, otherwise known as puerperal period, during the span of the study (November/December 2023). We excluded women unable to give informed consent by reason of mental defect and obviously those who chose not to participate in the evaluation.

To determine the sample size, we reviewed the department’s archives. Considering that the maternity unit performed approximately 4,989 deliveries the previous year, with an expected frequency of 50%, a margin of error of 5% and a confidence level of 80%, the minimum sample size was calculated to be 159 patients by the Epi info software. An adjustment of 10% was made to cover potential non-responses and missing data, resulting in a final sample size of 175 patients.

Procedure

We developed a questionnaire in creole covering all relevant variables. Questions were created around basic family planning concepts from an article on contraceptive methods by Rakhi Jain and Sumathi Muralidhar.5 The form included two categories: socio-demographic information such as age, marital status, education level, parity but also access to a family planning center and previous use of methods. The second half consisted of 24 questions on the level of knowledge rated on a total score of 72. The score was obtained using the Likert method, giving 0 points for incorrect answers and 3 points for correct ones. The total score assessing the level of knowledge was organized into 3 levels: a score of less than 36 points was considered low, between 36 and 53 the level of knowledge was average, 54 points and above was rated good.

Aiming to identify potential problems, pilot work was carried out with 10 patients in the post- natal unit to challenge the questionnaire in real conditions and make the necessary modifications before officially starting our study.

Data Analysis

The questionnaires were meticulously handled by designated team members and, after multiple revisions, compiled on a dedicated mainframe computer.

Questionnaires with missing data were automatically eliminated and replaced as we were able to interview more patients than our sample size requirements. Whenever filled forms came up with same identification code, one code was changed both on the system and on the paper form to avoid errors. The results were stored in Microsoft Excel 2021 software (Version 2309 Build 16.0.16827.20166) and analysed using Epi Info software (Version: 7.2.5.0). This software performed student’s T test to obtain descriptive data determining distributions of participants by variables (age, parity, religion, occupation, marital status) as well as ANOVA tests to compare said variables to level of knowledge in order to determine correlations. A P-value less than 0.05 was considered statistically significant, Confidence intervals were also included for better interpretation of results. Secondary data on use of contraception, sources of information and access to family planning centers were also assessed using the same process.

RESULTS

Socio-demographic characteristics

The ages of the 175 participants in our survey ranged from 15 to 49 years old with a mean of approximately 28.7 [±6.7]. Participants were divided into three age categories, women aged 20 to 30 years old were the most represented category with 103 participants representing 58.86% of our sample. Most of the participants, 63 women (36%), were single. In terms of religion, most respondents (57.71%) were Protestant. Vodou women only made up 4% of the sample. Regarding the area of residence, most women (70.29%) lived in a city.

Most participants were vendors (66.86%). As for education levels, 58.29% of the participants attended high school and only 13.14% went to university. According to parity, first-time mothers made up most of the patients (44.57%) and 8.5% had given birth five times or more. The data are presented in Table 1.

Table 1.Distribution of participants according to socio-demographic data
Variable Category N=175 %
Age Under 20 15 8.57%
Between 20 and 30 years old 103 58.86%
Over 30 57 32.57%
Marital status Married 47 26.86%
Divorced 2 1.14%
Single 63 36%
Widow 2 1.14%
Living with a partner 61 34.86%
Religion Catholic 24 13.71%
Protestant 101 57.71%
Vodou 7 4%
None 43 24.57%
Place of residence City 123 70.29%
Municipal section 52 29.71%
Occupation Vendor 117 66.86%
Farmer 4 2.29%
Employee 15 8.57%
Housewives 31 17.71%
Others 8 4.57%
Educational level Primary 43 24.57%
Secondary 102 58.29%
University 23 13.14%
Illiterate 7 4%
Parity 1 delivery 78 44.57%
2 deliveries 46 26.29%
3 deliveries 28 16%
4 deliveries 8 4.57%
5 or more deliveries 15 8.57%
Children alive 0 children 10 5.71%
1 child 74 42.29%
2 children 45 25.71%
3 children 25 14.29%
4 children 7 4%
5 or more children 14 8%

Source: Assessment of knowledge and use of contraceptive methods among puerperal women at Saint-Nicolas Hospital, November 2023

Use of Contraception

When asked about previous use of one or multiple methods of contraception, 156 participants (89.14%) answered positively. The most used methods among these women were male condoms (74.35%), withdrawal (43.59%) as well as injections (37.82%). The least common methods were contraceptive implants (1.92%) and IUDs (1.28%).

Some women (10.86%) declared no prior use of family planning methods. Most frequent reasons presented for not using any method were the desire to have children (36.84%) or fear of the side effects (26.31%). However, a similar number, 26%, stated simply either not having a particular reason or sufficient knowledge on the matter.

Most participants (92.6%) had access to family planning centers in their area of residence, whereas 7.42% had to travel to another city or municipal section. (Table 2)

Table 2.Distribution of participants according to use of contraception
Variable Frequency %
Previous use of contraception N= 156 87%
Condom 116 74.35%
Withdrawal 68 43.59%
Injections 59 37.82%
Lactation amenorrhea method 40 25.64%
Pills 31 19.87%
Calendar 26 16.66%
Abstinence 11 7%
Implant 3 1.92%
IUD 2 1.28%
Reasons for non-use of contraception N= 19 10.8%
Wanting children 7 36.84%
Fear of side effects 5 26.31%
Religion 1 5.26%
Partners opinion 1 5.26%
Other 5 26.31%
Access to family planning 162 92.57%

Source: Assessment of knowledge and use of contraceptive methods among puerperal women at Saint-Nicolas Hospital, November 2023

Level of knowledge

At the end of our analysis, participants were grouped according to their score evaluating knowledge into three levels: Low, average, or good. Among the 175 respondents, most (50%) had an average level and only 5% had a good level of knowledge. When asked to name several methods that could be used to prevent pregnancies, the most common responses were male condoms (85.71%), pills (85.71%) and injections (85.14%). Only 5.71% seemed to know of IUDs.

Regarding the origin of information on contraception, the main source was hospitals and health centers (53.14%), secondary sources were friends and family members (41.71%)

Means of telecommunications such as radio and television were mentioned by 6% and 1% of patients respectively, as shown in Table 3.

Table 3.Distribution of participants according to knowledge on contraception
Variable Frequency / N=175 %
Level of knowledge
Good 9 5.14%
Average 88 50.28%
Low 78 44.57%%
Knowledge of methods
Condoms 150 85.71%
Pills 150 85.71%
Injections 149 85.14%
Implant 54 30.86%
Tubal ligation 24 13.71%
Vasectomy 11 6.28%
IUD 10 5.71%
Source of information
Hospitals 93 53.14%
Friends/Family 73 41.71%
School 17 9.71%
Radio 11 6.28%
Internet 5 2.86%
Seminars 5 2.86%
Television 2 1.14%

Source: Assessment of knowledge and use of contraceptive methods among puerperal women at Saint-Nicolas Hospital, November 2023

The questions assessing the level of knowledge of contraceptive methods were divided into three determining themes: the definition or use of the methods, their effectiveness and their side effects. The analysis of these variables showed that the participants presented lower scores specifically regarding the side effects of the methods. (Table 4)

Table 4.Distribution of average scores according to theme
Themes Rated on Average Score Std error Std deviation
Definition, existence and use 15 7 .262 3.466
Efficiency 30 20.5 .392 5.187
Side effects 27 10.1 .357 4.722

Source: Assessment of knowledge and use of contraceptive methods among puerperal women at Saint-Nicolas Hospital, November 2023

Variation in the level of knowledge according to certain variables

During bivariate analysis, it was observed that the level of knowledge increased with age. Indeed, participants over 30 years old, with an average score of 39.96, presented a higher level of knowledge than the other two age categories (P value = 0.0226). Women with a college education had the best average scores, 43.5 points (P value = 0.0242). Those who had 4 deliveries or more and those with 4 or more living children had a higher level of knowledge compared to first-time mothers (P value = 0.02). Regarding occupation, employed women had better scores compared to housewives (P value = 0.0026). (Table 5.1)

Table 5.1.Bivariate analysis of the level of knowledge (1)
Variable Category Average score
(Out of 72)		 P value 95% Confidence Interval
Lower Bound Upper Bound
Age Under 20 31.46 0.0226 24.35 38.59
Between 20 to 30 years old 37.39 35.34 39.46
Over 30 39.96 37.23 42.70
Educational level Primary 38 0.0242 35.24 40.85
Secondary 36.1 33.96 38.25
University 43.5 38.71 48.42
Illiterate 40.1 27.65 52.64
Parity 1 childbirth 35.8 0.0217 33.34 38.25
2 deliveries 39.2 35.71 42.69
3 deliveries 36.2 32.41 40.09
4 or more deliveries 43.1 39.68 46.58
Occupation Employee 44.5 0.0026 37.81 51.26
Vendors 37.9 36.13 39.72
Farmers and others 40.6 32.78 48.56
Housewives 32.5 28.34 36.76

Source: Assessment of knowledge and use of contraceptive methods among puerperal women at Saint-Nicolas Hospital, November 2023

Women with a partner, married or cohabiting, had a higher level of knowledge than single, divorced or widowed women. A non-statistically significant trend (P value = 0.7229). There was no concrete correlation between the area of residence and the level of knowledge (P value = 0.6087). In terms of religion, women with no religious faith obtained better scores, this trend is also not supported by the statistical tests (P value = 0.5394). (Table 5.2)

Table 5.2.Bivariate analysis of the level of knowledge (2)
Variable Category Average score P value 95% Confidence Interval
Lower bound Upper bound
Marital status Married 38.8 0.7229 35.40 42.35
Divorced or widowed 36.7 19.50 54.00
Single 36.5 33.84 39.30
Living with a partner 38 35.48 40.72
Place of residence City 38 0.6087 35.96 40.04
Municipal section 37 34.46 39.69
Children alive 0 children 29.3 0.0272 24.13 34.47
1 child 36.5 34.02 39.09
2 children 38.6 35.04 42.16
3 children 39.6 35.21 44.07
4 or more children 41.7 38.39 45.03
Religion Catholic 36.9 0.5394 32.41 41.42
Protestant 37.3 35.14 39.51
Vodou 34.5 20.29 48.86
No religion 39.6 36.63 42.63

Source: Assessment of knowledge and use of contraceptive methods among puerperal women at Saint-Nicolas Hospital, November 2023

DISCUSSION

In this survey carried out among 175 women aged 15 to 49 years old, most of the participants were between 20 and 30 years old with an average age of 28.7 years old, results comparable to similar studies carried out among this same category in India and Cameroon.6,7 As presented in a study on family planning in Nigeria,8 the majority of the sample was single with a high school education, a small portion being divorced, widowed or illiterate.

Most women (89%) had used a modern or traditional method of contraception. The most used modern methods were the male condom and injectables, consistent with findings from the 2017 in the EMMUS VI report.3 For those who did not use any, fear of side effects and the desire to give birth were the main reasons, the same is true in many studies on the use of family planning in Asia and Africa.9–12 The least mentioned answers, namely, the husband’s opinion, religion and lack of information came up similarly in those studies. The low use of long-acting reversible methods such as IUDs and implants remains a common occurrence in low resource countries,13 reasons vary from lower costs, easier access to perceived fewer side effects despite the proven low failure rates of long-acting contraception.2 Considering that 38% of women in Haiti are unsatisfied with their current contraception method,3 these results highlight the need to educate families on the superior effectiveness of long-acting methods in order to decrease unwanted pregnancies rates and improve overall women’s health.

Most respondents had an average level of knowledge and very few had a good level. Similar results were obtained in a study assessing knowledge on contraception in India.14 According to our study, the best-known methods were condoms, pills and injections (Table 3), as demonstrated in many previous studies both in Haiti and globally.3,9,11,15 Likewise, the least known methods were surgical methods of female and male sterilization as well as the IUD. This disparity between long and short-term methods can be explained by the fact that short term methods like condoms and pills are more frequently offered within healthcare delivery points (PPS),16 even though surgical methods are also available in public hospitals. It is not surprising that knowledge was lower regarding side effects as other studies in low-resource settings have shown that popular myths and fears around negative effects often influence method selection and knowledge level.13 It is imperative for healthcare workers, when introducing contraception methods, to properly inform the public about possible side effects and ways to manage them to encourage a better attitude towards them and eliminate myths and taboos.

Bivariate analysis showed a statistically significant relationship between age, parity, education level or occupation and the level of knowledge, as seen in similar studies in Nigeria and Asia.10,11,17 The observed trend of women with children and over 30 having better knowledge was expected, as they are likely to be the ones seeking family planning to limit pregnancies in order to economically sustain their families. Moreover, young women generally do not have access to Sex Education programs as those are not part of strict school curriculums and the subject is commonly taboo around families.

Health institutions were the primary source of information on family planning, as established in several similar articles.6–8,11,18 Contrary to the findings of these studies, telecommunication means appeared to be underused for transmitting information on family planning (Table 3). Friends and family being the second main source of information would likely negatively impact knowledge, use and attitude towards contraception by spreading myths and reinforcing existing cultural barriers and fears against modern contraception in Haiti. Even though hospitals and health centers being the primary origin of information is commendable, it is also our prerogative to reach the broader population more effectively. It is necessary for the health department and contraception centers to increase use of telecommunication means to promote family planning to the crowds.

Limitations

The study’s cross-sectional nature limits causality inference. The single hospital setting, and small sample size may also reduce generalizability and not represent the broader population. Moreover, self-reporting represents a limitation since our results are entirely based on the participants’ statements without being able to confirm their veracity. Our study was also limited in assessing traditional contraception practices and cultural influences.

CONCLUSIONS

This study found that knowledge of contraception was lower among younger, less educated women with fewer children, and that barriers to using proper methods were mainly fear of side effects and lack of general knowledge. To improve contraceptive use and knowledge, comprehensive educational programs, leveraging healthcare providers and media, are essential. Addressing fears and misconceptions about modern methods can significantly enhance family planning efforts, reducing unwanted pregnancies and improving maternal and infant health outcomes. Ways to directly improve this study’s findings include targeting young people particularly in schools, scheduling free mobile clinics focused on contraception in rural areas and broadcasting information about contraception availability and effectiveness in the media. Further studies should be conducted to corroborate or challenge our findings, notably on practices of traditional and cultural methods and the intention of using contraception in the future.

Acknowledgements

We are grateful to several members of the staff of Saint-Nicolas Hospital who made this project possible:

  • Dr Léandre Frickson, Family doctor, for his assistance throughout the investigation

  • As well as the nurses and other maternity staff who gave us access to the archives and their workspace during the evaluation.

Ethics statement

This study was conducted according to the three ethical principles of the ‘‘Belmont Report’’.

After being informed of the study’s goal and process, each participant who understood and agreed to participate provided informed consent by signing our consent form. Patients could freely withdraw from the study at any time without affecting the quality of care in the unit. Each questionnaire was coded with participant’s initials followed by their age and year of birth, free of any confidential information allowing identification of the patient such as the name and file number. All participants were treated fairly.

Data availability

Extracted data may be obtained upon reasonable request.

Funding

This study did not receive any external funding.

Authorship contributions

  • Sarhns Lori Desruisseaux (Design, data collection, analysis and interpretation of results, writing and revision of the manuscript)

  • Anne Beverly Blanchard (Design, data collection, manuscript revision)

  • Calebe Delva (Design, data collection, manuscript revision)

  • Rose Evelyne Pierre (Design, data collection, manuscript revision)

  • Hendrick Etienne (Design, data collection, manuscript revision)

  • Vasthie Bernardin (Conception, revision of the manuscript)

  • Michaël Jean Baptiste (Conception, revision of the manuscript)

  • Chamberly Huguens Ulysnor (Data collection, manuscript revision)

  • Benjaminel Scaïde (data analysis)

  • Jonathan Leosthene, MD (design, conception, critical review)

  • Waquinn Saint-Loth ObGyn (critical review)

Disclosure of interest

The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant conflicts of interests.

Correspondence to:

Sarhns Lori Desruisseaux
Faculty of Health Sciences, Quisqueya University
Ave Jean Paul II, Port-au-Prince
Haiti
sarhns99@gmail.com