Perspective Chapter: Factors that Influence Young Women’s Decision-Making in Contraceptive Use in Ashiedu Keteke of Accra, Ghana

Abstract

Every young woman has the right to reproductive health care. It is quite important for every woman to make an informed decision when choosing contraception. This is because women of today face a lot of challenges when it comes to the issue of reproductive health care. Young women choose contraception to prevent unwanted pregnancies and other reproductive health-related risks. The increase in abortion and pregnancy complication rates among young women is far too much and needs to be critically addressed to reduce maternal deaths (MD) and infant mortality. The decision made on the use of contraception by many young women has interfered with some factors that prevent them from making the right decisions. This piece is to identify those factors that influence young women’s reluctance of using contraception and how to promote contraceptive usage among Ghanaian women.

1. Introduction

1.1 Background

The issue of teenage pregnancy is a global public health concern, especially in developing countries like Ghana. It is generally asserted that teenage pregnancy is a global public health concern. During the developmental stages of life, adolescents’ sexual instincts increase and they may engage in risky sexual activities, which may, in turn, lead to unintended pregnancies. However, it is confirmed that pregnancy during adolescence predisposes young women (YW) to a lot of risks, which may include unsafe abortion, maternal mortality, mental retardation and sexually transmitted infections (STIs).

The issue of childbirths among young women is a socioeconomic canker, which has a greater impact on the mother, family and the entire community. This comes from the unpreparedness of young women giving birth because their bodies may not be ready for a full-term baby, and may be dependent on their families and the social service providers, which also bring shame to the young women. According to Sedgh et al. [1], unplanned pregnancy globally is said to be 84.9 million and more than half of these seek abortion. A recent report states that apart from the complications mothers bear, newborn babies are also predisposed to risks of low birth weight and congenital abnormalities [2]. The global record for unintended pregnancies is reported to be 44% [3] and more than 56% of these result in abortions [4]. Meanwhile, a significant number of these come from the Sub-Saharan African (SSA) region [5]. According to Sedgh [6], about 11% of maternal mortality are a result of unsafe abortions. Sexual and reproductive health (SRH) care is one of the factors for reducing poverty in every nation.

For some decades, there has been a consistent reduction in the use of contraception among young women in Ghana. The study of Ashiedu Keteke in the Accra Metropolitan Assembly in the Greater Accra Region of the Republic of Ghana has a population of 149,185 with divergent ethnic groups from all walks of life [7]. Bain et al. [8] report 87% of unsafe abortions among young women within the community.

Recent studies by other studies have also recorded the promiscuous lifestyle of some adolescents who engage in coital activity at the early stages of life [9]. However, the World Health Organization [10] defines unsafe abortion as a procedure carried out to terminate unplanned or unwanted pregnancy by unskilled individuals or in an environment with less standard of medical care. It is a preparatory ground for gender equality as well as women’s empowerment. The inability of women to decide on the choices of their sexual and reproductive health needs is the root cause of their health-related problems. Women are denied their bona fide rights to choose from possible courses of action for fear of the ‘so-called’ societal norms.

Sexual and reproductive health decisions on contraception are essentially significant. Every individual who wants to start contraception has the right to choose, opinion, information, safety and access to quality service. A lot of young women face challenges when choosing contraception. The key mandate to contraceptive uptake is the woman’s ability to make a decision. Interestingly, one may ask if the decision to use contraception is taken by the woman or both the woman and the male partner? By what means can this be influenced if decisions on sexual and reproductive health care are taken by both parties?

Decision making (DM) is described as the study of finding out from possible alternatives and picking out the most convenient for a purpose. It is perceived as a cognitive study due to its functional role in mental reasoning or straight-thinking. Consequently, decision making is a process that limits uncertainty to a desirable level but not all uncertainty can be reduced; sometimes it has to be removed. This is because most decisions may involve some quantity of risks that needs to be obliterated [11].

The young woman’s decision on reproductive health care is a need to help prevent unplanned pregnancy as well as unsafe abortion and its complications which is a public health issue of international concern. These women request that their decision on contraception should be autonomously considered significant [12]. In Ashiedu Keteke a suburb of Accra, Ghana, a significant number of young women experience increased risks of sexually transmitted infections (STIs) and abortion-related complications as a result of unplanned pregnancy. Boah et al. [13] record that Ghana’s abortion rate as of 2017 is recorded to be 26.8%. The leading cause of death among young women and adolescents is complications from pregnancy and childbirth [14].

Within the reproductive age group, young women are described to be sexually active and if care is not given during peer relationship, their promiscuous lifestyle will likely increase the population growth of a nation as a result of an increase in the number of childbirths. A lot of these women are unable to develop academically, socially and economically and this affects the nation’s manpower as well as young women’s future growth and opportunities [15].

Consequently, the health and lives of these young women are undermined [16]. It also increases the economic burden of a nation because young women who become pregnant have to drop out of school without achieving their full potential in life. Across the globe, complications from pregnancy and childbirth are the leading killer of female adolescents and young women with 99% of maternal deaths [17].

Efforts made by the United Nations Fund for Population Activities (UNFPA) to support voluntary family planning (FP) among women of reproductive age (WRA) is an indication to secure human rights for sexually active women. The intention to decide when to become pregnant is a serious issue to consider in every woman’s life since it has an immediate impact on a woman’s health and well-being [18]. Ghana’s prevalence rate on MC methods was recorded to be 33.2% [19]. Reasons for non-contraceptive use among young women in Ghana are what stands to influence their decision making on contraception.

2. Contraception

The practice of contraception in spacing-out childbirth is an intervention to delay pregnancies in the at-risk population of young women who usually go through pregnancy-related complications [20]. Getting access to contraceptive education is the human right of young adults. Contraception as we know is a device used in preventing unplanned pregnancies and it reduces abortion rates as well as complications due to pregnancies and childbirths [21]. Also, consistent and correct use of barrier methods like condom is an effective method in preventing and reducing sexually transmitted infections (STIs).

Sexual and reproductive health care are services adopted to control maternal and infant mortality as well as promote the education of family planning services across the globe. This is World Health Organization’s core mandate to create awareness of “health issues for the young people” (Ibid); thereby making contraceptive devices more accessible, affordable, safe and effective.

Estimated results from recent studies also recorded that 218 women of reproductive age from the low and middle-income countries (LMICs) do not desire contraception, yet they wanted to avoid unintended pregnancy. Consequently, 171 sexually active women globally wanted to prevent pregnancy but feel reluctant to use any form of contraception [22] as a result of other health-related risks or side effects, misconceptions of some contraceptive methods, not being in a stable relationship or not having sex frequently [23]. Meanwhile, young women who use contraception are able to prevent maternal mortality as they limit or delay childbirth. As a service provider, clients who have accepted to use contraceptives are able to express the benefits gained after the use of modern contraceptive methods. This includes the restoration of their reproductive health after intermittent childbirths, engaging in gainful employment to raise their income and being able to further complete their education. Also, the number of contraceptive acceptors who happens to be young women prefer using more hormonal contraceptive methods (injectable, oral pills, implants) than the non-hormonal ones (condoms, EC, etc.) compared to older women.

3. YW’s perception towards modern contraceptive usage

Consistent review from related studies posits that some women perceived orthodox medicine (contraceptive methods) to be unsafe, causing infertility and deaths; also mistrust of provider’s information with the perception of not being competent could lead to low usage [24]. It is recorded that some women consider themselves naturally infertile, so no need for contraception, perception of being weak as a man to allow the woman to use contraception, perception of becoming promiscuous after using contraception, perception of low quality of service provision by healthcare experts, perception of becoming pregnant as a result of pre-ejaculation and misconceptions about methods of contraception or the perception of becoming sick when the number of children is limited [25]. Furthermore, some women perceive that women who engage in contraceptive usage give birth to abnormal babies, as well as making users disloyal or cheaters in their relationships [26].

4. Awareness, experience and knowledge of young women in modern contraception

Limitation in the knowledge of contraception was a result of a reduced rate of illiteracy, which contributed to the low use of contraception. The level of awareness of modern contraceptives was known to some women and they perceived some methods that cause infertility [24]. Inadequate knowledge of modern contraceptive methods is a barrier in the use of contraceptives [26]. Further to that, Hlongwa et al. [27] reported evidence on barriers to contraceptive use to be a lack of knowledge and understanding of contraceptive methods. It is recorded that the awareness of contraception, which was made known through peer relations, close relations, neighbors, mass media and providers of sexual and reproductive health care, is limited [28]. Also, modern methods of contraception are widely known to some women, whilst those with no level of education lack the awareness of modern methods of contraception [25]. However, individuals’ exposure to appropriate information and education on contraceptive methods enhances informed decision making in contraceptive uptake [29]. In the same vein, young women are able to make rightful decisions on their reproductive health needs.

5. The impact of decision making on contraceptive use among women

Women’s rights in decision making on sexual reproductive health care are undermined, making them unable to choose contraception [25]. In the same vein, women with higher decision-making autonomy accepted to practice contraception without the approval of partners [28]. However, women whose partners accepted contraceptive usage were very supportive of the cost involved as well as in managing side effects.

6. Hindrances to the use of contraception among young women

Giving account on my personal experience, women who discontinue the use of contraceptive devices or methods, do so as a result of significant occurrences; which include the experience of irregular menstrual flow or bleeding pattern, not being in a stable sexual relationship, partner not in support of contraceptive use, pleasure in the coital activity being interfered and misconceptions and myths on some contraceptive methods.

Social influence (husband/partners, in-laws and other close relations), a limited number of qualified health providers, low income, no desire for birth spacing or limitation, lack of accessible sexual and reproductive health clinics, misconduct of service providers to clients, side-effects of some methods and increase in the number of stock-outs of methods are factors contributing to low contraceptive uptake [24]. Lack of funds to procure contraceptives, non-availability and equitability of sexual and reproductive health clinics offering contraceptive services, issue of consistent stock-outs and its associated cost, the uncomfortable nature of singles walking into sexual and reproductive health clinics, the aftermath side-effects of some contraceptive devices and issue of socioeconomic status affected modern contraceptive uptake [26].

It is considered that dissatisfaction with methods, unable to switch to the most appropriate methods during contraceptive method failure, stock-outs of current methods, unable to seek consent from partners on contraceptive uptake, personal health issues, poor quality of care, social influence from peers and other family members and side-effects of modern contraceptive interfere with its usage [28]. In addition to this, the duration of a relationship, partner’s age difference, contraceptive methods availability, sexual experiment, poor attitude of providers towards clients and long hours of waiting influence the use of contraception [27]. Also, consistent abstinence in sex, the denial of family and partner’s approval, non-availability and non-accessibility of modern contraceptive methods and services, desire to increase family lineage, getting used to traditional methods, side-effects or associated health risks, low stock-out rate, cost of contraceptive methods and some provider’s adherence to cultural practices and demand for partners’ consent interferes with contraceptive usage [25].

7. Types of contraception and the mechanism of action

Per the views of the World Health Organization [20], contraception is ‘a core’ issue of public health. It contributes to the reduction of family size as a result of birth spacing and also improves the health of mothers, infants and children. In the same vein, women are able to further their education, secure a career and promote economic growth as well as the lives of families and communities (Ibid).

Contraception is a method used to prevent ovulation, which may intend to prevent unintended pregnancy leading to the reduction of induced abortion [30]. Some women prevent pregnancy as a result of delaying pregnancy, spacing out births and limiting the number of births they want to have. These are the reasons why contraception is used [31]. But then, one needs to consider the following factors while choosing the most suitable contraception. These include:

• Getting reliable information about the method to be used

• Knowing the benefits of contraception (including safety)

• The mechanism of action and the side effects of the method chosen

• Knowing the cost, accessibility and affordability of the chosen method

When these are made known, women would not be influenced when making a decision to use them. There are various types of contraception but when making a decision to use them, one needs to consider their needs and the circumstances involved. The commencement of these procedures can be done when there is no issue with pregnancy. These include:

• Short-term hormonal methods (HM) contraceptives like the birth control patch, vaginal ring, injection and the contraceptive pill.

• The long-term HM are the intrauterine system and implants

• Non-hormonal long-term methods like intrauterine device

• Non-hormonal barrier methods are the diaphragm, male and female condom

• Methods that are not reversible include vasectomy and sterilization

• Emergency contraceptive (EC) methods include the intrauterine device (IUD) and the EC pills

• Natural and traditional methods

The natural methods are the calendar, basal body temperature (BBT), cervical mucus and the symptothermal. Traditional methods are coitus interruptus and coitus reservatus which is done to prevent sperm from entering the body for fertilization to commence (Ibid).

Nevertheless, contraception is provided by a doctor or a trained nurse. These are how the various methods of contraception are provided. Short-term hormonal methods include patches, vaginal rings and injections. According to Trussell et al. [32], a hormonal patch is a method worn on the skin, either at the abdomen, buttocks or upper body, far from the breast to release hormones (estrogen and progesterone) into the bloodstream and it works for 3 weeks by changing it every week, and then removed in the fourth week during menstruation. The vaginal ring is a ring placed into the vagina for the release of estrogen and progesterone, then it is taken out in the fourth week to allow the flow of the menses before using it again. The patch and the vaginal ring keep the sperms apart from reaching the egg when estrogen and progesterone are released into the bloodstream.

There is also the hormonal contraceptive injection. The ‘Depo-Provera’ (150 mg), ‘Sayana Press’ (104 mg) and Noristerat are mainly progestin-based contraceptives. The Depo Provera is given intramuscular (IM) every 3 months at the buttocks or upper arm, while the Sayana Press is given subcutaneously every 13 weeks at the back of the hand, the front thigh or the abdomen, far from the naval. The Noristerat injection ‘(NET-EN)’ is given IM every 2 months. The progestin-only pill is good for women who cannot take estrogen-based contraceptives. The other contraceptive to consider is the combined injection contraceptive (CIC), which contains estrogen and progestogen and is given IM every month at the buttocks or upper arm [33]. The effectiveness of hormonal-based contraceptives can be reduced with some medications (e.g., Rifampicin/Rifabutin). Its usage ceases ovulation making the ovaries inactive to release eggs to meet the sperm. They are highly effective in preventing pregnancy when the injection is taken consistently and contraception takes up to seven (7) days to work effectively. Therefore, there is a need for a backup method during sexual intercourse.

The oral contraceptive pill is made up of the progestin-only pill (POP)/mini pill and the combined oral contraceptive (COC) pill. They are safe and effective when taken at the same time every day starting from the first day of menstruation and will need a backup method or abstain for the first 7 days [34]. It thickens the cervical mucus, ceases ovulation and also makes the uterine lining thin to prevent the passage of sperm for conception to take place. However, it is good to report to a service provider when a pill is missed or forgotten but condoms can be used as a backup method. The POP is good for lactating mothers. The COC pills are made up of 21 estrogen and progestogen pills and seven brown or iron pills per pack/cycle serving as iron supplements. There is a quick return to ovulation after stopping COC; good for the treatment of painful menstruation and gives protection against ovarian cancer [33].

The long-term hormonal IUD is a ‘T-shape device’ placed into the uterus to prevent pregnancy for 10–12 years. The copper component kills the sperm and thickens the mucus of the cervix preventing sperms from swimming to meet the egg. We also have IUDs that are non-hormonal. However, women eligible for IUD are those with no issue of pelvic infections, those whose uterus sound is more than 6 cm or less than 10 cm and those that are not allergic to copper. It is effective as soon as insertion is done. That’s why it is used as emergency contraception (EC) (Ibid).

The second hormonal method is the implant which is a ‘thin rod’ and is inserted subdermally into the left upper arm. They are of two types, the Implanon is one rod inserted under the skin of the upper arm for 3 years and Jadelle is a double rod inserted subdermally under the skin of the upper arm for 5 years. It also stops ovulation and makes the cervical mucus thick to prevent the sperm from reaching the egg. They are useful for women who are allergic to the use of estrogen hormones (Ibid). The IUD and the implant are conducted by a trained service provider.

The non-hormonal methods of contraception include the cervical cap (CC) or diaphragm, male and female condoms. The diaphragm or CC are placed inside the vagina to close or cover the cervix to prevent the sperm from reaching the eggs for conception to take place. This can be used in addition to spermicide to kill the sperms and is done before sex. Women who are allergic to spermicides cannot use it. The male and female condoms prevent the eggs from meeting the sperm for fertilization to place. The male condom is a ‘thin sheath made of latex rubber’, which is worn on an erected penis before inserting it into the vagina. The female condom is a ‘soft loose-fitting’ rubber sheath with two flexible rings. The inner ring is squeezed into the woman’s vagina to cover the cervix and the outer ring at the surface of the vagina. The penis is guided into the condom during sex; and after sex, the outer ring is twisted, squeeze and pulled out from the vagina and discarded into a trashcan or waste bin making sure the sperm does not split (Ibid).

Vasectomy and female sterilization (tubal ligation) is a non-reversible method of contraception. This method follows a ‘surgical procedure performed under local anesthesia’ on a man or woman preventing him or her from producing additional children. The client is supposed to make an informed decision about the chosen method. The method required a signed consent form from the spouse or a witness before the procedure is being performed. The vasectomy does not allow the spermatozoa to flow into the seminal fluid during ejaculation. The tubal ligation prevents the egg through the fallopian tubes to meet the sperm. It is very safe and effective (Ibid).

The emergency contraceptive (EC) pills and the IUD are the contraceptive methods for emergencies. The EC pills are taken after unprotected sex and they prevent pregnancy from the starting day to 5 days [35].

The natural and traditional methods of contraception include: the lactational amenorrhoea method (LAM), which prevents ovulation through the practice of exclusive breastfeeding for 6 months [33].

The BBT method is used to study a woman’s temperature to indicate if ovulation has occurred in order to prevent pregnancy during that period. Here the temperature is taken orally or rectally every morning waking up from bed and before any vigorous activity. The normal BBT to detect if ovulation is over is when ‘BBT has risen from 0.2 to 0.5 degrees Celsius’ with a constant elevation for 3 days and the readings should be higher than any of the previous days in that particular cycle. The rise in temperature will be constant until the beginning of the next period (Ibid).

The next method is the calendar method, which works like this: it requires the study of the cycle for 6 months to be able to indicate the longest and the shortest of the six cycles. This will help the client to tell which part of the month is fertile. An example is a client with the shortest cycle (SC) of 25 days and the longest cycle (LC) of 32 days. Here 20 will be deducted from the SC (25–20) = 5 and 10 from LS (32–10) = 22. For this reason, sex needs to be avoided from day 5 through to day 22 to prevent pregnancy (Ibid).

The cervical mucus method is a method used to detect when there is a feeling of wetness or mucus at the vulva to be able to tell when one is fertile in order to avoid sex. One can observe the mucus by wiping the vulva with a tissue or when there is wetness in the underpants. There is no sexual relation when mucus is found in the underpants or tissue paper. Consequently, the symptothermal method is the observation of the body temperature and the cervical mucus for the detection of fertile periods. This period ends 4 days after ‘peak’ mucus from the cervix or 3 days after a sustained rise in temperature. However, when not sure of the fertile period, abstain or use a condom for protection. Also, clients who have problems with the use of one contraception can be provided with a suitable alternative (Ibid). Contraceptive services are given by a practice service provider at the sexual health clinics.

In Ghana, the most available contraceptive methods include: the contraceptive injections (Depo-Provera, Sayana Press and Norigynon), the contraceptive pills (both POP (Microlut) and microgynon (COC), ECP (Postinor 2), implants (Jadelle and Implanon), IUD (10–12 years), vasectomy and female sterilization and condoms, cycle beads and the natural methods.

Recent studies recorded the methods used by women who are married are different from that of unmarried women. The use of modern contraceptives for men is limited to vasectomy and condoms. The prevalence of modern contraceptives among married Women of Reproductive Age as of 2019 is 57.1% [10].

8. The impact of contraceptive use

Every nation sees the advancement in sexual and reproductive health as a core value for its development. Sexual and reproductive health is the bedrock of the standard development goals [36]. This is a means of controlling the fertility rate of women of reproductive age, to pave way for economic growth and development. It has been evident in the development of nations with improved contraception services and healthcare among women to enjoy a better standard of living in the area of economic growth, investment, education and empowerment as well as decreased rate of maternal morbidity and mortality and infant deaths (Ibid).

When contraceptive care for young women is of greater quality, the decision to accept its usage will be manifested. Globally, maternal mortality has declined by 420,000 within 25 years [37, 38]. That’s why it is important to identify those setbacks that discourage young from accepting contraception.

The need to reduce the incidence of maternal and infant deaths associated with pregnancy and childbirth complications in every nation is of paramount importance. Contraceptive use in women is an essential human right to prevent complications from pregnancies and childbirths [21].

The impact of contraceptives according to the UNFPA annual reports states that over 14 million unintended pregnancies and 3.9 million induced abortions have been prevented by the use of contraceptive devices [18]. Consequently, over the past years in the LMICs, consistent use of modern contraceptives among women has led to a drastic reduction in maternal deaths, which records 40% [39].

9. Sexual health service and the type to use

Several clients are considered to be having special needs for contraception, especially those that may have some conditions that may prevent them from accessing sexual and reproductive health services. Sometimes these groups of individuals may be at risk of unplanned pregnancy and STIs. Young people form 41% of ‘new adult infections’ globally [40]. They may include adolescents, young people, post-abortion clients as well as people with disability. Although they are biologically or emotionally tortured, they all have equal rights to information and services on contraception [41]. It is highly important to provide sexual and reproductive health service information to these groups of people as well as help them to make decisions that can lead to positive sexual health outcomes. This call for the provision of sexual health services (SHS), a system that provides increased attention to SRH information to young people. The intention is to target young individuals with increased risk and provide them with information on sexual and reproductive health care to prevent them from unplanned pregnancy, maternal deaths and STIs (Ibid). This is because they have the right to decide on which contraception to use, obtain and where to get them. On that account, it is essential to make service delivery sites more comfortable and friendlier. The intention of this inauguration is to decrease maternal and infant mortality and encourage the promotion of reproductive health so as to increase the prevalence of contraceptive uptake.

Sexual health service is described as systems that make provision of preventive health services to youth on-site or in their community or within the health facility [42]. These are healthcare services provided by healthcare providers and school health nurses. So, increasing access to these services will help improve adolescents’ and young women’s immediate and lifelong health significantly, where other health issues would be detected early and services provided on time.

10. Strategies to enhance contraceptive uptake (CU) decisions

In order to build up the decision on contraceptive use, it is essential to periodically intensify the education on sexual and reproductive health care services on contraception by moving to the doorsteps of individuals and some household levels. Furthermore, much attention should be given to mass education in the communities, especially the remote villages to strengthen young women’s sense of well-being during decision making in contraception [43].

11. Conclusions

This work clearly explains the views of young women’s decisions on contraceptive usage within the context of Ghana. This manuscript is basically giving an account on decision making and its associated factors in contraceptive use. Information gathered from reviewed articles reiterates that perceptions on contraception, limited knowledge on methods of contraception, lack of support in contraceptive decision making and influence from environmental characteristics affect decisions on the use of contraception. However, there has been limited information explaining the positions of women when it comes to decision making in contraceptive usage. Therefore, it is expedient to understand women’s points of view with regard to contraceptive decision making. Findings from the study seem to be equally the same as other studies that are in the context of the research area. One area in the study, which seems significant and mostly considered problematic is the issue of partner’s support or cooperation as women have been denied household decision making [44, 45]. However, there should be possible mechanisms to promote the use of contraception. The medium of communication in the education of contraceptive services should be sensitized to include women in decision-making process and not undermine the rights of women in decisions concerning their health.

Definition of terms

Decision-making

it is a course of action used to arrive at the best option or a solution for a given issue or problem

Young women

a female between aged 10 and 24 years

Contraception

methods or devices used to delay or space or limit childbirth

Contraceptives

these are drugs or agents or devices that inhibit conception

Sexual and reproductive health

it is the right to good healthcare and to a safe lifestyle