Women's Participation in The Selection of Contraceptive Methods – Knowledge, Attitude and Culture

Timor Leste is one of the developing countries with one of the main problems faced is the population sector, namely the high rate of population growth. The purpose of this study is for what factors influence the knowledge, attitudes and culture of women to participate in the selection of contraceptive methods at the Formosa Health Center. This research method is carried out descriptively with a quantitative approach. The population of this study was Women of reproductive age who sought family planning services at the Formosa Health Center. The results of this study revealed that most participants or women sought family planning services at the Formosa Health Center, dominated by women from the age group of 20 to 24 years and with a higher level of education. We found that there was little information regarding the type of use and source of information, participants with knowledge and level of education preferred to use artificial methods, especially the most widely used ones were Injections, compared to Pills, IUD and Implant. It is highlighted that the side effects of the injection contraceptive method are dizziness and headache. However, there is no fundamental reason to stop use. It is emphasized that only a quarter of women have the knowledge that the advantage of using contraceptives is only to prevent pregnancy.


INTRODUCTION
Many developing countries have looked to family planning initiatives as a means to decrease fertility rates by encouraging the use of contraceptives.Evidence from a variety of research conducted in developing countries suggests that these initiatives have an influence on fertility/fecundity that was unrelated to economic or social development (Seltzer, 2002).
The success of the family planning program depends on the knowledge, attitudes, and culture of the family planning acceptor, such that the family planning acceptor understands the complexities of contraception and the advantages and downsides of contraceptive use, as explained by health workers, such as midwives (Rahayu et al., 2022).Family planning services need to take into account a variety of factors, such as the individual's health status, potential negative side effects, potential unintended consequences of an unsuccessful pregnancy or birth, the size of the family that was desired or planned, the approval of the partner, and even very high integral environmental cultural norms.Other reasons having to do with the social conditions of the considerations are that it would be too expensive (Indira, 2009).
In the current millennial era, utilizing contraception to plan a family stands to reason.As a result, it is indeed essential to use both hormonal and non-hormonal contraceptives while planning a family.Hormonal contraceptive devices include injections, pills, and implants, whereas non-hormonal contraceptive devices include intrauterine devices (IUD), condoms, and sterile/female/male surgical methods (BKKBN, 2020).
According to census data from 2010 to 2016, Timor Leste population has increased (de Estatística Timor-Leste, 2016).With such increasing number of population, the Family Planning program was designated as one method to suppress Timor Leste population growth in accordance with the Population, Family Planning, and Family Development program taken from one of the international sustainable development programs Sustainable Development Goals (SDGs) namely a healthy and prosperous life (Sari et al., 2019;WHO, 2016).Based on the prevalence of contraceptive method users in the world, Timor Leste was the 10th lowest country out of 71 countries in the world with the most users of contraceptive methods in the form of Long-Acting Reversible Contraception (LARC) methods (Nations, 2015).
A lack of public understanding of the LARC method was one of the factors contributing to acceptors' low interest in non-LARC methods (Jensen & Creinin, 2019).With knowledge about contraceptive methods and attitudes regarding the choosing of contraceptive methods, a behavior will be formed that was aligned with the acceptor's condition in the use of contraceptive methods (Soekidjo, 2012).
Timor-Leste has a total fertility rate of 7.8 and a fertility rate of 5.7 per woman of reproductive age.This indicates a decrease in growth during the past five years.There seems to be differences between the 13 districts, with Ainaro district having the highest fertility rate (7.2) and Covalima and Dili districts having the lowest fertility rate (4.6).In 2009, according to Demographic and Health Research, Timor-Leste, the prevalence rate of contraceptive use was 19.9%, and in 2010, it increased to 49.9%.This depends on the midwives' capacity to counsel prospective partners.Consequently, the partner must make a decision based on knowledge, desire, and awareness (Annual Report on Statistics, Ministry of Health 2014) The results of research conducted by Susanti & Habsi (2020) concluded that knowledge was the dominant factor in determining attitudes and behavior in choosing contraceptive methods.In addition, the research conducted by Saragih et al. (2018) in regard with the family planning acceptors of women of childbearing age in Bandarharjo Urban Village, Semarang City in Indonesia, concluded that the factors of age of women of childbearing age, knowledge, and attitudes of women of childbearing age had a significant relationship with the selection of non-IUD (non-LARC) contraceptives among women of childbearing age family planning acceptors.On the other hand, Putri et al. (2019) has led to the conclusion that one of the factors related to the choice of contraceptives was the level of knowledge of the mother on contraceptive methods.Further, Triyanto & Indriani (2018) in their research on the knowledge of contraceptive methods and attitudes towards choosing a contraceptive method, it was emphasized that if knowledge is increased, the attitude towards receiving contraceptive methods would be better and if there is an increase in knowledge and good attitudes, then the implementation of choosing contraceptive methods would ultimately be even better.
According to the findings of a survey that was carried out in Timor-Leste in the years 2009 and 2010, it was found that 78% of married women and 66% of married men were aware of at least one contemporary method of family planning.As such, the data showed that the majority of married women (78.1%) has knowledge of various types of contraception as follows.

METHOD
This research was carried out descriptively with a quantitative approach.The population of this study consisted of reproductive age women who seek family planning services at the Formosa Public Health Center.The research sample was set at 66 women with sample characteristics aged between 17 to 49 years.Further, contributed factors was determined to analyze and evaluate the factors that influence women in making decisions to use contraceptives, such as: level of knowledge, culture, religion and contraceptives themselves, as well as side effects that occur during use.

Participant Distribution by Women's Education Level Figure 2. The Result of Participant Distribution by Women's Education Level
As shown in Figure 2, the highest level of education attained by a majority of women was a senior high school degree 45%, followed by college graduates at 21%, junior high school at 15%, elementary school at 11%, and illiteracy at 8%.
Further according to the results of the analysis related to the distance between pregnancies before using family planning in women in the Public Health Center Formusa were mostly less than 1 year with a frequency of 31 people (47%), a distance of 1-2 years with a frequency of 25 people (37.9%), a distance of 2-3 years were 5 people (7.5%), and 3-4 years were 4 people (6.1%), while in 4-5 years only 1 people (1.5%).Meanwhile, the distance between pregnancies after using family planning for women in Formosa health centers was 3-4 years with a percentage of 39.4% (26 people), followed by 4-5 years with a percentage of 18.2% (12 people), less than 1 year with a total of 7 people (10.6%), 1-2 years were 6 people (9.1%), 2-3 years were 6 people (9.1%), while 4 people (6.1%) did not want to have any more children, the distance of more than 6 years were 3 people (4.5%), and the distance of 5-6 years were 2 people (3%).
Based on the results of the analysis, it was found that sources of information regarding family planning showed that women in the Formusa health center did not get sufficient information, this was indicated by the percentage rate of 57.6% (38 people), while sources of information based on the media as many as 18.2% (12 people), followed by health workers health services, both from midwives, nurses and doctors with a percentage of 13.7% (9 people), while only 4.5% based on family sources (3 people), as well as 3% of information sources from friends (2 people), and the rest came from brochures and schools with a percentage of 1.5% each (1 person).
Regarding knowledge related to family planning, participants stated that 60.6% (40 people) did not receive information related to family planning, while 37.9% (25 people) stated that they knew about family planning to distance their pregnancies, whereas 1.5% (1 person) knew about family planning with contraceptive methods.The reasons behind the majority of family planning choices were based on the reasons for preventing pregnancy with showed by 34 people (51.5%), while 31 people based on the reason for the distance between pregnancies, and only 1 person was based on not getting information.Based on table 1, the factors influencing the frequency of family planning consultations resulted the majority of women in the Formosa Public Health Center were not willing to mention the factors with a percentage of 87.9% (58 people), while 3 people said that they were influenced by family, 2 people were influenced by culture, and those influenced by religious factors, health factors, and husbands cultural factors with 1 person (1.5%) respectively.
Meanwhile, the were also factors that affects the participants decision to use contraceptive methods such as 2 people were based on the family decision, the decisions of husbands and husbands and each family with a frequency of 1 person, while 94% of people din not mention the factors that affects their decisions.This was supported by participants' statements that stated that family opinions about the decision to follow the contraceptive method were approved by the family with a percentage of 92.4% (61 people), while families who disagreed were 6.1% (4 people), but families who disagreed but husbands agreed only 1 person (1.5%).

Figure 3. Participant distribution based on contraceptive method information obtained
As shown in Figure 3, the vast majority of women who go to the Formusa Public Health Center are aware of the various methods that can be used to prevent pregnancy.This was demonstrated by the percentage of 95.50%, while the remaining 4.5% are unaware of the various methods that can be used to prevent pregnancy.According to the findings of the research, there were 57 individuals who were aware of the potential negative outcomes associated with the use of oral contraceptives, injectables, implants and intrauterine devices (IUDs).Although, 9 people mentioned that they were only familiar with the method preferred by women.Based on Figure 4, it was revealed that the majority of women in Formuso Public Health Center use artificial methods in the form of injections as much as 63.6%, women who use artificial methods in the form of pills as much as 21.2%, while women who use implants as much as 13.6%, and 1.5% using IUD.Based on the results of table 2, it was revealed that women at the Formuso Public Health Center stated that the advantage of using contraception was to prevent pregnancy with a percentage of 30.2%, while 17 people (25.8%) said that the advantage of using contraception was to adjust the time between pregnancies, and 29 people did not answer their reasons.Based on Figure 5, the data showed that the majority of family planning users are new users with a percentage of 28.8%, followed by 18.2% have been used it in 2 years, 12.1% of women have used it in 3 years, 6.1% have used it in 4 years, 4.5% have used it for more than 5 years, while the remaining 15.2% have used it in less than 1 year and within 1 year, respectively.prevent pregnancy.To find out the reality of the sample in the study and direct improvements in the services provided and assistance to the population, with the goal of empowering women so that they can decide with conscience, hence the focus of this study was highlighted on artificial methods, correlating them to the knowledge possessed or shown by women regarding their use, side effects, and seeking health services.This investigation was done in an effort to empower women so that they can make decisions with conscience.
Based on contraceptive effectiveness, it can be said that it was distributed among injectable (with a high percentage) and oral contraceptives, IUDs and subcutaneous implants.As such, research conducted by the Ministry of Health in conjunction with the National Directorate of Statistics, Ministry of Finance showed that the majority of married women (78.1%) has knowledge of various types of contraception and prefer injections (73.3%), oral pills (57.6%), and no subcutaneous implants (40.0%) (Demography andHealth Research, Timor -Leste, 2009/2010).In contrast to a study in 2003, more than 60% of women were not familiar with a particular type of contraception (Ministry of Health, Timor-Leste 2003).
According to Harahap (2012) it was discovered that there was an influence of belief and culture of family planning acceptors on the use of contraception.Religion allows family planning on the grounds that family planning was considered important to maintain the health of mothers and children.As said by Wahyuni & Oktriyanto (2011) regarding religious views, namely religious opinions that forbid the use of contraception, birth control was only limited to temporary pregnancy prevention because it does not change Allah's creation.However, if there were certain medical reasons, it could be justified because it was included in the emergency category.
In current study, the reproductive factors studied were the number of children before and after the use of contraceptives.The results obtained from the number of children before attending family planning consultations for 1-3 children, amounted to 65.2%, the number of children after following family planning was 53.1%.As for the gap before and after contraceptive use, which before was 84.9, was less than 2 years.In a study in 2009, revealed that there was a relationship between contraceptive use and the number of children.Contraceptive use was low among women without children (less than 1%), increased by 16% with 1 -2 children, and 26% among women with 3 -4 children (Demography and Health Research 2009/10).
After attending the family planning consultation, it was confirmed that 74.2% of the participants made a larger gap between pregnancies.In this study, it was revealed that, most of the participants indicated the distance between pregnancies before attending/following Family Planning, which 47% of them were less than 1 year compared to the distance after attending the family planning consultation, it can be shown that 39.4% of the participants did the distance between pregnancies 3 -4 years, 18.2% gap between 4-5 years.In other words, there was a progressive change in spacing between pregnancies before and after attending family planning.Although, 6.1% of women decided not to have any more children after attending family planning.
A person with multiple parities should accept family planning in order to plan or space out their pregnancies, but in modern society many family planning acceptors still struggle with this decision (Bongaarts & Sinding, 2009).The number of children affects couples of childbearing age in determining the contraceptive method to be used.In couples with a small number of children there was a tendency to use contraceptive methods with low effectiveness, while in couples with a large number of living children there was a tendency to use contraceptives with higher effectiveness.The results of this study indicated that the number of respondent's children in this research location has a relationship in the selection of the use of contraceptive methods.Although, this result was different with previous research which shows that there was no relationship between the number of children and the choice of LARC (Dewi & Daryanti, 2017).
Regarding sources of information on family planning, it should be noted that 57.6% of participants reported that they did not have any information, followed by the media 18.2% and health workers only 13.7%.This data gave the impression that a minority of participants received information about family planning directly from health workers.Likewise, multimedia technology was one of the most profitable means of spreading and promoting family planning.This was necessary to encourage health workers, especially midwives, to be actively involved in family planning promotion.Regarding the knowledge of the participants, most (60.6%) reported that they did not receive information about family planning, although 51.5% of the women stated that the reason for taking family planning was to prevent pregnancy.
Theoretically, there were various factors that affects women to consult about family planning, but this study showed that 87.9% of women answered "without mentioning influencing factors".As a factor that influences women's decision to use the type of contraceptive method, it showed that 94.0% without mentioning certain factors regarding their decision.Nevertheless, 92.4% of the families agreed with the decision.A study conducted by the Ministry of Health in 2009 revealed that 97% of husbands knew that their wives used certain types of contraception, indicating that Timorese husbands were generally encouraged for their wives to use family planning (Demography and Health Research 2009/10).
On the other hand, there were "significant others" factors which were came from the people around who have close relationships (husband, in-laws and family) and could affects the mother's behavior as a family planning workers to advise potential partners.Thus, partners must make decisions, according to their knowledge, desires and consciously and voluntarily.Additionally, multimedia technology can be one of the most effective ways to promote family planning in the community, especially for partners or sexual partners.

Figure 4 .
Figure 4. Participant distribution for modern/artificial contraceptive methods

Figure 5 .
Figure 5. Participant distribution based on length of use of family planning (Pills, injections, Implants, and DIU)