Content of table

Chapter one :introduction of computer

1.1 background
1.2 proplem of statement
1.3 objective of study
1.3.1 broad objectives
1.3.2 specific objecives
1.4 research of objectives
1.4.1 main research of objectives
1.4.2 The specific Research Question

1,5 signiicance of study

1.6 Conceptual and Operational Definitions
2.0 CHPTER TWO LITERATURE REVIEW

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CHAPTER 1
INTRODUCTION
1.1 Background
: Family Planning (FP) in which the major component is use of contraceptive methods is a key constituent of health
services and it benefits the health and wellbeing of women, men, children, families, and their communities. The
widespread adoption of family planning represents one of the most dramatic changes of the 20th century. The
growing use of contraception around the world has given couples the ability to choose the number and spacing of
their children and has tremendous lifesaving benefits. Yet despite the impressive gains, contraceptive use is still low
and the need for contraception high in some of the world’s poorest and most populous places (Esabella Jobu
Michael, BScN, November, 2012). Family planning has the power to save lives, yet today, more than 200 million
women in the developing world don't want to be pregnant but aren't using modern contraception especially Long
Acting Family Planning(LAFP)methods such as Implants, despite of meet their needs, can dramatically improve the
health and well-being of women, families, and communities. Long acting contraceptive is a human right and is
essential to women’s empowerment as well as it is central to efforts to reduce poverty, promote economic growth,
raise female productivity, lower fertility and improve child survival and maternal health which prevents 20-35 % of
all maternal deaths by enabling smaller family size and balance natural resource use with the needs of the
population. (Addis Adera Gebru 1 , Atsede Fantahun Areas 2, 2015). Reproduction is seen as totally women’s
responsibility in much of the world, although it is a dual commitment Men are mostly forgotten by health clients,
particularly in case of family planning services. The role of females in family planning has been receiving greater
attention recently as population planners have begun to recognize the importance of men’s influence over
reproductive 3 decisions around the world. Men have a direct and major role in contraceptive decision-making, but
also an indirect role as a dominant factor in women’s life concerning their own economic, social and family needs.
(Aisha Ayub 1 , Zeeshan Kibria 2 and Farzeen Khan, 2015). Uncontrolled population explosion is a burden on
resources of many developing countries. Of the world population, 75% live in developing countries characterized by
high fertility rate, high maternal & infant mortality rate and low life expectancy. The world population will likely to
increase by 2.5 billion over the next 43 years, passing from the current 6.7 billion to 9.2 billion in 2050.Birth
spacing not only reduce fertility but also improve health of the mother. The leading causes of death among
reproductive age women are due to complications arising during pregnancy and child birth. According to WHO,
family planning is defined as` a way of thinking and living that is adopted voluntarily, upon the basis of knowledge,
attitude and responsible decisions by individuals and couples, in order to promote the health and welfare of family
group and thus contribute effectively to the social development of a country. (Dr. Bhanu Pratap Singh Gaur,, 3May
2014) Most developing countries have been experiencing a rapid population growth due to high fertility rates. High
birth rates, a decline in death rates, and low prevalence and use of contraception are some of the accountable factors
for the rapid population growth in these countries, Contraception is a way to limit and space births in order to
achieve a desirable family size. Contraception also helps to improve the reproductive health of women thereby
decreasing maternal and child morbidity. Distal demographic and socio-economic factors influence current use of
contraceptive through proximal factors such as spousal communication, women’s sexual empowerment, access to
the service and attitudes and knowledge about family planning. (DAWIT ADANE, 2013) Worldwide population
growth has declined from its historic peak of 2.1% per year in the late 1960’s to 1.7% today. However, Sub-Saharan
Africa still faces the highest fertility and population growth rate in the world. Ethiopia is one of those countries
having high natural rate of population increase, with an estimate of 2.9% Recently family planning programs and
providers are seeing that involving men in addition to women in family planning results in an improved program
effectiveness. The 1994 International Conference on Population and Development also 4 encouraged family
planning programs and providers to consider both men and women jointly. (Yohannes Tolassa, MD, April 2004,
Addis Ababa).

1.2 Statement of the problem:

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About 75 million pregnancies worldwide are unplanned/unwanted. Unwanted pregnancies happen for many reasons.
One of them could be rape. Some people who engage in coitus simply do not know about contraception, or they are
unable to get contraceptives, or they are young, cannot discuss on using contraceptives with their partners, or the
contraceptives they use do not work as many of them fear technologies and thus, use traditional methods instead of
modern contraceptives. Most of these unintended pregnancies are not carried to full term, but aborted often in
unhygienic condition leading to serious consequences. It is estimated that worldwide about 46 million pregnancies
(22% of total pregnancies and 61% of unintended pregnancies) are aborted. (Sweta Tiwari, 2012). Rapid population
increase in the world especially 3rd world countries has become a major concern which requires mitigation. High
population leads to scramble for resources which are scarce. It is also difficult to plan how to divide national
resources and has become a cause for decline in economy. High population has its advantages like increase of
human labor but when it is more than the required it poses dangers of increase in crimes as a source of livelihood as
well as increases in the number of street children hence the need to curb population growth for better economic
management. Unwanted pregnancies are a major public health problem for both developing and developed nations.
Unplanned/mistimed pregnancies generally result from ineffective use of contraceptives and result in induced
abortions. Unintended pregnancies remain a major concern in developing countries with 120 million women
wanting to postpone child bearing or limit the size of their families, All the same contraceptive use in developing
countries has reduced the number of maternal deaths by 44%(about 270,000 deaths averted in 2008) but could
prevent 73% if the full demand for birth control were met. (Robert M. Kei, Taratisio Ndwiga, Stephen Okong’o,
2015) Fertility and future projected population growth are much higher in sub-Saharan Africa than in any other
region of the world, and the decline in birth rates, which was already modest, has slow even further over the past
decade. Concern that uncontrolled population growth will hinder the attainment of development and health goals in
Africa led to the present study, which rests on the assumption that fertility will decline only if the population at large
adopts effective modern methods of contraception, as witnessed in other parts of the world. (John G Cleland, a
Robert P Ndugwa, 2011) The effects of early unplanned pregnancies on adolescents could be devastating with
negative consequences such as affecting the educational progress or level of education that will be attained with
regards to females especially as well as future career options. It can also lead to socio economic deprivation of the
economy Adolescent sexual behavior is generally influenced by one or more factors which include their individual
desire, social and culture influence, their social interactions and changes in their culture. (BY LYNN KOMEY,
JULY, 2016) Women of reproductive age (15-49 years) maybe married or not married. Most of them know little or
incorrect information about modern family planning methods. Even when they know some names of contraceptives,
they don’t know where to get them or how to use it. These women have negative attitude about family planning,
while some have heard false and misleading information. The poor correspondence between knowledge, attitude and
acceptance of modern family planning methods has drawn attention to women’s perception about the positive and
negative aspect of Modern contraception noted that the reluctance to use modern methods stemmed from fear that
uses might cause infertility, producing damaging side effects and forgetting to take the contraceptive pills was a
serious risk. (Obalase Stephen Babatunde 1 * and Joseph Uchenna Evelyn, september 15 2017) In Somaliland,
demographic matters have gained prime prominence because of an extraordinary large growth in its population. This
enormous increase in population has emerged as a matter of great public concern because it is undermining our
efforts to raise living standards of our people. but the country is not showing sufficient sign of development, because
progress made by Somaliland is being nullified by its rapid growth of population
Due to the above situations it is necessary to carry out proper researchers in the field of family planning, because we
can only control the situation by making proper checks on population growth .
1.3. Objectives of the study
1.3.1. Broad objective To measure level knowledge, attitude, practice of family planning among the women of
reproductive age (15-49) at hospitals and clinic centers in northern Somalia (Somaliland).

1.3.2. Specific objectives

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 The specific objectives of the study were: 1. To define the knowledge, attitude and practice (KAP) regarding family
planning services among reproductive age. 2. To find out the socioeconomic and cultural factors related with the
knowledge, attitude, and practice of family planning among the women in Somaliland. 3. To determine the
demographic of respondents in term of gender, education, marital status. 4. To explore into socio-economic
conditions of facilities in Somaliland women

. 1.4. Research Questions

1.4.1. Main Research Question
The main research question of the study was what are level knowledge, attitude, practice of family planning among
the women of reproductive age (15-49) of (Somaliland)?

1.4.2. The specific Research Question

1. What are the socioeconomic and cultural factors related with the knowledge, attitude, an practice of family
planning among the women in Somaliland? 2. What are socio-economic conditions of facilities in Somaliland
women. 7 3. What is the knowledge, attitude and practice (KAP) regarding family planning services among
reproductive age?

1.5 Significance of study

This study can also be beneficial for other scientist to benefit valuable information concerning issue of awareness. It
can also be valuable to the association working in family planning division to distinguish the factors influencing and
comportment indispensable programs. This study can also provide information to those working in the area of
Human immunodeficiency virus (HIV) and Acquired immunodeficiency syndrome (AIDS) to guesstimate the
utilization and hindering influence for use of family planning methods. The main reasons behind the family planning
g division to distinguish the factors influencing and comportment indispensable programs. This study can also
provide information to those working in the area of Human immunodeficiency virus (HIV) and Acquired
immunodeficiency syndrome (AIDS) to guesstimate the utilization and hindering influence for use of family
planning methods. The main reasons behind the family planning requirements are necessary to be identified in order
to verbalize good plans and policies, in Somaliland of reproductive health responsibility.

1.6 Conceptual and Operational Definitions

1. Family planning: means working out a plan by a couple on when and how many children to have and how to
prevent unwanted pregnancies.
2. Contraceptives: Agents that are used to prevent the occurrence of pregnancy other than abstinence.
3. Current Contraceptive Use: Contraceptive method the study respondent was using at the time of interview.
Excludes all other method used prior to the interview 4. Literacy: the ability to read and write
5. Knowledge of family planning: the awareness of keeping family within limits through means such as
contraceptives and other medical aids
. 6. Empowerment of women: the attitude of taking initiative and leadership in women.
7. Availability of electronic media: access of audio- visual means of communication like TV and radio.
8. Co-operation of husband: A willing attitude of husband in adoption of contraceptive methods for keeping the
family size in limits.
9. Attitude towards family planning: the way of feeling about family planning it would be positive or negative. 8
10. Socio-economic status: the condition which defines the social and economic condition of a person in society.

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 11. Practice of family planning: A conscious effort of couples to regulate the number and spacing of birth through
artificial and natural methods of contraception.
12. Access of family planning centers; Availability of government sponsored mother and child health care centers
who provide family planning services.
13. Traditional Contraceptive Methods: Contraceptives which are prescribed or supplied by traditional healers or
methods used traditionally in specific cultures without any prescription.

2.0 CHPTER TWO

LITERATURE REVIEW
Introduction Family planning program planners tend to assume that men are opposed to family planning and will, if
involve in reproductive decision making, prevent women from regulating their fertility. Available data, however,
suggests that the most successful family planning programs target women as well as men and promote
communication about contraception between spouses. ( Karra et al 1997).

2.2 Global use of contraceptives

The World Health Organizations (2009), view reproductive rights as “Reproductive rights rest on the recognition of
the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their
children and to have the information and means to do so, and the right to attain the highest standard of sexual and
reproductive health also include the right of reproduction free of discrimination, coercion and violence” can serve as
guidelines in reviewing adolescent contraceptive use. As at 2011, the prevalence rate off contraceptives was
estimated at 63% worldwide. The use of contraceptives is increasingly becoming one of the essential basic element
to adolescent reproductive health’ as it gives them a sense of freedom to exercise their sexuality and a sense of
power in view that they will be able to manage their lives in dignity

. Attainment of easy access to the reproductive health need globally is still quite far from being achieved; it is
estimated that about 143 million women in sexual relationships globally, face an unmet need for contraceptives; this
number has a probability of rising up to 215 million when traditional methods of contraceptives are included.
(LYNN KOMEY, JULY, 2016).

2.3 Family planning use and options in Sub-Saharan

Africa Sub-Saharan Africa has the highest fertility rates of any world region, 5.4 births per woman on average-
double that of Asia (excluding China) and more than three times that of Europe. One of the factors underlying high

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maternal mortality rate is the low use of modern contraception. Only 18% of married women in Sub-Saharan Africa
use modern methods of family planning. An estimated 35 million women in Sub-Saharan Africa have unmet need
for family planning. They want to delay or stop childbearing but are not using any method. (ANTONY M.
WAIRAGU
An estimation of 358 000 maternal deaths occurred worldwide in 2008, a 34% decline from the levels of 1990,
despite this decline, developing countries continued to account for 99% (355 000) of the deaths. Sub Saharan
Africa (SSA) and South Asia accounted for 87% (313,000) of global maternal deaths and more than 350 million
couples worldwide have limited or no access to 11 effective and affordable especially to LAFP methods. Over 200
million women worldwide who want to use contraceptives don’t have access to them and the world’s poorest
women and men are not empowered to decide the number of children and timing of their births. Experience in
countries of Ghana, Kenya, Malawi, Tanzania, and Zambia confirms this, for example, Ghana removed policy
barriers to allow trained nurses to insert implants and they trained 600 nurses, and as a result more than 88,000
Ghanaian women chose Norplant® up from 1998 to 2006, for example the CPR for implants rose over 10-fold, from
0.1% to 1.2 % in Ghana. Ethiopia, the most populated country in Africa making the second nation in Africa, has
increased its population nearly seven times from 11.8 million at the beginning of the 20th century to about 80
million todays. The total fertility rate of Ethiopia is 4.8 children per women and population growth rate are
estimated at 2.7% per year, in addition, contraception use among married women ages 15 to 49 was at 15%, with
14 percent use of modern methods (up from five percent in 1990) and most of the women were married as young
as 15 years of age or younger, had an average of 7 or children, and believed that pregnancy needed to occur every
year in order to prove their fertility to their husbands and the community. (Addis Adera Gebru 1 , Atsede Fantahun
Areas 2 ., 2015.
2.4 Knowledge and Attitudes of Women to Family Planning Machipisa (1997) noted that while approximately 73%
of African men approved of family planning, only 22% couples use either a modern or traditional method. There
are clearly many checks at the individual, community, institutional, and policy levels to increase both the level of
active male involvement in Family Planning and acceptance use of appropriate methods. A study done in Kenya by
Fapohunda and Rutenberg (1998) found that family planning awareness was high, but condoms and vasectomy
were found to be stigmatized, and family planning was considered women’s responsibility. Men gave Family
Planning only limited support because they believed that contraceptive usage had an adverse effect on women’s
sexuality. Rondi and Ash fold (1997) found that in Egypt 87% of women approved of the use of family planning with
the level of approval not varying much among men of different age groups or education levels, or between rural
and urban residence. 18% of married women surveyed reported having used a male method of contraception in
the past, but vasectomy was extremely rare even though 60% of the surveyed men indicated desiring to have no
more children. Mungai (1996) noted that while African men are largely apathetic to family planning, they are not
necessarily uninterested. Many African men want to participate more actively in deciding how many children they
should have and when to have them, but they lack sufficient information to do so. In some cases, many men do not
know about contraceptives. Even those who are aware have little access to such services because family planning.
programmes are designed to serve women. In most African countries, family planning services are widely offered
in perinatal units of public hospitals where many African men feel uncomfortable visiting. Studies in parts of Africa
have shown that there is a strong link between knowledge and use of contraceptives and the level of education as
well as economic status; the levels of knowledge and use of contraceptives are lower among the relatively less
educated. Surveys have shown that while men in many cases are informed generally about family planning, they
do not have detailed knowledge of the operation and use of converse methods. A reason for the men’s superficial
knowledge of contraception lies in the way they obtain information: mainly from mass media and informally from
relatives and friends. Radio, and Television are frequently the men’s source of information (Adamchak, Mbizo
1991). The mass media’s messages on family planning are mostly of general nature. This may account for their
knowledge which is general and lacks detailed information on methods, which is one of the pre-conditions for
continuous use of modern family planning methods. Health workers and family planning helpers give a

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comprehensive counselling and explanation of application, effects and side effects of the various methods.
However health facilities and family planning institutions have so far addressed female target groups, men are
often excluded from detailed knowledge of the various methods of preventing pregnancy (Riedberger, 1994). In a
study carried out in Eastern Uganda by Ebanyat(1990) on the pattern of birth intervals it was noted that an
outstanding reason for nonuse of contraception among women who knew about contraception was because
husbands did not approve of it. Opio (1986) considering the need to involve men in family planning concluded that
family planning is a joint responsibility of both women and men and that they should participate themselves.
25.4% of men in peri-urban areas around Kampala had the knowledge about family planning andhad at least ever
used a method of contraception.
Kabarangira(1996) noted that men’s opposition to family planning was not as wide spread as it was popularly
believed. Women have a major role in the decision to use family planning methods and in determining the number
of children a couple should have although they do not encourage women to participate in decision making about
family size and share responsibility in women’s health. The problem appeared to be lack of communication
between couples/ partners which if it was available, men’s consent for family planning use would be favorable.
Male knowledge of various family planning methods was as high as was approval and ever use of family planning
and their important factor to prevent frequent and unwanted pregnancies or limit family size for financial reasons.
Current usage of family planning was low with one man using a permanent method (vasectomy) and the rest used
condoms mainly for prevention of STDS especially AIDS other than for fertility. 2.5 Factors Influencing Women
Participation in Family Planning. There are various factors that influence male participation in family planning.
These include cultural norms and values, religious beliefs, socio-economic factors, psychological factors. These
factors can act as barriers to male involvement.

2.5.1 Religious beliefs

Religious beliefs have a direct influence on family planning acceptance. For example, the Islamic region does not
subscribe to tubal ligation in women. For Muslims the Koran provides the infallible rules of conduct fundamental to
their way of life. Previously conservative religion leaders represented a force opposing changes in the traditional
status of women and large family norms in Egypt. However, the Grand Mufti openly expressed his support for
responsible parenthood and family planning in an interview where he said that family planning is compatible with
the trading of the Koran and there is no problem in promoting family planning. Among Islamic countries, Egypt is
one of the few countries where family planning has been well accepted. The total fertility rate would not have
dropped to 3.9 in Egypt without the strong support for family planning by the Grand Mufti. Religious leaders,
medical doctors, and mass media specialists recognized that the Koran’s teachings harmonize with family planning,
therefore the promotion of family planning has been successful. More people in other Islamic countries will come
to practice family planning as they comprehend the Koran’s teachings accurately. Men should definitely participate
in family planning since family planning fits in with the Koran (Hata1994). Membership of a certain religion is less
determining for behaviour in family planning than the practiced religiousness. This may be one of the reasons why
many Muslims do not practice family planning although the teachings of Islam do not forbid contraception while
Catholics employ artificial contraception massively despite the ban by the church (Riedlberger1994). The
Adventists advocate for the idea of the small family, according to which a family should have as many children as
they can adequately feed, educate and give religious instruction. Men who behave accordingly attain social
prestige.

2.6 Cultural Factors In traditional societies of Africa

children mean the reproduction of the lineage. The ancestors determine the maintenance of the tradition by as
many descendants as possible. Families with few children refuse themselves the right of the fore bearers in the
continuation of the line of descent (Caldwel 1987) Barriers to male participation include the perception of family
planning and reproductive health as concerns of women maternal-child health services that do not target men, the

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limited availability of women contraceptive methods, and societal attitudes unfavourable to explicit support for
equality of men and women (Ormel 1997).

2.6 Cultural Factors

In traditional societies of Africa children mean the reproduction of the lineage. The ancestors determine the
maintenance of the tradition by as many descendants as possible. Families with few children refuse themselves the
right of the fore bearers in the continuation of the line of descent (Caldwel 1987) Barriers to male participation
include the perception of family planning and reproductive health as concerns of women maternal-child health
services that do not target men, the limited availability of women contraceptive methods, and societal attitudes
unfavourable to explicit support for equality of men and women (Ormel 1997).

2.7 Socio-economic Factors

Factors such as education level, social class, urbanization and employment play an indispensable role in
contraceptive behavior of men. The compulsion to move to the towns and the dependence upon monetary income
associated with that, often changes that attitude of men to family planning because as a rule in an urban
environment they are the main provider for the family: An urban environment promotes the use of contraceptives
although improved access to support facilities on one hand, and better education possibilities on the other are
factors to consider (Kirumira 1991).

2.8 Psychological Factors/rumours

The equation of potent with procreation of as many children as possible can also be seen as one reason for lack of
sexual responsibility by women. In African countries, it is seen as a sign of poverty, sickness or disability for women
who haveintercourse with only one sexual relationship (Hawkins 1992). In Bangladesh a pilot distribution project
found that most couples who received free condoms did not use them. The reasonwas that they thought that
condom use could cause impotence. Population reports 1982). Family planning service providers are trained to
counter such norms by reporting the facts.

2.9 Family Planning in Somaliland

Somaliland has one of the highest maternal mortality ratios in the world at 1,044 deaths per 100,000 live births
(MICS, 2006). According to MICS, 2006, only thirty-two percent of women received antenatal care (ANC) from
skilled health personnel; whereas ANC coverage is only 26%, TT coverage stands at 26.3% and pregnant women
receiving Vitamin at 4-25%. Although this is low coverage, given the Somali context, it is an opportunity to reach
out with preventative services to women. "Somaliland has one of the worst maternal mortality ratios in the world,
estimated to be between 10,443 and 14,004 per 100,000 live births," said Ettie Higgins, head of the UN Children's
Fund (UNICEF) field office in Hargeisa, capital of Somaliland. "Maternal mortality is the leading cause of death
among women of reproductive age; it is caused mainly by haemorrhage, puerperal sepsis, eclampsia and
obstructed labour," Higgins said, adding that women in Somaliland had a one in 15 risk of dying of maternal-
related causes. some societies gives scope for longer birth intervals, thus affecting the fertility among such women
(McNeilly, 1979)

Religious institutional impact on government family planning policy, just like its impact on individual behavior, is
complex and varied. In the majority of countries, faith leaders and religious institutions more broadly have not had
a major impact in supporting or opposing the launch of government programs. In many cases, this occurred
because government programs were instituted in a period (the 1960s or 1970s) when novel birth control methods
such as the pill and IUD were relatively new and religious organizations were still digesting the implications. In
some countries, religious leaders spoke out against family planning programs, but not in an organized, concerted
fashion that influenced policy. However, there are country cases where religious institutions have either actively

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opposed or supported reproductive health policy, with clear discernible impact. These complex faith roles have
been varied and uneven by place, denomination, and time. Faith leaders have supported public family planning
measures in some cases, especially where governments have sought them out as partners (though they have rarely
led efforts to expand access to family planning information and services). In contrast, faith actors have in some
instances been early instigators against government family planning programs, blocking or delaying them from
getting off the ground. (WFDD, 2014) An indicator of progress in family planning adoption is the change in the type
of contraceptive methods used by family planning acceptors. The use of traditional methods tends to be higher in
settings where acceptance of family planning is low and use of family planning programs is weak. Traditional
method shave a high failure rate compared withhold- earn methods and are therefore not considered an effective
mode of contraception. Trends in contraceptive choice show that in many countries of the region, use of
traditional methods has declined and use of modern methods increased (figure 25.4). The use of modern methods
has increased most markedly in countries that had the greatest increases in CPR (Madagascar, Mal awi, Namibia,
Zambia, and Zimbabwe). Use of traditional methods in these countries has either remained stagnant or has
decreased. Ghana, Kenya, Tanzania, and Uganda showed owed increases in use of modern methods while
maintaining use of traditional methods. In West African countries such as Benin, Burkina Faso, Cameroon, Senegal,
and Togo, traditional method use declined and relatively modest gains in modern method use were observed.
Family planning programs that have been successful in Africa a have promoted birth spacing. Marriage patterns in
Africa differ from those in Asia, possibly accounting for a cultural preference for spacing methods. Various studies
in the region document African cultural preferences for spacing rather than limiting births (Cohen 1998). In con-
trust to Asian family planning programs, which have emphasized permanent contraceptive methods, such as
sterilization and abortion, programs in Africa rely on temporary methods, such as pills, inject tables, and implants
(Caldwell and Caldwell 1988). It has been suggested that successful program strategies in Africa must promote
methods that are temporary, can be used covertly by women, and do not have to be stored at home (Caldwell and
Caldwel l 2002). (MonaSharan)

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