الفهرس 
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Abstract
Access to safe, voluntary family planning is a human right. Family planning is central to gender equality and women’s empowerment, and it is important factor in reducing poverty. According to EDHS 2014, 59% of currently married Egyptian women are using contraceptive method. The survey also clarified that urban women were more likely to use contraceptive methods than rural women (61% and 57%, respectively). Studying the dynamics of contraceptive use (discontinuation, switching and unmet needs) can reveal problems in the use of contraceptive technologies and the gaps in the provision of services and, therefore, it could provide guidance for improving these services.
Contraceptive discontinuation is a poorly understood phenomenon that has a significant implication, not just for family planning and maternal and child health, but also for the population growth and countries’ overall economic development. According to EDHS 2014, around 3 in 10 family planning users stop using within 12 months of starting use. The survey also grouped the reasons behind discontinuation into six categories; Method failure, Desire for pregnancy, Fertility-related reasons, Side effects/ health concerns, Wanted more effective method, and Method-related reasons.
Not all women who discontinue contraception become nonusers; some switch to other contraceptive methods. Couples who stop using a method because of side-effects or other method-related reasons need to switch promptly to another method, to avoid the risk of an unintended pregnancy. According to EDHS 2014, only 8 percent of the women switched to another method in the first 12 months after discontinuation.
In Egypt, 13% of the currently married women don’t use any contraceptive methods despite they report not wanting any more children or wanting to delay the next child and leaving themselves exposed to the risk of unintended pregnancy. Unmet need for family planning can contribute to about 290,000 maternal deaths, 2.9 million newborn deaths, 74 million unintended pregnancies every year, and abortion-related death. Intervention focused on this group could have a significant public health impact on the rate of unintended pregnancy and abortion. According to EDHS 2014, many Egyptian women are having more births than they consider ideal and 16% of pregnancies in the five years prior to the survey were reported unwanted.
Accordingly, this study was conducted to assess the contraceptives use dynamics among women of reproductive - age who are attending primary health care settings in rural areas in Alexandria governorate and to identify the role of health care providers regarding contraceptive use dynamics among clients.
A cross sectional descriptive design was used. The study was conducted in ten rural primary health care settings in Alexandria governorate present in five zones namely; El-Montazah, East, Middle, El-Amria, and Borg El-Arab. The study was conducted on 663 woman who were attending the vaccination, prenatal and family planning clinics at the selected rural primary health care settings, 40 health care providers who are working at family planning clinics and 20 Centers Administrative managers.
Three tools were used to collect the required data. The study tools were tested for validity and reliability. Approvals were obtained for conducting the study at the specified settings. A pilot study was carried out accordingly modifications in the tools were done. Data was collected by the researcher then coded, fed to PC and analyzed using the statistical package for social science (SPSS version 25). Appropriate descriptive and analytical statistics were carried out.
The main findings obtained from the study were as follows:
Part I: Contraceptive methods use dynamics among the studied women:
• The vast majority (95.2%) of the studied women had previously used contraceptives methods, only few (4.8%) of them did not use any method.
• Intrauterine device had been previously used by the majority (87%) of the studied women, while progestin-only pills were had previously been used by about two fifths (41.5%) of them, combined oral contraceptives and progestin-only injectable had previously been used by about one fifth (21.7%&20.3% respectively) of them. On the contrary, a minority of them had previously used implants (6.7%), lactational amenorrhea (5.7%), monthly injectable (4.8%), male condom (3.6%), withdrawal (1.1%) and spermicidal contraceptives (0.9%).
• Intrauterine device was the first selected method of choice among two thirds (63.07%) of the women, while progestin-only pills were the first selected method of choice by less than one quarter (23.46%) of them. However, a minority of the women selected Progestin-Only Injectable (6.97%), lactational amenorrhea (3.8%), implants (1.11%), withdrawal (0.63%), male condom (0.48%), monthly injectable (0.48%) and combined oral contraceptives (0.32%).
• As regards to the time of starting use of contraceptive methods, the majority (85.1%) of the women used contraceptive methods after they had their first child; while the minority (0.6%) of them used method immediately after marriage
• Almost all of the women had decided to use contraceptives method in order to make them and their children healthier, and improve the financial condition of their family (99.2% and 98.3% respectively). In addition, the majority (88.1%) of them used contraceptives method in order to postpone pregnancy.
• Concerning women’s source of information about family planning, the most commonly reported source by the women were physicians and nurses (76.1% and 39.6% respectively). This was followed by television (33.4%), friends (32.5%), and counselor (28.4%).
• With respect to the role of health care providers with the women in the family planning clinic as reported by the studied women, almost all of the women reported that health care providers take their medical history and conduct necessary medical examination, recording their history and the results of the examination in their file (99%, 99% and 99.8% respectively). Moreover, the majority (92.7%) of them also reported that health care providers reminded them with time of follow up visit, while 79.6% reported that they receive treatment, while 73.9% reported that they get counseling and information from them, while more than half (55.8 %) said that they conduct follow-up visits . Only more than one third (36.9%) of them reported that they received group teaching about the methods.
Contraceptive Discontinuation
• As regards discontinuation among COCPs users, more than three quarters (76.6%) of the women who used COCPs for one time during their reproductive life and more than two thirds (67.7%) of the women who used it for two times discontinued it. On the other hand, only one tenth (12.5%) of the women who used it for three times discontinued the method.
• With respect to reasons of discontinuation from COCPs, desire for pregnancy reported by less than two thirds (61%) of the one-time users and by less than three quarters (71.4%) of the two-times users, occurrence of unwanted pregnancy while using the method was reported by one fifth to more than one tenth of them (21% &14.3% respectively) . While method side effects were reported by less than one fifth and more than one tenth of them (18.1%, 14.3% respectively). While all of the studied women who used it for three times during their reproductive life reported that the desire for pregnancy was their main reason for discontinuation from the method. There is a significant association found between method discontinuation and the frequency of method use, where Monte Carlo P value < 0.001.
• Regarding discontinuation among users of POCPs, more than one third (34.5%) of the one-time users, more than three quarters (81.7%) of the two-times users and one third (35.7%) of the three-times users discontinued from the method. There is a significant association found between method discontinuation and the frequency of method use, where Monte Carlo P value < 0.001.
• Concerning reasons of discontinuation among users of POCPs, method side effects reported by more than half (52.8%) of the one-time users and by more than one third (34.5%) of the two-times users, the doctor changed it was reported by one quarter and half of one and two-times users (25.3% & 50% respectively) and occurrence of unwanted pregnancy while using the method was reported by more than one tenth and one tenth of one and two times users (14.8% & 10.3% respectively). On the other hand, the doctor changed it and just ending exclusive breastfeeding were the most commonly reported reasons for discontinuation as reported by more than half and less than half of the three-time users (60% & 40% respectively).
• Concerning discontinuation among users of Progestin-Only injectable, less than three quarters (73.4%) of the one-time users, less than two thirds (60%) of the two-times users and more than two fifths (42%) of the three-time users discontinued from the method. There is a significant association found between method discontinuation and the frequency of method use, where Monte Carlo P value 0.020.
• Regarding reasons of discontinuation among users of Progestin-Only injectable, method side effects reported by half and more than one tenth of one and two-time users (50% & 14.3% respectively) ,desire for pregnancy was reported by less than half (43.6%) of the one-time users and the majority (85.7%) of the two-time users. On the other hand, desire for pregnancy and the occurrence of unwanted pregnancy were the main causes of discontinuation among the majority and one tenth of the women who used the method for three times and more during their reproductive life (87.5% and 12.5% respectively).
• Regarding discontinuation among monthly injectable users, more than three quarters (80%) of the one-time users discontinued the method. On the other hand, all of the two-time users were still using the method.
• With respect to the reasons for discontinuation among the monthly injectable users, for the one-time users, method side effects was the main reason for discontinuation as reported by about two thirds ( 66.7%) of them. on the other hand, the desire for pregnancy was reported by one quarter (25%) of them. It was also noticeable that occurrence of unwanted pregnancy while using the method was reported as a reason for discontinuation among one tenth of discontinued users (12.5%).
• Regarding discontinuation among implant users, more than half (57.1%) of the users discontinued from the method. The desire for pregnancy, method side effects, expelled implant and occurrence of complications that led the doctor to remove the method these were the main reasons reported for discontinuation by the discontinued users (37.5%, 37.5%, 12.5% and 12.5% respectively).
• Concerning discontinuation among IUD users, about three quarters (73.8%) of women who used IUD for one time during their reproductive life discontinued it. On the other hand more than half (59.3%) of women who used it for two times during their reproductive life discontinued it. in addition, about one third (33.3%) of women who used it for three times and more discontinued it.
• Desire for pregnancy was the most commonly cited reason for discontinuation as reported by the majority (75.3%, 77.5% respectively) of those who used it for one and two times during their reproductive life, followed by method side effects as reported by one tenth of them (12.8% & 13.1% respectively). On the other hand, desire for pregnancy and occurrence of unintended pregnancy while using method were the main reasons of discontinuation among women who used IUD for three times and more. There is a significant association found between IUD discontinuation and the frequency of method use Monte Carlo P value 0.001.
• Concerning discontinuation among male condom users, more than three quarters (73.9%) of the one-time users discontinued using the method. Desire for pregnancy, method failure (occurrence of unwanted pregnancy while using the method) and husband refusal were the main causes of discontinuation as reported by more than two fifths , more than one third and less than one fifth of them (41.2%, 35.3% and 17.6% respectively).
• With respect to discontinuation among spermicides users, all of the users of spermicides discontinued the method. Difficulty in obtaining the method, husband refusal, and feeling of discomfort during the use of the method and desire for pregnancy were the most commonly mentioned reasons for discontinuation as reported by all of them, equally half and more than one third of users (100%, 50%, 50% and 33.3% respectively).
• Regarding discontinuation among lactational amenorrhea users, all users of lactational amenorrhea discontinued it, mainly because of method unreliability with occurrence of unwanted pregnancy while using it; in addition they had their menstrual period returned 6 month after birth. These were the most common causes of discontinuation as reported by two fifths, more than one third of them (38.9% & 33.3% respectively).
• Concerning discontinuation among withdrawal users, more than half (57.1%) of the one-time users and all the two-time users discontinued the method. Desire for pregnancy was their main reason of discontinuation among all of the one-time users. On the other hand, husband objection was the main cause of discontinuation among all the two-time users.
Contraceptive Switching immediately upon method discontinuation:
• Concerning switching behavior after discontinuation from COCPs, only less than one fifth and more than one tenth of women who discontinued from COCPs after one and two times use (17.1% and 14.3% respectively) switched immediately to another alternative method. Intrauterine device (IUD) was the most common method that women switched to it after discontinuation as reported by less than half to more than two third of them (44.4% & 66.7% respectively), implants reported as an alternative method was reported by one fifth to one third of them (22.2% &33.3% respectively). Also, less than one quarters (22.2%) of the one-time users switched to progestin-only pills. On the other hand, all women who used it for three times didn’t switch to alternative method after discontinuation due to their desire for pregnancy.
• In relation to switching behavior after discontinuation from POCPs, more than three quarters of one and two times users of women who discontinued from POCPs (79% & 89.8% respectively) switched immediately to alternative method after discontinuation, firstly to COCPs ( 47% & 67.3% respectively) then secondly IUD ( 38.1% & 23.1% respectively). Switching pattern was immediate among almost all women of one and two times users (98.3% & 100% respectively). The consequence of delayed switching was the occurrence of incidence of unwanted pregnancy among about two thirds (66.7%) of women who delayed switching decision.
• With respect to switching behavior after discontinuation from progestin-only injectable, less than half (43.6%) of the one-time users switched immediately to alternative method after discontinuation. Combined oral contraceptives, IUD and to a much lesser extent Monthly injectable were the most commonly methods which women switched to them after discontinuation as reported by two fifths, less than two fifths and one tenth of women (43.9%, 36.6% and 12.2%respectively). On the other hand, more than one tenth (14.3%) of the two-time users switched immediately to alternative method after discontinuation. All of them switched to IUD after discontinuation. In addition, all women who used progestin-only injectable for three times and more during their reproductive life didn’t switch to alternative methods after discontinuation. There is a significant association found between switching behavior after discontinuation and the frequency of method use Monte Carlo P value 0.007.
• Regarding switching behavior after discontinuation from monthly injectable among the one- time users around two thirds (62.5%) of them switched immediately to an alternative methods after discontinuation. IUD, Progestin-Only Pills, Progestin-Only Injectable and Combined Oral contraceptives were the most commonly used alternative methods as reported by two fifths, one quarter, one fifth and one tenth of discontinued users who switched to alternative methods (40%, 26.7%, 20% and 13.3% respectively). It is also noticeable that the switching pattern was immediate among three quarter of switchers (73.3%) and not immediate among one quarter (26.6%). The consequence of delayed switching after discontinuation was the incidence of unwanted pregnancy which occurred among three quarters (75%) of women who delayed their switching decision.
• Regarding switching behavior after discontinuation from implant, more than the half (58.3%) of discontinued women switched immediately to an alternative method after discontinuation. IUD, Combined Oral contraceptives and Progestin-Only Injectable were the most commonly used alternative methods as reported by half, one third and one fifth of switchers (50%, 28.6% and 21.4% respectively).
• Switching behavior after IUD discontinuation, majority of IUD discontinuers did not switch to alternative methods. For few who switched one tenth after one or two times they used progestin only pills after one time or two times use (44.8% & 28% respectively) or combined oral contraceptives (20.7% & 32.0 % respectively). For all discontinuers after three times and more they shifted to progestin only injectables .
• Switching behavior after discontinuation from male condom, only less than one fifth (17.6%) of discontinued women switched immediately to an alternative method after discontinuation. Intrauterine devices and combined oral contraceptives were the most commonly alternative methods reported to be used by more than two third to one third of the switched women (66.7%& 33.3% respectively).
• With respect to switching behavior after discontinuation from spermicides, all of discontinued women switched immediately to an alternative method after discontinuation. Withdrawal, combined oral contraceptives and male condoms were the most commonly used alternative methods reported by half, one third and one fifth of the users (50%, 33.3% and 16.7% respectively ).
• With respect to switching behavior after lactational amenorrhea discontinuation, half (50%) of discontinued women switched immediately to an alternative method, male condom (27.8%), IUDs (22.2 %), and Progestin only injectable (22.2%).
• In relation to switching behavior after withdrawal discontinuation, all the one time users didn’t switch immediately to an alternative method due to their desire for pregnancy. On the other hand, all the two time users switched immediately to an alternative method. Intra uterine device was selected as the alternative method by all of the switched women.
Unmet needs for family planning
• Unmet needs for family planning was observed among the studied women who had unintended/ mistimed pregnancy while using the method, those who exceeded their desired number of children, and those who had fatalistic attitudes toward desired number of children especially at the beginning of marriage, who never use any contraceptive method although their desire to limit or space the next child.
• Regarding the causes of never use among non-uses, findings showed that the most common cause of never use was husband refusal (65.6%). The second cause was fatalistic attitude (53.1%). The third cause is conflict with religious beliefs (37.5%). In addition to, one quarter (25%) of them reported that not expecting occurrence of pregnancy was the main cause of never use among them while fear of methods side effects were reported by 18.8%.Also, desire for pregnancy was reported by 12.5%, While lack of knowledge about contraceptives methods, husband away or absent and other causes (difficulty of using method, do not like any of the methods) represented by small percent (6.3%).
Part II: Current Use of Contraceptive Methods
• Concerning the type of the current contraceptive methods used by the women, it was found that intrauterine device was the most currently used method by about half (51.9%) of the women, compared to less than one tenth (8.9%) of those who used progestin-only injectable, less than one tenth equally also use combined oral contraceptives and the lactational amenorrhea (7.4% & 7.2% respectively). However, minority of the women are currently using implants, monthly injectable, male condom and withdrawal (2.9%, 1.2%, 1.2%and 0.5% respectively). On the other hand, one tenth (12.8%) of the women reported that they are not using any contraceptive methods currently because of being pregnant and another 6% of them reported that they not using any method because they have a desire for pregnancy.
• In relation to the women’s satisfaction with the current method, more than one quarter (26.2%) of them were dissatisfied with the current method. Change in bleeding pattern, dysmenorrhea, vaginal infections, headache and fear of osteoporosis were the main reasons of dissatisfaction as reported by the majority, less than half, more than one third and more than one fifth equally (72.3%, 48.2%, 34%, 22.7% and 22.7% respectively). While diminished libido and weight gain were reported by 12.1% & 11.3% respectively.
• With respect to the women’s future plan for the current used method, the majority (91.3%) of them indicated that they will continue with the current method while less than the tenth (8.2%) of them will switch to another method.
• Regarding the causes of never use among non-users, findings of the present study showed that, the most common cause of never use was husband refusal (65.6%). The second cause was fatalistic attitude (53.1%). The third cause is conflict with religious beliefs (37.5%).
• In relation to intention to use contraceptives methods among non-users in the future, findings of the current study showed that more than half (56.3%) of them were not sure whether they will use contraceptives in the future, while more than one quarter (28.1%) of them are intending to use contraceptives as compared to 15.6% who are not intending to use contraceptives in the future.
Part III: Contraceptive dynamics as Reported by the Primary Health Care Service Providers (PHCSPs) and the administrative managers:
Contraceptive discontinuation
• More than three quarters (80%) of the managers and all of the FP physicians reported that there was discontinuation problem among the contraceptive users attending their PHC unit with no statistically significant difference between both of them. In line with same findings almost majority (90%) of the head nurses and all FP nurses also reported that there was discontinuation problem in their PHC unit with no statistically significant differences between both of them.
• from the administrators and service providers point of view, the reasons for discontinuation were mainly: husband refusal, method unreliable as incidence of pregnancy has occurred and husband away as reported by all or almost all (95%) of physician managers, F.P physicians as well as head nurses and to a slightly lesser extent FP nurse in range of 75%, 90% and 95% respectively). On the other hand, method side effects were reported by majority of FP physicians and FP nurses equally (85%) as compared to (87.5&77.8% respectively) of physician managers and head nurses with statistically significant differences. All and majority (95%) of FP nurses and FP physicians respectively mentioned desire for pregnancy as reason for discontinuation as compared to only one quarter (25%) of managers and one third (33.3%) of head nurses with statistically significant differences
• There was no statistically significant difference between physician’s manager and FP physicians regarding the most common method that the women discontinue from it. where the progestin only injectable was reported by all manager physicians and the majority of FP physicians (100% and 85% respectively) and the majority of head nurses and FP nurses (88.9% and 90% respectively), this was followed by Progestin-Only Pills as reported by three quarters (75%) of the physician managers and more than half (60%) of the FP physicians, and the majority of head nurses (77.8%) and more than half of FP nurses (55%). This was followed by Monthly Injectable which was reported by less than two thirds (62.5%) of the physician managers and more than half (55%) of the FP physicians, and more than half of head nurses and FP nurse (55.6 % & 60% respectively). The fourth method was combined oral contraceptives as reported by half of the managers and two fifths (40%) of the FP physicians, and less than half and half of FP nurses (44.4% & 50% respectively). In addition to, local vaginal contraceptives methods which was reported by only about tenth (12.5%) of the managers and one quarter of the FP physicians, and about one fifth (22.2%) and very few of FP nurses.
• Concerning the role of (PHSPs) toward the contraceptive discontinuation, all physicians and nurses reported that they make monthly report to show discontinuation rate and encourage discontinued women to switch immediately to alternative method to prevent unwanted birth. Furthermore, all nurses and the vast majority (95%) of the physicians reported that they communicate with discontinuing women and conduct counseling session with them, with no significant differences among the groups.
Contraceptive switching
• In relation to the presence of contraceptive methods switching problem at PHC Unit, almost majority of the managers and all FP physicians and all head nurses and FP nurses reported that there was switching problem (90% and 100% respectively).
• As for reasons that the providers gave for the contraceptive method switching, the first reason reported by all of the providers was method side effects or complication. The second reason was the uncomfortable feeling of the women with the selected contraceptive method (95%). Objection or refusal of the husband to the method used was third reason that FP physicians and FP nurses reported (95% to 100% respectively). In addition irregularity of using the method as method relies heavily on memory and thus their need to switch from a short term method to longer term such as ”implants or IUDs”.
• Regarding the most common method that the women switched to it, where intrauterine devices were reported by the majority of the managers, FP physicians, head nurses and the FP nurses (77.8%, 85.9%, 90.0% & 90.0% respectively). Implants was reported by about two thirds (66.7%) of the managers and the majority (85%) equally of FP physicians, head nurses and by 90% of the FP nurses. Progestin-Only Injectable were reported by less than half to one third of the managers, head nurses and the FP nurses (44.4%, 40% & 40% respectively) to slightly more than one third (35%) of the FP physicians.
• Regarding the lapse period of time between the woman stopping old method until she switched to the new one, half of the FP physicians and FP nurses (50% & 55% respectively) reported that it ranged from one month to less than 6 months and two fifth (40%) of them reported that it ranged from 6 months to less than 12 months, only 5% of both the FP physicians and nurses said that the lapse period of time was less than one month.
• In relation to the role of the PHSPs toward the contraceptive switching, all of the physicians and nurses reported that they give advice to the women when they feel uncomfortable with the used method and tell them to go to the clinic immediately, apply a good follow up system and setting the dates of follow-up visits in the FP card, correct misconceptions and misbelieves about the methods and provide health education to the women about the risk of switching to another method without doctor’s consultation, with no significant differences among the groups.
• Regarding the administrative managers responsibilities toward dropout and switching, all of the physicians and almost the majority (90%) of the head nurses reported that they organizing the awareness campaigns on family planning methods and submitting a report to the Directorate of Health indicating the need for extra methods. While almost majority (90%) of both of them reported that they reviewing the monthly reports to show dropout rate. Almost majority (90%) of the manager physicians and 80% of the head nurses reported that insuring counseling session for all clients. Furthermore, more than three quarters (80%) of the manager physicians and 90% of the head nurses reported that they monitor follow-up system for the clients. 50% of both of them mentioned that they conducting home visits for the discontinuing users.
Unmet needs for family planning:
• The majority of the managers, FP physicians (70% & 95% respectively) as well as all the head nurses and FP nurses reported that there are unmet needs among the clients, with no statistically significant difference between the groups.
• As for the reasons for unmet needs which reported by PHSPs and Administrative Managers: Objection of the husband which was reported by all managers and the vast majority of F.P physicians, head nurses and FP nurses (94.7%, 90% & 90%). Furthermore, having fatalistic attitudes was reported by all administrative managers and around three quarters (73.7%) of F.P physicians and around two thirds (65%) of F.P nurses. Encountering conflicts with religious beliefs was reported by all managers and less than two thirds (63.2%) of F.P physicians majority of head nurses (80%) and more than half of staff nurses (60%). Fearing of side effects was also reported by majority of administrative managers, FP physicians and FP nurses (85.7%, 90%, 73.7%, and 90% respectively). Lastly lack of necessary knowledge about contraceptives method which was reported by more than half of managers and FP physicians (57.1% & 52.6% respectively) and less than three quarters (70%) of head nurses and to lesser extent by less than half (45%) of FP nurses. In addition lack of ideal preferred method among available methods at the PHC Unit was reported with significant differences by only two fifths (42.1%) of F.P physicians, none of managers, 10% of head nurses and three quarters of FP nurses (75%).
• Regarding the role of (PHSPs) toward unmet needs for family planning, all nurses and the vast majority (95%) of physicians and nurses reported that they give health education session to women attending vaccination and antenatal sessions about the importance of family planning and to post-partum and breast feeding women about how to prevent or postpone pregnancy, Write monthly reports showing unavailability of some of the methods and its effect on attendance rate and also participate in mobile family planning clinics. Moreover, the majority of physicians and nurses added that they communicate with religious and community leaders in order to correct false religious beliefs about family planning methods, with no significant differences among groups.
• Concerning the administrative managers responsibilities toward unmet needs, all of the manager physicians and head nurses reported that they give health education sessions in their Centre/ unit, they also give health education sessions to the women attending the vaccination and antenatal care clinics about the importance of family planning and for postpartum and breastfeed women about how to prevent or postpone pregnancy. In addition, all of them reported that they submit a report to the Directorate of Health indicating the need for extra FP methods, share in mobile family planning clinics and give health care providers training about unmet needs and how to deal with it. Furthermore, half (50%) equally reported that they communicate with the religious and community leaders to correct false religious beliefs about family planning methods and improve the use & continuation rate.
In light of the findings of the current study, the following recommendations could be made:
Recommendations directed to the Ministry of Health and Population (MOH):
1. Continue to improve FP services through implementation of quality of care. In particular the need for improving counseling services is very important. Nurses should play important role in counseling
2. Intensifying the role of health care providers especially nurses in counseling through providing clients with complete and accurate information about method especially (how to use, advantages and disadvantages and possible side effects and what they should do if they encounter any of the effects, follow up-visit continuity). Immediate counseling and follow up to be done by well-trained health care providers can significantly increase the contraceptive switching after discontinuation especially among the women who discontinue the method for reasons other than the desire to get pregnancy.
3. Revise the training provided to H.C.P, especially counseling component for nurses and doctors as well , it should be practical and using non- traditional approaches. In addition, it is important that providers get more intensive training on helping and supporting clients cope with method disadvantages and overcome methods side effects.
4. During counseling sessions nurses should take into consideration the client’s socio-demographic and personal characteristics to help them continue and not DROP out .
5. Stress the importance of using the new tools developed by the WHO to enhance the performance of health care providers during counseling session such as medical eligibility criteria supportive tools, clinical guide counseling tool and also interactive tools of contraceptives.
6. Provide a tool for measuring women satisfaction with the method to be used during follow up visits. In addition to, studying the causes of method dissatisfaction among the women and address it during counseling.
7. The family planning program should focus on the husband’s/male attitude toward family planning use and the ideal family size because male involvement helps not only in accepting a contraceptive but also in enhancing its effectiveness and continuation.
8. Incorporate Emergency contraceptives methods (ECM) within pool of methods available at the PHC settings. Ensure that health care providers are well trained in dealing with it.
Recommendations directed to the Ministry of Communications and Information Technology (CIT):
1. Raise community’s awareness about family planning through mass media and awareness campaigns including its importance for the family and community, different types of contraceptive methods, sources available to get the methods, serious consequences of discontinuation and delayed switching decision that can lead to unintended/ mistimed pregnancy and unsafe abortion, correcting misinformation and deeply rooted fatalistic attitude toward family planning use.
2. Health education campaigns should be directed to improve beliefs and attitude of men toward contraceptives use, increase male awareness about the ideal family size (two-child family), the serious consequences of having more children than ideal on the health of the mother and their children and the whole family.
Recommendations directed to the Ministry of Religious Endowments and Islamic Affairs:
1. Intensify religious leaders’ efforts in family planning through correcting improper information about religious aspect of contraceptives use, preparing qualified religious leaders who can convey the family planning massages correctly and without bias especially in rural areas.
Recommendations directed toward women and men:
1. Empower women by increasing their autonomy which will help to raise their awareness concerning their reproductive rights and their ability to make decision about their family size.
2. Conduct community sensitization programs aiming at improving male involvement in F.P to be provided by governmental and non-governmental organizations (NGOs).
Recommendations directed to the community at large:
1. Expanding private sector involvement in addressing family planning needs especially among youth.
2. Develop social behavior change materials (informational posters) targeting the importance of F.P and safe postpone of the first birth.
Future researches to be conducted:
• Studies needed to help in identifying the challenges facing male involvement in the family planning, these studies should focus on assessing men’s knowledge, attitudes and practices toward modern contraceptive methods, assessing the effect of spousal communication about FP on contraceptive discontinuation and unmet need, investigating men’s opinion about their role in F.P decision making and impact of male partner’s support on improving contraceptive continuation.
• Conduct qualitative researches with women, community leaders and health providers are required to clarify in depth the real barriers and challenges against achievement of zero percentage of unmet need for family planning.
• Conduct a Contraceptives use dynamics among attendees of Primary Health Care Settings: comparative study between urban and rural areas in Upper Egypt as well in Lower Egypt.