Research consultancy

Family planning

WHO in conjunction with United States department of Health and Human Services, Office (USDHSO) of Population Affairs defined family planning as a factor that allows individuals and couples to anticipate and attain their desired number of children, spacing and timing of their births, this is achieved through use of contraceptive methods and the treatment of involuntary infertility, (WHO April, 2016).

WHO has in its guidelines the traditional methods consisting of Lactation Amenorrhea Method (LAM) and Fertility Awareness Based (FAB). Current guide indicate that virtually all these methods are safe for nearly every person with HIV. FP services have been integrated into HIV care and treatment facilities just as the reverse is true; what is noticeable is the fact that there has not been a lot of information published focused to FP use among HIV positive clients, (WHO, 2008).

Globally four different analyses have confirmed that the importance to eMTCT effort of preventing unintended pregnancies in women with HIV is vital, and it was stated that moderate decrease in the number of pregnancy to HIV infected women ranging from 6% to 35% depending on the country, could result in numbers of averted HIV positive birth equivalent to those averted by Arts according to (WHO 2009).

In the same way another study demonstrated that adding family planning to PMTCT services in high-HIV prevalence countries could avert 71,000 child HIV infection compared with the 39000 HIV positive birth averted with PMTCT only (Janet Fleischman, 2006).

In some cases women with unintended pregnancies are more likely to carry out unsafe abortion, which predisposes them to infections such as puerperal sepsis; FP plays a key role in reducing such incidences, improving maternal health and minimizing the cost of caring for the child in case infected with HIV alongside prevention of unintended pregnancies; condoms specifically prevent against sexually transmitted infections including HIV cross and re-infection (WHO, 2009).

A third analysis in the same study suggested that recurrent levels of contraceptive use in sub Sahara Africa may be already preventing 173,000 (22%) of HIV positive birth annually, despite contraceptives not being widely available in sub Sahara  Africa (WHO 2009)

According WHO (2009), If all women in the region who did not wish to get pregnant access contraceptive services, as many as an addition 160,000  HIV positive birth could be averted every year.

Access to FP services is vital as it was found in a study conducted by MOH in western Uganda that the married women in urban settings were twice as likely to use FP as those in the rural areas, women prefer getting at least one child before accepting using these methods because they may be assumed to be barren in case of no child, this is affected by age differences among women, yet by age 15, 14.2% are already sexually active (MoH 2009).

Elements of PMTCT program that could reach women and their partners outside ANC settings before they get infected thus; prevention of primary HIV infection in women before they become pregnant; prevention of unwanted pregnancy; preventing those already infected from infecting their infants and providing appropriate treatment, care and support to them and their children and families, (MOH 2012)

Implementing element 2 (prevention of primary HIV infection in women before they become pregnant) can be accomplished in two ways. One approach is to strengthen vertical family planning services; the other is to ingrate family planning services into HIV prevention, care and treatment services, (MoH PMTCT guidelines 2012).

Global family planning and HIV/AIDS program a funded though separate mechanism. While resources for HIV/Aids have dramatically increased in recent years, effort to strengthen international family planning program have been hampered by a decline in funds. In 2008 US$ 3600 million for HIV service went to the 15 PEPFAR focus countries compared to 67.5 million for family planning PEPFAR, report (2008).

1.3 Problem Statement

Factors influencing use of FP in the general population are known but what is lacking is linking these and other factors to HIV care. Factors that have been highlighted among the general population include socio-demographic characteristics like age, educational background, place of residence like rural or urban, desire for children and partner approval. HIV positive clients are a special population that has a regular follow up schedule, unique challenges are access to family planning services. On top of the factors faced by the general population, they could be having other additional issues that need to be addressed. It is therefore vital to determine the possible factors influencing the use of FP services among HIV positive clients (UDHS, 2011).

United Nations, Department of Economic and Social Affairs during its latest national survey, noted that one in three married women of reproductive age have unmet need for family planning, which translates into approximately 1.6 million women of these, about 60% wanted to space their next birth, and the other 40% did not want to have any more children, (UNDESA, 2013).

Family Planning utilization in south western Uganda stands at 30% among female users in comparison with northern Uganda  which has a high level of knowledge about family planning methods among the PLHIV which is at 96%, with significantly higher proportion of males (52%) than females (25%) who report the use of contraceptives, (UBOS and ICF International, 2011).

There is no information documented on the proportion of HIV positive clients using FP for contraceptive purpose and yet the services are being provided, with low levels of FP use in the general public, hence there is a possibility of it being lower among HIV positive clients as well. If FP use among HIV positive clients remains low, negative effects can be realized such as unwanted pregnancies which in turn lead to poor health conditions among the HIV positive women who already have a weak immunity; the new born child may contract HIV infection which may lead to death; increased family expenses incurred for treatment and its associated costs due to client’s illness may be too costly for many Ugandans. Therefore this research seeks to assess the factors influencing the use of family planning services among HIV positive mothers in Hoima district in order to come up with solution to overcome the challenges on the ground.

1.4 Purpose of the Study

To determine the factors affecting family planning use among HIV positive mothers in Hoima district, in order to identify the gaps and find interventions required to over come challenges

1.5 Specific Objectives

1. To determine the socio-economic factors influencing family planning services uptake among HIV positive mothers in Azur Christian health centre IV Hoima district.
2. To assess the Knowledge of HIV positive mother on the use of family planning methods in Azur Christian health centre IV Hoima district.
3. To establish the individual related factors influencing family planning use in HIV positive mothers in Azur Christian health centre IV Hoima district.

1.6 Research Question

1. What are the socio-economic factors influencing family planning services uptake among HIV positive mothers in Azur Christian health centre IV Hoima district?
2. What is the Knowledge of HIV positive mother on the use of family planning methods in Azur Christian health centre IV Hoima district?
3. What are the individual related factors influencing family planning use among HIV positive mothers in Azur Christian health centre IV Hoima district?

1.7 Justification to the Study

The study will come up with intervention to increase use of family planning in HIV positive mothers in Hoima district.

This findings helps health workers in the area come up with measures aimed to improve FP services among mothers who are HIV positive in the area.

The findings could assist the health planners and policy makers by identifying the potential areas which require improvements in funding, development and support programs targeting to improved family planning among women who are HIV positive in Hoima district.

The findings of this study may be beneficial to stakeholders such as the Ministry of Gender and community development, The Uganda Human Rights commission, the Ministry of Health and UNICEF and other stakeholders operating in the region.

The findings of this study will act as a research reference for further studies by other nursing scholars or researchers.

The study will be of great importance to the researcher for the award of the requirement of a diploma in Nursing

CHAPTER TWO

LITERATURE REVIEW

• Introduction

This chapter highlights the literature review cited by other scholars about the factors influencing family planning use among HIV positive mothers. The literature is presented in sequence of the specific objectives thus socioeconomic, knowledge and individual factors.

2.2 Socioeconomic factors influencing family planning services uptake among HIV positive mothers

Findings from a study on the impact of antiretroviral therapy on incidence of pregnancy among HIV infected women in sub-Saharan Africa revealed that the rate of new pregnancies was significantly higher among women receiving ART compared to women not on ART; the chance of pregnancy was 80% greater among ART group than the pre-ART group. Other factors that were cited to be independently associated with increased risk of incident pregnancy were younger age, lower educational attainment, being married, cohabiting, failure to use non barrier contraception, (Myer et al., 2010)

Preventing unintended pregnancies among women living with HIV is a critical step towards elimination of mother-to-child transmission (eMTCT), and is a core component of the international standards for a comprehensive approach; all women, irrespective of HIV status, need services that can help them make informed reproductive decisions and provide contraceptive options, if and when they are desired, by enabling women living with HIV to prevent or delay pregnancies, access to these services could avert its infection in infants, (MOH Uganda 2012)

Use of FP among HIV positive clients is supportive in preventing high-risk and unintended pregnancies, which limits births by these clients; in some cases women with unintended pregnancies are more likely to carry out unsafe abortion, which predisposes them to infections such as puerperal sepsis, (WHO, 2009).

FP among HIV positive females who never desired children were less likely to use the methods compared to those who still desire children, those who never wanted children said FP has side effects like constant bleeding and others feared ARVs and contraceptive pill burden, (MOH/ACP 2012)

In Africa, studies have revealed that societal expectations in relation to childbearing, specifically, pressures to have children, the need to have boys as heirs, and large families (Beyeza-Kashesya J, 2009)

Expectations of child bearing also influence the fertility desires among PLHIV especially women who are HIV-positive, (Nattabi B, 2009)

2.3 Knowledge of HIV positive mother on the use of family planning methods

A study done in South Africa to assess the level of use of family planning services among both HIV-positive women and HIV-negative women revealed that there is a higher pregnancy desire and lower contraception and condom use in HIV-positive women than in HIV-negative women (Peltzier, Chao, & Dana, 2009).

Study done in the Kabarole district of Uganda revealed that the probability of HIV-positive women wanting to stop childbearing was 6.25 times higher than it was for HIV-negative women, HIV-positive women tended to want fewer children than their HIV-negative counterparts mainly because they are aware of the risks of MTCT and they do not want to go through the difficulties of having an HIV-positive child (Hey, et al., 2011).

The observation made at Katutura CDC noted that HIV-positive women were falling pregnant despite knowing that they run the risk of having an HIV-positive baby; this finding pointed to the need to respect the reproductive needs and desires of HIV-positive women according to Ikerra, H.T, (2014)

According to UNAIDS, (2010), in many countries women are less likely to be able to negotiate condom use, therefore they are more likely to be subjected to unprotected sexual intercourse and, thus, to HIV and other sexually transmitted infections STIs

However, HIV-positive women have a need for and a right to children, it is important for their pregnancies to be planned, planning in this context means making sure that their CD4 is equal or above 500 and that their viral loads are at the minimum level; this is one of the most important interventions for reducing MTCT of HIV, as unplanned pregnancy could pose a high risk it, (MOH, 2008).

Family planning is the key strategy for reducing the number of babies born to HIV-positive women. According to MOH, (2010), if they make an informed choice about contraceptive use it will involve recognizing and acknowledging different methods and their effectiveness against pregnancy, as well as the need to prevent STIs and HIV,

Though FP interventions have been under utilized in HIV care, it is more beneficial than antiretroviral prophylaxis (MOH ACP 2007), the Ugandan data for 2007 estimated FP to be responsible for the prevention of 6,100 infant infections in the country compared with 2,200 infections prevented by antiretroviral prophylaxis

2.4 The individual related factors influencing the use of family planning among HIV positive mothers

According to Reynolds HW, (2006) Most children with HIV are infected by mother-to-child transmission (MTCT) of the virus, and especially across Africa, up to 1,900 children are infected daily with HIV, and three million children younger than 15 years are living with the disease, effective contraception has been shown to reduce MTCT of HIV by preventing unwanted pregnancies

Beyeza-Kashesya J et al., (2009) stressed further that PLHIV are more likely not to want to have more children once diagnosed with HIV, literature also shows that a substantial proportion (20-50%) of men and women living with HIV desire to have children

Furthermore, Reynolds HW and Rutenberg N, et al., (2006) estimated that approximately 120,000 HIV-positive births per year would be averted if the family planning needs of all HIV-positive women in sub-Saharan Africa could be met, however, most antiretroviral therapy (ART) programs focus on providing ART to HIV-positive women without integration with contraceptive services,

Anand A, and Shiraishi RW et al., (2009) noted in a study that the desire to reproduce, lack of information on MTCT and poor outcome of previous pregnancies were among the factors that prompted parents living with HIV to desire children Berhan Y, et al., (2013), and several HIV-positive women encounter unintended pregnancies with a concomitant risk of MTCT

Studies have demonstrated that HIV-infected women who know their status have a lower fertility desire and better use of contraceptives as compared to their HIV-negative counterparts (Taulo F et al., (2009); a study done by (Tweya H, et al., 2013) in Malawi indicated that women with longer follow up time on ART were associated with increased chance of becoming pregnant.

CHAPTER THREE

METHODOLOGY

3.1 Introduction

The chapter focuses on methodology which includes the study design, study setting, study population, sample size determination, sampling procedure, inclusion criteria, definition of variables, research instruments, data collection procedure, data management, data analysis, ethical consideration, dissemination of results and limitation of the study,.

3.2 Study Design and rationale

The study design is a cross sectional and descriptive, employing both quantitative and qualitative data collection methods. This design is selected because it will assist in easy getting the required data for the study.

3.3 Study setting and rationale

Azur Christian health centre IV is among four health centre IVs and as one of the referral health units Kahoora division Hoima Municipality with a population of 2400 people targeted for family planning services and it is located in Hoima district about 3 kilometers away southwards of Hoima Municipality within Hoima town and it boarders Masindi, Kibale, Bulisa, and Kyankyanzi districts. Azur Christian health centre IV offers the following services to its clients: HAART services; ANC, PNC, OPD, Nutrition, Deliveries, Immunization services, Family Planning, cervical cancer screening, radiography services and many others to mention but a few.  The study area is selected because of the convenience of this area and it is near the residence of the researcher

3.4 Study Population

The study population will include the women of child bearing age and possibly those who are HIV positive and get services in Azur health centre IV in Hoima district.

3.4.1 Sample Size Determination

The study will consists of a sample size of 30 respondents who will be found in Azur health centre IV

3.4.2 Sampling procedure

The researcher will use simple random sampling procedure to get the required respondents for the study. In this procedure, the researcher simply will write two words on paper YES and NO scrambled them up and throw them on the ground then will tell the respondents to pick one per person and this will enable the researcher select all the respondents who will voluntarily consent to participate and will be included in the study without a bias. This will continue until a total of 30 respondents are obtained.

3.4.3 Inclusion criteria

The study will include mothers attending services at the Azur Christian Health Center IV Hoima district who will be available at the parish during data collection, and are free and willing to voluntarily consent to participate in the study.

3.5 Definition of Variables

The independent variables for the study included:

Socioeconomic factors influencing the use of family planning methods among HIV positive mothers

Knowledge of HIV positive mother on the use of family planning methods

Individual related factors influencing the use of family planning methods among HIV positive mothers

The dependent variables for the study included:

Utilization of Family Planning services among HIV positive mothers

3.6 Research Instrument

The researcher will collect data using a structured questionnaire which will be developed and pre-tested for the study. It will have both closed and open-ended questions written in English. The researcher will also be available to translate the questionnaire into the most commonly spoken local languages like Runyoro,Rugungu and Aluru and this will aid efficiency of data collection.

3.7 Data Collection Procedure

The researcher will administer the questionnaires to respondents from their various wards or departments where they are being provided services. This will be done to increase efficiency and privacy during data collection.

3.7.1 Data analysis and presentation

The study data will first be analyzed manually for completion of questioner edited and after will be transferred to Microsoft Excel 2010 for the graphical presentation of results and will be presented in figures and tables.

3.8 Ethical Consideration

A letter of introduction will be obtained from Public Health Nurses College, introducing the researcher to the administration of Azur health centre IV seeking permission to carry out the study. After permission is granted, the health centre administrator will introduce the researcher to the in charge who then will introduce the researcher to the respondents. The study will only commence after the objectives of the study have been clearly and well explained to participants and they have understood and voluntarily consent to participate in the study. Respondents will be assured of maximum confidentiality of all the information they give and numbers will be used instead of respondents’ names.

3.9 Limitations of the study

The researcher anticipates encountering financial constraints in gathering information from the internet and libraries as well as printing and transport costs. The researcher will overcome this limitation by drawing up a budget which will strictly be followed to utilize the available means.

The researcher contemplates encountering time constraints in the course of the study, balancing the research study and other demanding course works. The researcher will overcome these limitations by considering only priorities.

The researcher expects some clients to fear being interviewed; hence he will use confidential approach by interviewing the respondents in a quiet and private environment to gain their confidence in the study.

3.10 Dissemination of results

The results will be forwarded to the following bodies:

Uganda Nurses and Midwives Examinations Board (UNMEB),

Kyambogo Public Health Nurses’ College

The District Chief Administrative Officer Hoima district and the administrator of Azur health centre IV

The research will have a copy for further references.

REFERENCES

ACQUIRE Project (2008). Champion stories: Integrating Family Planning with HIV services in Uganda community engagement marketing and communications from the field/Uganda champion stories final.

Agadjanian V, Hayford SR: PMTCT, HAART, (2009). And childbearing in Mozambique: an institutional perspective. AIDS Behav., 13 (Suppl 1):

Anand A, Shiraishi RW, Bunnell RE, Jacobs K, Solehdin N, et al. (2009). Knowledge of HIV status, sexual risk behaviors and contraceptive need among people living with HIV in Kenya and Malawi. AIDS.;23(12):1565–73.

Asiimwe, D. Kibombo, R. Matsiko, J. (2005). study of the integration of family planning and VCT/PMTCT/ART. Programs in Uganda available

Berhan Y, Berhan A. (2013). Meta-analyses of fertility desires of people living with HIV. BMC Public Health.;13(1):409.

Beyeza-Kashesya J, Kaharuza F, Mirembe F, Neema S, Ekstrom AM, Kulane A: (2009). The dilemma of safe sex and having children: challenges facing HIV sero-discordant couples in Uganda. African Health Services 9: 2-12.

Bishop, m. & foreit, K. (2010). Zero discordant couples in sub Saharan Africa: What Do survey Data Tell Us? Washington DC: Futures Group, Health Policy Initiative, Task Order 1

Heys, J. Kipp Walter, J. Gians, J. Arif, A. & Rubaale, T. (2011). The impact of Antiretroviral therapy on fertility desires among HIV-infected persons in rural Uganda. Reproductive health 2011.8:27doi:10, 1186/1742-4755-8

Hopkins Bloomberg School of public health/center for communication programs (CCP), INFO project (2007). Family Planning; a global hand book for providers. Baltimore and Geneva: CCP and WHO

MOH (2012). the integrated national guidelines on ARVs prevention of mother to child transmission of HIV infant and young child feeding

MOH, (2008). Uganda reproductive health commodity security situation analysis, Kampala: MOH

MOH, (2009a). 2010/11-2014/15, Uganda Reproductive Health Commodity security strategic plan, Kampala; Ministry of Health

MOH, (2009b). Uganda Reproductive Health Commodity security situation Analysis Kampala: MOH

MOH, (2009c), Ministry of health statistical Abstract 2008/09.December 2009.Kampal: MOH

MOH, (2010a). UNGASS country progress report Uganda: January 2008-December 2009. Kampala: Ministry of Health

MOHSS, (2008). Prevention of Mother to Child Transmission of HIV Namibia

MOHSS, (2010). Report of the National Sentinel Survey. Namibia.

MOHSS, (2011). Namibia Estimates and projection on HIV impact 2010/2011.

Myer L, Morroni C, Rebe K: (2007). Prevalence and determinants of fertility intentions of HIV-infected women and men receiving antiretroviral therapy in South Africa. AIDS Patient Care STDS, 21 (4): 278-285.

Nakayiwa S, Abang B, Packel L, Lifshay J, Purcell DW, et al. Desire for children and pregnancy risk behavior among HIV-infected men and women in Uganda. AIDS Behav. 2006; 10(1):95–104.

Nattabi B, Li J, Thompson SC, Orach CG, Earnest J: (2009) A systematic review of factors influencing fertility desires and intentions among people living with HIV/AIDS: implications for policy and service delivery. AIDS Behav., 13: 949-968.

Ninsiima, M. (2010), Uganda family planning landscape assessment April 2010.Advance Family planning, Health Communication partnership, Kampala: Uganda

Ogunjuyigbe PO, Ojofeitimi EO, Liasu A. (2009). Spousal communication, changes in partner attitude, and contraceptive use among the Yorubas of Southwest Nigeria. Ind J Comm Med; 34 (2):112-116

Okundi, B. Aloo-Obunga, C. Sanders, R.& Shepherd, C. (2009) Rapid Assessment on Policy and Operational Barrier to the Integration of FP/RH/HIV services in Kenya. Washington, DC: Health policy Initiative, Task Order1, Futures Group International.

Peltzier, K., Chao, L.W., & Dana, P. (2009), Family planning among HIV positive and negative mothers: PMTCT clients in poor resource setting in South Africa.AIDSBehaviour, 13 (5), 973–979.

Taulo F, Berry M, Tsui A, Makanani B, Kafulafula G, et al. (2009) Fertility intentions of HIV-1 infected and uninfected women in Malawi: a longitudinal study. AIDS Behav.;13(1):20–7.

Tesfayi G, Mishra V. (2007), spousal Agreement on Family Planning in Sub-Saharan Africa. DHS Analytical studies No. 11. Calverton, Maryland: Macro International

Tweya H, Feldacker C, Breeze E, Jahn A, Haddad LB, et al. (2013). Incidence of pregnancy among women accessing antiretroviral therapy in urban Malawi: A retrospective cohort study. AIDS Behav.;17 (2):471–8.

UAC, (2007), (20112007/8-/12) Moving towards Universal National HIV/AIDS strategic plan, Kampala Uganda AIDS Commission

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APPENDIX I

CONSENT FORM

I am Barongo Jerome, student from public health nurses’ college kyambogo carrying a research on the factors affecting the use of family planning among HIV positive mothers of child bearing age in Azur Christian health center in Hoima district. This research study is for the fulfillment of requirements of a Diploma in Nursing.

I’m kindly requesting for your consent to participate in this study. Information obtained from the study will be treated with confidence and no one else besides the investigator will have access to it, except for research purposes. Codes will be used instead of names to ensure confidentiality and protection of participants. The questionnaire will last approximately 20 minutes and you are free to withdraw from the study at any time or decline to participate in this study and your decision will be taken in to consideration without dispute. The questionnaire includes questions on personal information, socio-economic factors, practices, knowledge of HIV positive mothers. For any questions pertaining to this study, you can contact me during the week on telephone 0775696831.

I have read (or this consent form has been read to me) and I have understood this consent form and voluntarily consent to participate in this study.

Respondent’s signature……………………………………..       Date……………………….

Investigators’ signature…………………………………….        Date……………………………….

APPENDIX II

QUESTIONNAIRE

SECTION A: DEMOGRAPHIC DATA OF THE RESPONDENTS 

(This section relates to information about you). [Tick    the most appropriate answers]

1. How old are you?
2. 18 to 25 years
3. 26 to 35 years
4. 36 to 45 years
5. 45 years and above
6. What is your marital status?
7. Single
8. Married
9. Divorce
10. Widowed
11. Separated
12. What is your religion?
13. Christianity
14. Traditional
15. Muslims
16. Apostolic Faith
17. Others (specify) ………………………………………………………………………
18. What is your level of education?
19. None
20. Primary
21. Secondary
22. Tertiary
23. What is your occupation?
24. House wife
25. Casual worker
26. Self-employed
27. Peasant farmer

SECTION B: SOCIOECONOMIC FACTORS INFLUENCING FAMILY PLANNING SERVICES UPTAKE AMONG HIV POSITIVE MOTHERS

6. How do you relate with your sexual partner?
7. He is caring
8. He supports my baby with every thing
9. He does not provide food
10. Does not stay with me
11. How far is the health facility from you home?
12. ½ to 1 kilometer
13. 2 to 3 kilometers
14. 4 to 5 kilometers
15. Do you pay for the services from the health facility
16. Yes
17. No
18. If Yes, how much do you pay?
19. 1,000/- to 2,000/-
20. 3,000/- to 4,000/-
21. 5,000/- to 6,000/-
22. Others specify…………………………………………………………………….
23. Which services are being provided in this health facility?
24. HIV counseling and testing
25. Family planning
26. Treatment of other diseases like STIs/STDs
27. I do not know

SECTION C: KNOWLEDGE OF HIV POSITIVE MOTHER ON THE USE OF FAMILY PLANNING METHODS

11. Have you ever heard of family planning?
12. Yes
13. No
14. If Yes from who did you hear it from?
15. Health workers
16. Friends or colleagues
17. Traditional healers
18. Grand mother
19. What are some of the methods of family planning you know?

………………………………………………………………………………………….………………………………………………………………………………………….

14. Which family planning methods do you use?
15. Implant
16. Injection
17. IUD
18. Pills
19. Natural method
20. How did you choose the method of family planning that you used?
21. Through counseling
22. Decided to choose it alone
23. A friend chose it for me
24. I was coerced to take it

SECTION D: THE INDIVIDUAL RELATED FACTORS INFLUENCING THE USE OF FAMILY PLANNING AMONG HIV POSITIVE MOTHERS

16. Have you ever tested for HIV?
17. Yes
18. No
19. If Yes, what were the results?
20. Negative
21. Positive
22. Not sure
23. How do you feel when they say you are HIV positive?

……………………………………………………………………………………………………………………………………………………………………………………

19. If Positive are you on drugs?
20. Yes
21. No
22. Do you have any bad reactions when you use family planning methods?
23. Yes
24. No
25. If Yes, what kind of reactions do you get when you use these methods?
26. Heavy bleeding
27. Body itching
28. Nausea
29. No bleeding

22. What does your society say about HIV positive woman having children?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

23. Do you need to produce more children?
24. Yes
25. No
26. If Yes, at what interval do you need to produce them?
27. After 2 years
28. After 3 years
29. After 4 years
30. So long as God gives
31. As many as you my husband wants them
32. What does your husband say about producing more children?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

26. What do health workers tell you about family planning?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

APPENDIX III

WORK PLAN

APPENDIX IV

BUDGET