The findings of this descriptive study indicated that there are various obstacles to modern contraceptive use among withdrawal users. The main factors were, health concerns and fear of side effects, misinformation related to modern contraception, lack of confidence in modern methods, dissatisfaction with sexual sensation, and unwillingness of their husbands. Surprisingly religious factors were not noted by women in our study to be a reason for inability to choose effective methods.
We found that the most common reasons for using withdrawal were the fact that women believed this method did not involve any costs, had no side effects, and was easy to practice. Other reasons in our study that prevented contraceptive use were dissatisfaction with sexual sensation, and husbands' unwillingness. Similarly, other investigators reported that most couples considered withdrawal due to health problems and side effects of modern methods [10, 11]. A study from Turkey found that the reasons for using traditional methods and not effective methods among women were: wrong beliefs and fear of side effects (45.8%), unwillingness of men to use effective methods (37.5%), and cost of the methods (16.7%) [12]. In addition, the findings from present study indicated that preference of husbands, as a reason for using withdrawal, was relatively high (54.7%). A study from Turkey also showed that 31.2% of women used withdrawal due to the preference of their husbands [8]. Yet men are still not an important target group in most programs, and inadequate attention is paid to their role and their perspectives on issues of fertility control and they did not attend to health center for birth control. Even, in traditional societies such as Iran asking these questions from husbands is a very difficult task.
The present study showed that the main reasons for giving up oral contraceptives and intra uterine contraceptive device (IUCD) were side effects and health problems, while condoms stopped being used because of spouses dislike. This clearly suggests that two major reasons could be identified for withdrawal use: women-related and husband-related factors. With regard to women-related factors although we believe there should be a right for women, it seems that there is need to provide more support in order to help them to make a right decision. As far as husband-related factors involves, however, the issue of power and gender role might be relevant to discuss. This is consistent with the argument that men sometimes use withdrawal as a way to reinforce their decision-making and sexual control [13]. It has been suggested that gender-based power relations can have a direct effect on the ability of partners to acquire information relevant to their reproductive health, on their ability to make decisions related to their health, and on their ability to take action to protect or improve their health [14]. A study reported that side effects or health concerns accounted for a large portion of the relatively high first-year discontinuation rates for pills and injections (21% and 29%) [10]. The IUCD discontinuation rate was the lowest (%9) among all methods, compared with 38% for withdrawal and 56% for the pill [15]. In another study it was found that discontinuation rates for method-related reasons varied widely by method: IUCD was associated with the lowest probabilities of discontinuations (11% within 12 months, 30% within 4 years), followed by the pill (22% and 48%, respectively) and discontinuation rates were significantly higher for all other methods (condoms, withdrawal, fertility awareness methods and spermicides) [16]. Since modern contraceptive use may be associated with transient side effects, therefore for women who not prepared for these effects and not knowing where to go for follow-up and advice; discontinuation in the practice and development of fear regarding the use of modern methods might be expected.
The findings from current study showed that 72% of women could talk to their spouses about family planning. This suggests that the decision related to family planning is usually a jointly negotiated agreement by the couple, rather than a husband's imposition or a woman's choice alone (see Table 4). A study from Turkey reported that in 86 to 88% of cases the couple jointly made their contraceptive choices [17]. In general it is argued that reproductive decision-making is typically a jointly and co-operatively negotiation process by couples [18].
The scientific assertion that withdrawal has a relatively high failure rate is based on reports from a small number of studies, primarily conducted in North America, and with small sample sizes that may not be representative [19, 20]. In one study among typical withdrawal users about 19% failed during the first year [21]. In another study, it was found that 48.6% unplanned pregnancies occurred while the couples were practicing withdrawal [8]. Prevention of unintended pregnancy is a significant public health issue and should be focus of health policies as it was the focus of healthy people 2010 in the USA [22].
Data from Iranian Demographic Health Survey in year 2000 indicated that about one-third of pregnancies were unintended [5]. Results from the present study showed that 37.2% of unwanted pregnancies occurred when the couples were practicing withdrawal and 62.8% were related to other reasons. Perhaps these pregnancies might lead to abortion. There are no reliable data on abortion in Iran as abortion is illegal except on occasions that the mother's life is in danger or in the case of fetal impairment [23]. A study of withdrawal users revealed that one out of four women reported that they terminated a pregnancy because it was unplanned [8]. The results of our study showed that 86 women experienced unwanted pregnancy while using different contraceptive methods. Of these 17 women reported that they terminated a pregnancy because it was unplanned (see Table 1). These women usually should pay a large amount of money for illegal abortions in illegal clinics; otherwise it could have serious consequences both for women and practitioners. It is argued that one reason for taking such a risk is that women do not want to have more children. For instance, a study from Turkey reported that women who had sufficient number of children preferred induced abortion instead of using an effective family planning method [24].
The current study found that 34% of women knew about emergency contraception while a study from Turkey revealed that only a few women (13.4%) knew about emergency contraception [8]. Emergency contraception has been defined as the use of a drug or a device to prevent pregnancy after intercourse and it has been shown to be safe and effective method to reduce the number of unwanted pregnancies [25]. Thus, there is a need to improve women's awareness about emergency contraception. The primary health care providers can play a major role in informing their patients about emergency contraception and it needs to become part of routine reproductive health counseling. To improve emergency contraception, awareness campaigns should be designed and implemented.
Limitations
This study has some limitations. First, the study was carried out in one district of Tehran, and thus the findings cannot be generalized to withdrawal users who live in Iran. Secondly, the sample size was small. In addition the study was limited to women. Knowledge and attitudes of men need to be considered as well if we hope to make changes in the use of contraceptives in this population. However, this is the first study that investigated the experiences of and attitudes toward contraceptive methods among women who were using the withdrawal method in Tehran, Iran.
