|Year : 2022 | Volume
| Issue : 1 | Page : 10-17
Women's awareness and rate of the use of contraception in the Kingdom of Saudi Arabia: A systematic review
Hamdah Musallam Alruwaili1, Hanan A Badr2, Wafaa A Fahim2
1 Department of Gynecology and Obstetrics, Domat Al Jandal General Hospital, Aljouf, Saudi Arabia
2 Department of Maternal and Child Health, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Submission||16-Feb-2022|
|Date of Decision||16-Apr-2022|
|Date of Acceptance||03-Jun-2022|
|Date of Web Publication||27-Jul-2022|
Mrs. Hamdah Musallam Alruwaili
RN, Department of Gynecology and Obstetrics, Domat Al Jandal General Hospital, Aljouf
Source of Support: None, Conflict of Interest: None
Background: The prevention of unplanned pregnancies brings many benefits for women and their families alike, as well as for society in general. However, recent statistics indicate a need for increased knowledge and use of contraception in addition to the introduction of educational family planning services in the countries of the Middle East. Objectives: This review sought to explore women's awareness and rates of contraceptive use in the Kingdom of Saudi Arabia (KSA) and to determine whether and to what extent women currently receive counseling on modern contraception at health-care facilities in KSA. Methods: Three electronic databases – MEDLINE, ProQuest Central, and PubMed – were searched, in addition to the academic search engine Google Scholar. Three reviewers independently assessed the eligibility of studies, abstracted study data, and assessed study quality. Results: Thirteen studies were identified for inclusion in this review; overall, these studies were cross-sectional and showed awareness and use of contraception to be at a relatively low level in KSA. Conclusion: Although the few studies that were identified for inclusion in this review reported a relatively low level of awareness and rate of use of contraception in KSA, each conclusion was supported by high-quality research with low risk of bias. Overall, this review has shed light on the gaps in studies that have been conducted in KSA on modern contraception.
Keywords: Contraception, family planning, knowledge, Saudi Arabia, use
|How to cite this article:|
Alruwaili HM, Badr HA, Fahim WA. Women's awareness and rate of the use of contraception in the Kingdom of Saudi Arabia: A systematic review. King Khalid Univ J Health Sci 2022;7:10-7
|How to cite this URL:|
Alruwaili HM, Badr HA, Fahim WA. Women's awareness and rate of the use of contraception in the Kingdom of Saudi Arabia: A systematic review. King Khalid Univ J Health Sci [serial online] 2022 [cited 2022 Nov 28];7:10-7. Available from: https://www.kkujhs.org/text.asp?2022/7/1/10/352517
| Introduction|| |
Prevention of unplanned pregnancies is associated with many benefits for women and their families, as well as society in general. It is important for promoting the health of women and children and keeping rates of maternal and neonatal morbidity and mortality low. Despite these advantages, in countries with a low prevalence of contraceptive use or where the majority of women use traditional rather than modern contraceptive methods, a large gap remains between the overall demand for family planning and the use of modern methods of contraception.
In Middle Eastern countries, approximately 50% of women between the ages of 15 and 49 years use birth control methods. This statistic indicates a need for increased contraceptive use and raised awareness along with the introduction of educational family planning services in the countries of the Middle East. Unintended pregnancies that result from the lack of use of contraception can jeopardize women's health when putting a burden on society. Furthermore, Saudi society's sociodemographic pattern has rapidly changed, as the rate of women finding employment has increased. As a result of these social changes, the use of contraception has become crucial to most Saudi women of childbearing age.
Appropriate intervention – specifically, counseling and provision of information – is required to increase the rate of use of modern contraceptives. This systematic review explores women's awareness and use of contraception in the Kingdom of Saudi Arabia (KSA) and examines whether and to what degree women receive counseling on modern contraception at health-care facilities in KSA.
Aims of the systematic review
- To explore women's awareness and use of contraceptives in KSA
- To determine whether and to what degree women receive counseling on modern contraception at health-care facilities in KSA.
| Methods|| |
This review was conducted through a systematic approach using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The present review was guided by the following two research questions: (a) to what extent do women know of and use contraception in KSA? and (b) do women receive counseling on modern contraceptive methods at health care facilities in KSA? To examine a wide range of studies, which is important for answering the proposed PICOT format research questions, three electronic literature databases and Google Scholar were used. Three reviewers independently assessed the eligibility of studies, abstracted study data, and assessed the risk of bias. In addition, we examined the reference lists of the included studies and relevant review papers to identify missed articles.
This review focused on studies that met the same standards of inclusion and exclusion according to the developed questions. Studies eligible for inclusion in this review were full-text articles, English-language articles of weighted research quality published between January 2015 and June 2020, and where the study population sample consisted of reproductive-age women that either examined women's knowledge and use of contraception or provided information on modern contraception counseling in KSA. The exclusion criteria did not allow for articles published before 2015 or in any language other than English; articles that were not relevant to the review topic; or studies conducted on populations with human immunodeficiency virus infection or any other medical, obstetrical, or psychological disorders to be included. All initial studies identified had a quantitative design and met the inclusion criteria.
To find studies that addressed the research questions, three electronic databases – MEDLINE, ProQuest Central, and PubMed – were used in addition to the search engine Google Scholar. On June 15, 2020, electronic searches of MEDLINE, ProQuest Central, PubMed, and Google Scholar were completed, resulting in a total of 12,823 studies. Seven hundred and sixty-five records were found through ProQuest Central, 30 records were found through PubMed, and 28 records were found through MEDLINE. The remaining 12,000 studies were extracted from Google Scholar. Search terms used to find these articles included “contraception,” “family planning,” “knowledge,” “use,” and “Saudi Arabia.”
The limiters applied to the search were the following: full text, English language, and year of publication, which was set from January 2015 to June 2020. Once the standards of inclusion and exclusion were established, the results were narrowed to 1173 articles from the three databases and Google Scholar [Figure 1]. Studies published before 2015 (11,650) were excluded. Upon removal of duplicate studies, the remaining 645 were then screened by title, resulting in 85 potentially relevant studies. Fifty-seven further studies were excluded after screening the abstracts for relevance.
Depending on the availability of full-text electronic copies, three researchers independently examined the remaining 28 articles using the standards of inclusion and exclusion. Fifteen studies were excluded due to the following reasons: thirteen had been carried out in other countries, and two were at risk of above-minimum bias. Finally, 13 studies were included to address the two questions guiding this systematic review; of these, two articles each were retrieved from the ProQuest Central, MEDLINE, and PubMed databases and seven articles were retrieved from Google Scholar [Figure 1].
| Results|| |
The results in this review are presented through a description of the included studies' characteristics, followed by a critical appraisal process and, finally, a presentation of extracted themes.
In the literature search, a broad range of studies concentrating on contraceptive use was observed and each of the included studies was evaluated separately through a review of its goals and/or objectives, nature, data collection and analysis methods, key findings, and practical implications. Moreover, a data extraction table was used to group the main studies by themes to classify the research topics. This approach aimed to discover similar themes presented among the included studies and identify both the common features and discrepancies of them. Data were extracted from 13 studies.
The data extraction table contained a summary of several elements necessary to distinguish specific and appropriate data from each of the articles included. The critical elements were the following: references (author and year of publication), country of study, nature of the study, total representative sample, type of participants, intervention group, control/placebo/comparison group(s), and key findings [Table 1]. All 13 studies were conducted in KSA. All included studies were cross-sectional surveys.
Critical appraisal is a process that examines the trustworthiness, value, and relevance of research in a particular context; it helps researchers to discern the most relevant papers and evaluate the validity of research to exclude weak and/or irrelevant studies. In this investigation too, a critical appraisal tool – designed by Hawker et al. – was applied to appraise the quality of the studies included in this systematic review. This appraisal tool consisted of the following nine items that aid in the evaluation process of abstracts and titles: introduction and aims, methods and data, sampling, data analysis, ethics and bias, results, generalizability, implications, and usefulness. The tool was converted into a numerical scale – where 1 = very poor, 2 = poor, 3 = fair, and 4 = good – to measure the quality of the studies in this review; Hawker et al. quality-assessment tool does not offer a scale against which to assign an article's overall quality rating but this approach has been proposed by others such Lorenc et al., who suggested a rule of thumb. Thus, we used this rule as a quality grading system, in which a low-quality study was represented by scores ranging from 9 to 23 points, a medium-quality study was represented by scores ranging from 24 to 29 points, and a high-quality study was represented by scores ranging from 30 to 36 points. During the critique of the studies included, 11 of the 13 studies were rated as being of high quality and the two were rated as being of medium quality. More specifically, these 11 studies were evaluated as good because their titles were clear and their abstracts were well organized and gave complete information; moreover, the findings were comprehensible and relevant to the research goals and questions, while charts and tables were clarified in the text if present [Table 2].
Three themes emerged from the assessment of the included literature relating specifically to the present study's topic: (1) contraception knowledge and use in KSA, (2) the source of women's knowledge of contraception, and (3) counseling on modern contraception. In the subsequent subsections of this review, these themes are examined in more detail.
Contraception knowledge and use in the Kingdom of Saudi Arabia
Contraception awareness is correlated with the increased use of different birth control methods, which in turn results in a decrease in the number of unintended pregnancies and their consequences on women's health. Thus, many studies have explored contraception knowledge and use in KSA and most have indicated the existence of both limited knowledge and usage of contraceptives in KSA.,,,,,,,,,,,,
In the Aseer region, a quantitative cross-sectional study was conducted among 500 women of reproductive age (18–45 years old) with the aim of evaluating the awareness, practices, and attitudes of Saudi women toward the use of birth control methods and factors influencing their use. This study concluded that a large number of the participants were well informed with positive attitudes toward birth control methods, yet the rate of adoption of birth control methods was low.
In 2017, 300 female teachers participated in a cross-sectional survey in Madinah Al-Munawarah city. The study's aim was to evaluate the awareness, practices, and attitudes of female teachers concerning birth control in that city. The study revealed that the included women had little knowledge of the variety of birth control methods available and that there was average use of these methods among them.
In the same year, 393 women in the Obstetrics and Gynecology Department of King Abdulaziz University Hospital in Jeddah were enrolled in a cross-sectional survey. The results of the study showed that close to two-thirds of the women used family planning methods and that the most popular option was oral contraceptive pills (OCPs), followed by intrauterine devices.
Similarly, a cross-sectional survey of a simple random sample included 708 women from Al-Kharj city in Saudi Arabia. The purpose of this study was to explore women's awareness and perceptions with regard to OCP use and safety. The study found that most of these women had inadequate knowledge regarding OCP use and side effects.
Moreover, Moawed et al. conducted a cross-sectional prospective study in 2017 to examine women's awareness of intrauterine contraceptive devices and OCPs in Riyadh and to assess the factors influencing their level of awareness. Two hundred Saudi women (18 years and older) from 10 different primary care centers in Riyadh were recruited for the study. The findings of the study indicated that these women's level of knowledge about contraceptives was relatively low.
Parveen et al. conducted a quantitative cross-sectional study in the Hail region among 500 Saudi women of childbearing age aimed at elucidating the contraceptive awareness of Saudi women and the sociodemographic factors influencing their level of knowledge. The study showed that more than one-half of the women felt that they had inadequate knowledge regarding the different methods of contraception; moreover, these women urged greater public awareness of this information.
Similarly, Alharbi et al. conducted a cross-sectional descriptive study on 370 married fertile women in Riyadh between January and April 2018. The study results indicated little knowledge and low use of emergency contraception existed among these women, yet they showed a positive attitude toward the future use of emergency contraception.
Another quantitative cross-sectional survey was performed in 2018 in Riyadh among 477 Saudi women aged 14–50 years to assess the knowledge, behaviors, and practices concerning OCP use among women living in Riyadh. The survey results revealed haphazard use of OCPs among the women, with low levels of knowledge of contraception.
In addition, a cross-sectional survey was conducted by Alhusain et al. in the city of Jeddah to assess the awareness and use of contraceptive methods among Saudi women; this involved a sample of 979 Saudi women (18–50 years old). The findings of this study suggested knowledge gaps regarding birth control methods, while the prevalence of contraceptive use among study participants was 67%.
Similarly, another cross-sectional survey was conducted in Abha to explore the prevalence rate of the use of birth control and sociodemographic factors associated with women's use of birth control methods. The study sample consisted of 374 married women aged 15–50 years and reported that the rate of contraceptive use was approximately 50%. It also found that the most popular methods were intrauterine contraceptive devices and OCPs.
Another study conducted by Karim et al. assessed the knowledge, attitudes, and use of emergency contraceptives among 289 married women of reproductive age. Its results revealed limited awareness and use of emergency contraceptive methods existed among the women in the study sample.
In Jeddah, a cross-sectional study was conducted at King Abdulaziz University Hospital. The study aimed to evaluate women's awareness of OCPs and to discern relevant factors. In this study, it was concluded that the women had limited knowledge of OCPs.
In addition, a cross-sectional survey was conducted in 2015 to determine the use of contraception among Saudi women in the Taif region. This study was conducted on a sample of 250 women of childbearing age and reported that 67.7% of these women used contraceptive methods. The most used contraceptive method was OCPs, followed by injectable hormonal contraception and intrauterine devices.
Source of women's information
Seven of the 13 studies explored the sources of women's information regarding contraceptive methods.,,,,,, The most frequently listed sources of information regarding contraception were doctors, social circles (i.e., family members, relatives, and friends), social media/the Internet, and print and broadcast media; books were the least commonly mentioned sources of contraception knowledge.
Although health personnel constituted the most frequently mentioned source of contraception knowledge in all seven studies, the percentage of their involvement varied greatly from 6.6% to 89.5%.,,,,,,
The next most common source of information regarding contraception was one's social circle, which included family members, relatives, and friends. Social media/the Internet was the third most common source of women's knowledge regarding contraception.,,,,,
Finally, this review found that print and broadcasting media (e.g., television, radio, newspapers, and magazines) contributed as relatively insignificant sources of women's knowledge regarding contraception,,,, with the most insignificant source of knowledge being books, although they still added in some way to women's knowledge of contraception.,
Counseling on modern contraception
This review found no studies that investigated the provision of counseling on modern contraception in KSA. However, several studies concluded that the incorporation of family planning counseling into postpartum services resulted in a noticeable increase in the percentage of women using modern contraceptive methods, suggesting that effective educational interventions can improve women's awareness of modern contraception and enable them to use contraceptive methods properly.,,, Moreover, the studies addressed the need for written materials – such as booklets – to promote long-term knowledge.,
| Discussion|| |
This review investigated women's awareness and use of contraceptives in KSA as well the availability of counseling on modern contraception at health-care facilities. The 13 studies included in this review suggest that both levels of awareness and rates of use of contraceptives are relatively low in KSA.
Regarding contraceptive knowledge, ten studies explored women's awareness of contraception.,,,,,,, Data from nine cross-sectional surveys suggested that the majority of study participants had limited awareness of contraception. In contrast, one study conducted in the Aseer region showed that the majority of women had good knowledge of contraception;, however, this may have been because the majority of study participants (93%) were well educated.
With respect to the use of contraception by women, several recent studies have shown a low-to-medium rate of contraceptive use in Saudi Arabia.,,,,, Two of these studies found that women's use of emergency contraception was very low,, while four studies indicated a medium rate of contraception use (58%–67%).,,, These findings are expected since our data showed low awareness of contraception among women.,,,,,,, The other logical explanation, according to the findings of our study, is that sources of information regarding contraception, including social media sites and relatives, could have an impact on women's use of contraceptives.
On the other hand, two studies showed a relatively high rate of contraceptive use (75%–76%)., A study conducted in Al-Madinah Al-Munawarah city found that 75% of the study participants had used contraceptive methods. The study sample, which was limited to female teachers, could explain this contradiction. Similarly, Mubashar et al. showed a high percentage of contraceptive use among women. However, this could be explained by the sociodemographic characteristics of the study participants, with well-educated participants accounting for 93% of the study sample.
Unfortunately, this review found no studies assessing the impact of providing counseling on modern contraception in KSA, although several studies have shown that counseling results in a noticeable increase in the use of modern contraception by women.,, In addition, the need for counseling was indicated by a systematic review conducted in 2017 in KSA.
Our results are consistent with a systematic review conducted in Ethiopia, which found low levels of knowledge and use of emergency contraception in female university students. Similarly, another review conducted in Ethiopia showed a low rate of IUD use among postpartum women. In 2021, a systematic review with a focus on the US, Europe, Australia, and New Zealand indicated low use of contraception and an unmet need for contraceptive counseling among women.
In contrast, a systematic review conducted in Saudi Arabia identified adequate knowledge about contraception among women, contradicting the results of the current study. However, this might be due to differences in the locations included in the two studies. While the review referred to above included 13 studies with a focus on central, western, and eastern regions of Saudi Arabia, our review included studies covering northern, central, eastern, western, and southern regions of Saudi Arabia.
Overall, this systematic review has identified gaps in the studies conducted in KSA on modern contraception. Furthermore, its aim to provide information in addition to KSA's scientific literature on the topic has been achieved.
Our review has some limitations. First, our focus on studies published in English may have resulted in the exclusion of important studies published in other languages. Second, the search strategy was limited to recently published studies. Finally, the number of studies included in this review is relatively small, and data were not found for six provinces of Saudi Arabia, potentially causing problems in terms of representativeness.
| Conclusion|| |
The systematic review showed that the level of awareness and the rate of the use of contraceptives are relatively low in KSA. In addition, this review illustrated that social circles (e.g., family members, relatives, and friends), doctors, and social media/the Internet were common sources of women's knowledge about contraceptive methods. Unfortunately, no evidence was found regarding the effect of educational interventions on women's knowledge and rates of use of modern contraception in KSA. However, although the few studies that were identified for inclusion in this review reported a relatively low level of awareness and rate of use of contraception in KSA, each conclusion was supported by high-quality research with low risks of bias. Future studies should seek to evaluate the effect of contraception education on women's knowledge and the use of modern contraceptives in KSA, discern the most effective aspects of educational interventions, and assess the extent to which women's behaviors are affected by educational interventions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]