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Dr WM Pick r'rn chB; MFGP(sA);
I)TM&H; DPH; FFCH(CM) M Med ( C o n n u n i t v H e a l t h )
Dept Communin'Health Mcdical School Universitt' of Capc Tos'n Obsenaton'
7 9 2 5
Curriculum vitae
William Moses Pick l'as born ancl educated in Cape'Iol'n, matriculated at Trafalgar High School in I958, ancl in l96tt received the MBChB at UC'f. Aficr some time at thc Barirgr.r'an:rth Hospital he joined a fiimily practice in Cape Torvn from 1967 to l9B4;
d t r r i n g t l r i r ti n r c lr e a l s u s p e n t r r c l r i r r England in farnily'prilcticc units in Dorchester and London. Sincc I985 William has bccn in the Dcpt of Comn.runitv Health at UCT.
C a p e T o w n w M P i c k
Surnm.nry
This atticle repzrts 0n the pattetn of clntvrlceptiln in n genet nl fataily practice in Cape Town; the type of conh,aception wwd. the reason Jbr wsing it (or toot using it), patity, age-J'actots, rel'igion, sid,e fficts, smohircg, blood.
ptessure - all these aspects contribwte to the pnttern.
S AJi, Faru Pract 1990; l1: 12-17
I(EYWORDS:
Contraception; Birth Control;
General Practice; Teenage Pregnancy; Smoking
Background
In 1985 the 4I5 \,vomcn attendins a general practice in Ravcnsmead oicr a three month ocriod were
intcn'icu.ed rvith rcgard to their usc of contraccption. Of thcsc women 20I (48,4o/o) uscd some lbrrn of contraceDtion at tlte timc of tl're inte rview while 231 (55,670) had cver used contraception. Of the teenagcrs intcrvielvec1, 2070 uscd some lbrm of contraceDtio n and 7 5o/o of these r.l,ere on injectiblc hormones.
Hormonal methods (both oral and intramuscular) caused the grcatcst numbcr of side cfl'ccts of rvhich headaches and irregular bleeding
\\'ere tne malor ones.
Methods of contraception used u,rre strongly associated with age and pariw with 87o/o of tlte \vorre n ovcr 40 y,cxp5 having had tubal occlusion.
Of women with morc than 3
children, 57o/o had tubal ligation and 22o/o used oral contraception.
Married women wcrc more satisflcd rvith rhcir method of t'onrracetrtion than singlc \\romen.
Of the users 38,370 had chosen thc method of contraception themselves and the rest had thC method of contraception prescribcd by a health u'orker. Approximatelv 9 0o/o rcportecl that ther'\\/ere satisfied u.ith thc method being used.
Socio-economic status had no relationship with either the use or non-use of contraccption, or u'ith the method of contraception used.
About onc third of pill r.rscrs smoked, a fact that sives cause fbr concern in vieu. of thJincreascd morbidin' and m o r t r l i n ' f h a t o c c t r r s i n t h c s e subjccts.
Introduction
Tl're importancc of individualisccl
"tailormade" contraception l-ras bccn recognised arrd strongly advocated by Sapire.t In ordcr to develop sucl-r s c r u l c c s . i t i s n e c e s s a n t o h a v c infbrmation on oatterns of contraceptive practice.
Although various communitv based studies har.c been conductcd br, the H u m a u S c i e n c c s R e s e a r c h C o i r n c i l (HSRC), little information regarding contraceptiVc practice in $ orrrerr attending general practiccs in South Africa exists.'z
This article reports on the pattcrn of contraccption in a gcncral practicc.
Infbrmation conccrning thc npe of contraception used, thc reason fbr Lrsagc, and factors related to Lrsage were collected. Thc general pracrice is in Ravensmead, a suburb situated about 16 km north ofthe cin, of Cape Tou'n. Contracepr ilc s.'n ice, 12 SA Far-nil.v Practicc January 1990 SA Huisar-tsprakq,k Ianuarie I990
are provided in the area by 2 general practitioners, a local authority clinic and the nearby Tygerberg Hospital.
Tl"re population is approximatcly 22,632 people.'There were 1,368 births in 1985 of whichI2.To/owere to teenagers.a
Methods
The studv is of a cross-sectional descriptive design. A trained interviewer administered a pretcsted questionnaire to all women between the ages of 15 ,vears and 54 years who attended the general practice over the three-month period between August and October 1985. Demographic data which included age, marital status, religion, and occupation of respondents was noted. Information on method of contraceorion. reasons for use or non-use, parit,v, side- effects, cigarette smolcing, and on blood oressure measurement was collectid but no inquiry about sexual activity was made.
Results
The study included 415 women. The response rate was close to l00o/o as thcre was only one refusal.
Information was incompletc in 8 cases.
The mean age was 27,9 years whlle the median age was 26 years. Of the se women 2Ol (48,4o/o) practised some method of contraception at the time of the intervicw.
Contraceptive Methods
Of those who used any form of contraception 32,8o/o (66) used oral contraception, 29,8o/o (60) used injectable hormones, 12,4o/o (25) uscd an IUCD, 20,3o/o (4I)
had undergone tubal ligation, 2,lo/o (5) used withdrawal, 1,9%o (4) used thc Condom. (Table I).
Injectable hormones were the commonest method uscd in
teenagers, though the numbers were small; (5 out of 7).
Betwcen 20 and 29 years, oral contraception and inj ectable hormones were equally popular, whilc tubal occlusion was the most commonly used method in tl're 30 to 39 year age group, especially when they had had more than 3 children.
Reasons for choice of Method
Whrle 77 (38,27o/o) had chosen the method themselves, 84 (4l,93o/o) had the method prescribed by a nurse or doctor. For 7o/o ( 14) other methods werc medically contra-indicated while l2Vo (24) had experienccd side cffects with other methods. Five ( 5) subjects (2.5o/o) gave no explanation for choice of method.
Non-use of Contraception Thc proponion of subjects using contraception increased with increasing age from l5 years to 39 years, (Table I).
Of the 214 subjects who did not use any form of contraception 13,4o/o were Pregnant ar rhc time of the interview: 2.5olo stated that their sexual partners disapproved of contraception, while 28,8o/o provided other reasons, including the planning of a prcgnancy. Side effects were citcd as the reason for non-use in l27o of subjects;4.0,7o/o provided no reasons lor not usrng contraccptlon.
Womcn were not asked whether they were post-menopausal or not.
Marital Status
Of the interviewees 265 (640/o\ were married while I34 (32.50/o) were single, 7 (1,7o/o) were divorced, 3 of whom used contraception and 9
Table I: Method of Contraception vs Age
(percentages in brackets)
Method
Age Category (Yrs)
1 5 1 9 20.29 30.39 40-49 50+
TotalOral Con
r ( 1 4 ) 44(42) 20(2e) i ( 4 ) 0(0) 6 6 ( 3 2 , 8 ) IUCD 0 ( 0 ) e(e) r4(20) 2(e) 0 ( 0 ) 25(r2,4)
IM horm
s(72) 43(4r) r2(r7) 0(0) 0 ( 0 ) 60(29,8)
Condom
0(0) 2 ( 2 ) I ( I ) 0 ( 0 ) l ( 3 3 ) 4 ( r , 9 )
Withdrawal
l ( 1 4 ) 3 ( 3 ) 0 ( 0 ) 0 ( 0 ) r ( 3 3 ) 5 ( 2 , t ) Tubal lig 0 ( 0 ) 3 ( 3 ) 22(32) r s(87) r . ( 3 3 ) 4r(20,3)
Total
7( 100) r04( 100 6e(ee) r 8 ( r 0 0 ) 3( ro0) 20r(99,3)
o/o Users
1B
. i J1 15 8 59 I00
1 . 3 S A F a m i l y P r a c t i c c f a n u a r y 1 9 9 0 SA Huisartspraktyk Januarie 1990
(2,2:/o) were widowed of whom 2 usect contracePtlon.
A greater proportion of married women (8070) than single women (257o) used contraception (p lcss than 0,05) and a greater proportion of single women (547o) than married women (27Vo) used injectable homones, (p less than 0,006).
Marital status was statistically significantly related to agc and parity, the proportion of married women increasing with increasing agc and parity.
Parity
Increasing parity, as shown in Table II, is associated with an increasing use of contraception, (Correlation coefficient 0,82; p less than 0,05).
Oral contraception was the major method used by the few nullipara ( l l out of Il0) who Dractised
contraceotion. Withdrawal was the
second most commonlv used metl"rod in nullipara.
As parity increased, the method of contraception changcd. The use of inlcctable hormones decreased as parity increased. Tubal ligation was the main method of contraccption in subjects with 3 or morc children.
Religion
Religious affiliation had no effect on the use or the non-use of contraception with no statistically
significant difference in the proportion of Roman Catholics and Protestants usi ng contraception.
Social Class
Most subjects fell into social classes II, III and fV as defined by Schlemmer and Stopforth.'
This had no influence on the use or non-use ofcontraception and had no
influcnce on methods of contraceDtion.
Table II: Parity and Contraception
Mcthod Parity
0 l 3 4 5 o 1 Total
Oral con.
s(4,s )
30127 ) 27130) 8( l6) 5(22) 0(0) L ( l 0 ) 76IUCD 1(0,e) 7(6) L 0 ( i l )
e(r8)
0(0) 2(14) 0(0) 29IM Hormns l(0,e) 36(32) 20(22) 9( 18) l / q I 3(21) 0(0) 7l
Condonr r(0,9) 2(2) 0(0)
o(o) o(o) ()(o )
r( 10) 4\\'ithdra*al 3 ( 3 ) 0(0) I ( l ) 0(0) I 14r 0(0) 0(0) 5
Tubal lig 0(0) l ( l)
s(6)
t4(2e) I3(57) 6(42) 7(70) 4 None 99(90) 35(32) 27(30) 9( l8) , / 0 | 3(21 ) i ( 1 0 ) \76Iotal L 10( 100,2) 1 1 1 ( 1 0 0 )90( 100) 49(99) 23(101 ) 14(98) t0( 100) NB: L subjects with incomplete data were not included
2. pcrcentages in brackets
14 SA Famill,Practice lanuary 1990 S A H t r i s a r t s p r a k n k ] a n u a r i e 1 9 9 0
Table III: Side Effects
Side Effects
Questions about side cffects were asked of all those women who we re currently practising contraccption or u'ho had cver used contraccDtion. Of all use rs, 70o/o (all mcthods)
responded affrrmatively to closed questions about side cffects.
The major side effects reported by respondents were headaches, bleeding disturbance, loss of libido and obesity. (Table III) Subjects who were using injectable hormones reportcd the most side effects, followed by those on oral
contraceptives and the IUCD (Table IV). Side effbcts were reported with all methods of contraceotion ( i n c l u d i n g t u b a l o c c l u s i o n ) e x c e p t f o r the use of the condom.
Satisfaction
While 90,4olo of subjects reported that they were satisfied with the method of contraception used, 9,60lo were not satisfied, most of the latter rcporting side cffects as th€ main reason for dissatisfaction. A
signifi cantly larger proportion ( 960lo )
Side Effect No. o/o
Headache
70 3 2 , 1
Bleeding
3 7 16,4
Loss of Libido
3r 14,2
Weight gain
26 TT,92
Rash
20 9 , 1 7
Nausea
2 0 9 , r 7
Other
I 3 5 , 9 6
Table IV: Side Effects and Method of Contraception
Method Numbcr of Patients with Side Effects
Nir
Bleeding Rash Headache s Weight GainLibido LossOral Con I 5 0 l l 7
24
7 1 lruCD 72
z0
6 I JIM Hormn
t 3 8
l 5+
1 tt2 t2
Condom l i
0 0 0 0 0
Mthdrarval I4
0
0 00
Tubal Lig t 1 6 o aA 9 2 L
Otlicr 2T
0 0
I I0
in the 30 - 39 ycar age group were satisfied than in the 15 - J,9 year age group (630lo). (Chi square test, p less than 0,004)
Cigarette Smoking
33,97o/o (n:141) of all subjects interviewed, smoked cigarettes.
2l out of64 users oforal
contraccption smoked (32,89o/o).
I20 (85%) of all smokers smoked fewer than l0 cigarettes per day.
Homonal methods caused most side effects especially headaches and irregular bleeding.
In spite of the small number of smokers, smoking (both in terms of number of cigarettes and duration) increased with increasing pariry.
Blood Pressure Monitoring
80,58% (n:166) of the subjects using contraception had their blood pressures checked regularly at the source of contraception (mainly the local family planning clinic).
Discussion
The proportion of women using contraception in this study was smaller than that (7370) found in a study in Hanover Park, Cape Town rn 1974.6 The two studies are however not directly comparablc as the llanover Park study was community-based while the present study concerns women attending a general practitioner and clearly are not representative ofthe general female population in Ravensmead.
The proportion of women in this study practisi ng contraception (48,8%) corresponds almost exactly with the figure reported by the Medical Officer of the Cape Divisional Council for 1984.4
15 SA Family Practice lanuary 1990 SA Huisartspraktyk Januarie 1990
A study on women attending antenatal and family planning clinics in Caoe Town showed a similar rate of use." While the proportion of ferti le femalcs u sing contraception varies from area to area in South Africa, data from some arcas in developed countries, for example the West Suffolk Health Authority in England where only 3l7o of the'at risk' females (thosc between the ages of 15 and 44 years) used
contracePtion, suggests that low levels ofcontraception are not peculiar to women in this country.s The geatest proportion of women using contraception were found in the older groups. At the same time, the proponion of teenagers using contraception in this study (19,5olo) was slightly higher than the 14,2o/o found by Van Tonder in a
countrywide survey of clinic attenders rn 1978.e
The method chosen is directly related to the way in which it was presented
The finding that 51,60lo of the subjects in this study used no contraception is significant even though the level ofsexual activity and the number of post-menopausal women were not establishcd. As not all the non-users may have been sexually active at the time of the interview and were therefore strictly speaking not (at
risk,'the rate of use in those truly'at risk' is therefore likely to be higher than 48,4o/o.
Side-effects, such as irregular bleeding and headaches were cited as the reason for non-use of
contraceptlon in a certain proportion (l2o/o) of non-users. Careful
monitoring of sidc efTects
accompanied bv tailoring the method t o t h c i n d i v i d u a l m a v a s s i s r i n encouraging these subjects to conti nuc rvith c0ntraccDtiol.t.
As was found in other studics 2'7'10 vcry few malcs used any fbrm of contraception in the group under study. This is an area that needs attention.
Teenagers mostly used injectable hormones
Extensive studics in India, I(orea thc Phillipines and Tr.rrkcy havc shown that thc mcthod of conrraccotion choscn uas rclatcd directlv to the $a\
in r.vhich the diffbrent methods of contraception was prescntcd. The pattern of usc of contraccption in this study probably reflects the way in which the differcnt merhods wcre ofl-ered to thc subjccts. The fact that only 38,37o of the users of
contraception chose thc method of their orvir free u'ill undcrscores rhis fact. Factors such as the subiects' knou ledge and rttitudes, information provided and the attitudes ofthe rrroviders havc been shou,n ro influence the choice of method."
The trend to r.rse tubal occlusion in patients ovcr 40 vears reflects good contraceptitre practice in view of the incrcased risk of circulatory
complications with hormonal
methods, espcciall,v in smokers in this age group,--.
Tccnagers, most of rvhom were on iniectable hormoncs. were fbund to
be poor attenders in a study at the local Family Planning Clinic.to It is possible that injcctable hormones are beirrg prescribed by the se rr,'icc providers in vicw ofthe poor attendance by tecnagers. It may well be that the method and its side effects leads to dissatisfhction and
subsequent non-attendance.
Teenagers may be less tolerant of side effects and this may affect
compliance. Therefbre tl-re rnethod of contraception needs to be considered particularly carefully in tl"resc young women. The importancc of pre- treatmcnt counselling and continr.red reassurance cannot De
ove remphasized.
However, there is no ideal method of contraception for teenagers who sometimes prefer not to use the oral contraceptive for fear of being'found ollt' by disappror,ing parents.
The lack of a statisticallv significant relatiorrship hcrween socio-cconom ic status and contraceptive method suggests that the method prescribed was not influenced by the indir,.iduai's level of sophistication.
One third of subjects on oral contraceDtion smoke. a combination that has been shown to increase the risk of cardiovascular mortalitv four times in the United l(ngdom.i, This potentially lethal combinarion is a cause for concern and patients on oral contraception should be actively discouraged from smoking.
The monitoring of Blood Pre ssure in the subjects in this study was excellent, rcflccting good
contraceptive practice by the serwice providers. The risk ofhypertension as a side-efFcct ofcontraceDtion is thereby rcduced.'3
The pattern ofcontraception usage found in this study suggests rhar providers of the scrvice should take cognisance ofthe uniqueness ofthe individual and the importance of pre- treatmcnt counselling and continuous rnonitoring in prescribing any form of contraception. To improve this service more research is needed in the area of compliance as it rclates to contraceptive methods, influenced as these are by side effects, client- provider relationships and knorviedgc and attitudcs of both client and provider.
Aknowledgements
The patients who so willingly patticipated in the stwd.y anrl. Dr A Mitho who allowed. access to his pt actice, are thonhed. wost sir'tcet e$,.
Drs M Holfinan, l) Whittaker, J T Mets and. J E Myerc are thanhed. for their wseful comments and Dr K E Sapire is thanhed. for hsr paluable n iticism.
References
1 Sapire I( E. Thc prcsenr sratus of Fami\' Pl2n1ing. S Afr Med / 1988;
7 4 : 2 - 3 .
Oral contraception combined with smoking, increase the risk of cardiovascular morralitv four times
The high prcvalence of side effects in this str-rdy may be due to bias as the subjects .ll'ere attenders at a general practice. The fact that9O,4o/o of users were satisficd with the method of contraception in spite of side eff-ects in70o/o of users, suggests that rvomen have come to exoect that
contraception lclds to side effects.
t6 SA Family Practice lanuary 1990 SA Huisartspraktl,k lanuarie 1990
2. Mostert W P, Erasr-nr.rs G.
Strceksvcrskillc in f-ertiliteit cn kontrasepsie onder Indiers, I(curlingc en Swart Suid Afiikancrs. HSRC (sn 253), P r c t o r i a . 1 9 8 6 .
3. 1985 Ccnsus. Central Statistic Sen'ice. Pretoria.
4. Annual Rcoort of thc Medical Officer of Hcalth, Cape Divisional Cor-rncil, I985.
5. Schlemmer L, Stopfbrth P. A guide to the Coding of Occupations in South Africa.
Fact Paoer No 4. Centre for Applied Social Sciences, Universitv of Natal, 1979.
EIJANSSEN
EI PHARMACEUTICA
Committed to prcgress through research
Toegewy aan vooruitgang deur navorsing
l l . 6 .
1 2 . 7 .
Groeneu'ald H f. Fertilrtert en Gesinsbeplanning in Hanover Park. HSRC: Prctoria, I976.
Ror"rx A. Family Planning among a group of u'omen. S Afr Med J 1 9 8 4 ; 6 5 : 8 9 8 9 0 f
Schopflin I( E. Comrnunin' F a m i i v P l a r r n i n g C l i n i c s : A n Evaluaticln. The Practitrcncr 1983;227: 829-31.
Van Tondcr, I L. Die demo- graticsc proficl van klientc vln gesinsbeplanning klinicke: Junie 1978. Pretoria. RGN. 1980.
P i c k W M . F a m i l y P l a n n i n g a t Ravensmead Clinic, 1986.
(Unpublished Rcport).
"There are still manV severe problems for which there is no cure at all and for which effective drugs have to be found quickly in the interests of all those who are suffering.
This is the wav we see our duw here and we would like to think that we have contributed to the solution to some of those problems.
And wewill continue...
...becausethere is so much more that needs to be done."
Dr. Paul Janssen, Chairman. Directorof Research.
\ fHO Task Force on
Psvcirosociai Rcsearch in Familv P l a n n i n s . S t u d i c s i n F a m i l v P l a n n i n [ ]9 8 0 ; I l g / t 9 t : 2 6 7 7 3 .
Iloy;rl Collegc <>f Gencral
Practitioucrs' Oral Conrraccptiol.l Stud1,. l4,rttaliqv among Oral Contraceotive Llscrs. Lancet
1 9 7 7 : O & : 7 2 7 3 0 .
Cook N R, Schcrr P S, Evans D et al. Regrcssion Anah.sis of Changcs in Blood Prcssure with Oral Contraception Usc. A.m J E p i d e m i o l I9 8 5 ; l 2 l ( 4 ) : 5 3 0 9 .
1 3 . 8 .
9 .
t0.
"Daar is nog talle ernstige probleme waarvoor daar hoegenaamd geen genesing bestaan nie en waaryoor effuktiewe middels spoedrg gevind sal moet word jn belang van al dregene wat lyding verduur.
Dit is die wyse waarop ons ons plig hier vertolk en ons sal graag die wete wil h6 dat ons 'n bydrae kan lewer in die oplossing van sommige van hierdie probleme.
En ons sal aanhou...
...aangesiendaar nog s6 baie is wat gecloen moet word."
Dr. Paul Janssen, Voorsitter Direkteurvan Navorsing.
JANSSEN PHARMACEUTICA (PW) LTD./(EDMS) BPK. (REG. NO.8O/11122/OZ 1sth ROAD/WEC HALFWAY HOUSE 1685 OJPh. SA SAMJ 11,/87 RP
