The European Journal of Contraception & Reproductive Health Care
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Female Romanian university students’ attitudes and perceptions about contraception and motherhood Iolanda Elena Blidaru, Gheorghe Furau & Demetra Socolov To cite this article: Iolanda Elena Blidaru, Gheorghe Furau & Demetra Socolov (2016) Female Romanian university students’ attitudes and perceptions about contraception and motherhood, The European Journal of Contraception & Reproductive Health Care, 21:1, 39-48, DOI: 10.3109/13625187.2015.1066495 To link to this article: http://dx.doi.org/10.3109/13625187.2015.1066495
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The European Journal of Contraception and Reproductive Health Care, 2016; 21: 3393 –48 38
Female Romanian university students’ attitudes and perceptions about contraception and motherhood
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Iolanda Elena Blidaru∗, Gheorghe Furau† and Demetra Socolov∗ ∗Department of Obstetrics and Gynaecology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania, and †Department of Obstetrics and Gynaecology, Arad University, Arad, Romania
ABSTRACT
Objectives The aim of our study was to investigate the knowledge, perceptions and attitudes of female Romanian university students, as possible future opinion leaders, about contraception and motherhood, by assessing their level of contraceptive use, opinions and knowledge with regard to combined oral contraceptives (COCs). Methods A knowledge, attitudes and practice questionnaire was conducted among 1105 female university students aged 19 to 30 years. The participants were recruited from six faculties at universities in Iasi and Arad, Romania. The study protocol was approved by the university ethics committees. Statistical analyses included percentages, χ2 tests and Fisher’s exact test. Results Two-thirds of respondents were in a relationship or married. Average age at first sexual intercourse was 18.6 years. Two out of three (69%) students identified themselves as sexually active. The same percentage showed a positive attitude towards contraception and stated that they used it. The most commonly used contraceptive methods were condoms, COCs and withdrawal. The students’ perceptions of the benefits and adverse effects of COCs were analysed. Half of the students had heard about extended COC regimens, but only 24% showed interest in using them regularly. A large proportion of pharmacy and non-medical students appeared to have poor knowledge about contraception and reproductive health, which generated misperceptions and negative attitudes. Two-thirds of the participants considered 25 to 29 years to be the optimal age for starting a family, and 85.5% intended to have children in the future. Conclusions Medical students, but not pharmacy students, showed higher levels of knowledge. Improvement of students’ knowledge, perceptions and attitudes towards general contraceptive use, COCs and childbearing is needed. Evidence-based information is required to address poor knowledge about the physiology of reproduction, misconceptions relating to COCs, and the possibility of menstrual suppression using hormonal contraceptive methods. Compulsory reproductive health education for students is desirable.
K E Y WO R D S
Childbearing; Combined oral contraception; Contraceptive use; Family planning in Romania; Female university students; Reproductive health knowledge
Correspondence: Gheorghe Furau, Department of Obstetrics and Gynecology, Emergency Clinical County Hospital of Arad, Vasile Goldis Western University of Arad, 4 Romei Street, 310118 Arad, Romania. Tel: ⫹ 40 722 483640. E-mail: [email protected]
© 2015 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2015.1066495
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I N T RO D U C T I O N
Between October 1966 and December 1989, due to the demographic policy established during the communist era by Romanian ex-president Nicolae Ceausescu, abortion on demand and use of modern contraceptive methods were banned by law and severely punished. The result was a significant increase in maternal mortality to 147 per 100,000 live births, due to the large number of illegal abortions. In 1989, unsafe abortions reached a peak of 169 per 100,000 live births1. Legal abortions were rarely permitted, and only in women who had already delivered five children, were older than 45 years of age or who had serious maternal health conditions. After December 1989, this law was abolished, and the abortion rate, mostly comprising at that time legal ‘on demand’ abortions, attained a peak of almost one million in 1990. This highlighted the need for education about contraception and its use. Consequently, since 1990, a network of family planning centres has been set up and governmental and non-governmental family planning programmes have been introduced with the purpose of providing mass education and direct access to contraception. Nevertheless, in spite of the current recorded increase in contraceptive use, there are still many unwanted pregnancies that end in legal abortions or unwanted births2. This is probably caused by the lack of information and education about contraception. Reproductive health education is not a compulsory topic in school curricula, universities and other learning communities. Much of this type of education is carried out on a voluntary basis. Using a scientific approach to identify gaps in knowledge about family planning and reproductive health could be a starting point for establishing appropriate policies to bring about improvement in reproductive health.
OBJECTIVES
The aim of this study was to investigate the level of knowledge and the prevalence of positive and negative individual perceptions and attitudes regarding contraception in general, combined oral contraceptives (COCs) in particular, and childbearing. This was achieved by measuring the responses of a group of medical and non-medical female university students to a specific questionnaire. Their high educational status created expectations of a higher level of knowledge 40
and understanding in this area than may be found among the general population. Beliefs regarding COCs were considered by analysing the opinions of the whole sample of welleducated young women on contraceptive efficacy, side effects and the possibility of menstrual suppression using extended COC regimens. Certain differences in knowledge between medical students and other academic students were then examined. Our assumption was that many of these students would become future opinion leaders, and some of them even policy-makers, and they need to be accurately informed and educated. Our investigation would provide insight into gaps in academic curricula in the area of family planning and modern contraception.
METHODS
Study population and design Our cross-sectional study was conducted at universities in Iasi and Arad, Romania. It included 1105 female undergraduates from the faculties of medicine, pharmacy, psychology, textiles and leather, economics, and law. These faculties were chosen in order to show the differences in knowledge between medical and other students. Due to the randomised selection of the group and the sample size, participants in the survey may be considered representative of female Romanian students in the same disciplines and of the same age. The sample size was statistically calculated for each academic centre by considering the total number of students, the sex distribution per faculty and the year of study. We accepted a margin of error of less than 5% for estimating the population size, resulting in a sample of about 500 students per academic centre. In our study, every ninth female student from Iasi and every sixth female student from Arad registered at the above-mentioned universities was invited to participate. Those who accepted completed a consent form and a study-specific questionnaire. The study protocol was approved by the ethics committees of Grigore T. Popa University of Medicine and Pharmacy, Iasi, and Vasile Goldis Western University, Arad. The following inclusion criteria were used: female sex, a high educational level represented by attendance at one of the above-mentioned faculties, consent to participate in the study, and completion of at least 19
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out of 22 questions in the questionnaire. The age range of the students was 19 to 30 years. Our study excluded students who were outside this age range, who refused to sign the informed consent form or whose questionnaires were incomplete. Consequently, 1105 participants were selected (93% of the 1188 distributed questionnaires: 641 from Iasi and 547 from Arad) and 83 were excluded, which represented a 6.9% rejection rate.
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Study questionnaire After signing the consent form, the participants filled in the anonymous questionnaire, which took about 30 min, in the presence of an investigator. The data collected in Romania represent partial results from a larger simultaneous study conducted in six academic centres in three countries (Romania, Hungary and Serbia), entitled ‘Women’s experience and attitudes regarding menstruation, contraception and childbearing’, which was partly funded by the European Society of Contraception and Reproductive Health. The questionnaire was a study-specific, validated, self-administered knowledge, attitudes and practice survey comprising 33 questions, common to all three countries. The questions covered four areas of interest: (i) socioeconomic and educational data; (ii) menstrual profile; (iii) sexual and contraceptive behaviour; (iv) knowledge and intentions with regard to childbearing. For our paper we assessed 22 questions (see Appendix to be found online at http://informahealthcare.com/ doi/abs/DOI:10.3109/13625187.2015.1066495). The first four questions outlined the inclusion criteria and the demographic characteristics of the subgroups (age, residency, area of study, marital status), and the rest allowed us to investigate the following dependent variables: • Knowledge related to the menstrual cycle; results were split into correct and incorrect answers (questions 12, 15, 16 and 19).
• Individual perceptions regarding regular menstrual bleeding, menstruation-related disorders, beneficial and adverse effects of COCs, optimal age for having a first child (questions 5, 7, 8, 11, 14 and 21); results were interpreted as positive (true) or negative (false). • Attitudes toward contraception use, menstrual suppression induced by extended COC regimens and childbearing (questions 6, 9, 10, 13, 17, 18, 20 and 22); part of the results could be classified into positive and negative outcomes. The Excel database was completed in the county statistical office of Szeged, Hungary. Statistical analysis was performed using SPSS software, version 17.0 (SPSS, Chicago, IL, USA), and Epi Info 7.1.4.0 (http:// wwwn.cdc.gov/epiinfo/7/index.htm). Percentages were calculated and χ2 tests performed using SPSS statistics. The confidence level for the odds ratio (OR; Fisher’s exact test, 95% CI) was computed using Epi Info. The significance level for p was set at 0.05.
R E S U LT S
Results regarding the total sample of students Our study group included 1105 female students aged 19 to 30 years (average age 22.6 ⫾ 3.0 years, median age 22 years), enrolled in the faculties of medicine, pharmacy, psychology, textiles and leather, economics, and law from the university cities of Iasi (605 participants) and Arad (500 participants). The distribution of students per faculty (Table 1) reflects our intention to balance the number of students from medicine and pharmacy (n ⫽ 548) with those from non-medical faculties (n ⫽ 557), starting with the assumption that the former would be better informed and educated about the issues under discussion. The sociodemographic features of the group revealed that most respondents were in a stable but unofficial relationship (48.7%); 14.8% were married
Table 1 The students’ distribution per faculty. University Iasi, n Arad, n Total, n
Medicine Pharmacy 242 216 458
90 0 90
Psychology 171 47 218
The European Journal of Contraception and Reproductive Health Care
Economics Law 0 129 129
0 108 108
Textiles and leather 102 0 102
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and the rest were single. Almost all were living in urban areas (95%).
The level of knowledge concerning the menstrual cycle in the whole study group may be considered insufficient given that fewer than one out of 10 (9%) of the participants knew that it is not necessary to have a monthly menstrual bleed in order to be healthy (question 15) and only 14% knew that methods interfering with the menstrual cycle did not harm future fertility (question 16). Menstrual suppression induced by extended COC regimens was known by only 53.6% (n ⫽ 592) of our respondents, half of whom, namely 45.8% (n ⫽ 271), were medical students (question 12). Furthermore, we found a noticeable lack of knowledge among all participants regarding the fact that maximum fertility occurs in the middle of the menstrual cycle, as only half of students (n ⫽ 561) knew about this (question 19).
disorders (question 5). Such complaints were reported by 967 students (87.5%), dysmenorrhoea being by far the most prominent complaint (Figure 2). Half of those with complaints had adopted a positive attitude and become temporary COC users. They stated that COCs eased their symptoms (question 7), which represents a positive perception. Almost two-thirds of the students said they would prefer less frequent menstrual bleeding (61%) (question 10). Several positive perceptions were behind this attitude: fewer menstrual problems (n ⫽ 340, 30.8%), better hygiene (n ⫽ 251, 22.7%) and improved quality of life (n ⫽ 194, 17.6%) (question 11). However, even though more than half of the participants in the study declared they would prefer fewer menstrual periods, two-thirds (n ⫽ 662) had negative perceptions and would not accept extended use of a COC (question 13). The main reasons given were fear of adverse effects and fear of infertility (Table 2) (question 14). We noticed that one-third of students did not answer this question, which we believed was most likely due to lack of knowledge.
Perceptions
Sexual attitudes and sexual/contraceptive practice
Our respondents’ perceptions concerning the beneficial and adverse effects of COCs are shown in Figure 1 (question 8). The figure shows that about one-third considered COCs to be safe and effective and was aware that COC use reduces dysmenorrhoea. Weight gain, fear of numerous side-effects and of interference with future fertility were the three most common negative perceptions about COCs in the study group. The present investigation revealed a large range of individual perceptions about menstrual cycle-related
Our investigation into sexual attitudes and sexual/contraceptive practice revealed that age at first intercourse was between 13 and 30 years (average 18.6 ⫾ 2.3 years, median 18 years) (question 17). At the time of the investigation, 68.7% (n ⫽ 759) of respondents declared they were sexually active and an equal number reported they were contraceptive users (question 9). We noticed a clear preference for barrier methods, namely condoms, followed by COCs (Table 3). The negative perceptions about COCs were
Figure 1 The students’perceptions about the positive and negative side effects of the oral contraceptives in the study group.
Figure 2 Symptoms associated with the menstrual cycle reported by the students.
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Knowledge
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Table 2 Reasons provided for the non-acceptance of suppressed menstruation by oral contraceptives. Reason
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Fear of pregnancy, % Fear of infertility, % Fear of adverse effects, % It is unnatural, % I think it’s dangerous, % No answer, %
Medicine
Pharmacy
Psychology
10.5 14.2 28.8 9.6 0.9 36.0
4.4 15.6 28.9 6.7 6.7 37.8
5.0 22.9 24.3 12.4 3.2 32.1
reflected in the fact that despite almost two-thirds reporting they would prefer less frequent menstrual bleeding only 24.1% (n ⫽ 266) stated that they were interested in using a daily low-dose COC without the pill-free interval for as long as they wanted. Moreover, one in 10 of the respondents (9.2%) would accept this opportunity only for special occasions such as exams, summer holidays or parties. The positive attitude towards motherhood was manifested by the majority of respondents (85.5%) who stated their intention to have children in the future, while 6.3% stated the contrary, and 8.1% were undecided (question 18). More than half of the participants (50.5%) stated that they might want to have two children. Equal numbers (14.4%) said they would like to have one child or three children, and a few (6.3%) considered having more than three children (question 22). Two-thirds of the participants (68%) positively perceived 25 to 29 years as the optimal age for having a first child (question 21).
Economics
Law
7.8 13.2 32.6 10.9 2.3 33.3
Textiles and leather
12.0 8.3 26.9 8.3 0.0 44.4
5.9 9.8 32.4 9.8 2.9 39.2
Attitudes toward childbearing were also investigated by ranking its importance among 13 socioeconomic and personal goals scored by the participants as follows: 1 ⫽ very important, 2 ⫽ not so important, 3 ⫽ not important at all (question 20). Our results revealed that, for our respondents, having good health, a job and being in a stable relationship with a partner were the top three most important factors associated with the dependent variable ‘childbearing’. Results comparing perceptions about COC use among subgroups of students When analysing perceptions about COC use among the six faculty profiles certain differences became obvious (Table 4). Oral contraceptive pills were positively perceived to be ‘safe and effective’ by significantly more medical students than by pharmacy students (OR 0.32; 95% CI 0.16–0.60; p ⬍ 0.001) and psychology students (OR 0.68; 95% CI 0.47–0.99; p ⬍ 0.03). Also,
Table 3 The contraceptive methods regularly used by the students in the entire study groups. Contraceptive method regularly used Condom, n (%) COCs, n (%) Interruption, n (%) Combined method: condom ⫹ COCs, n (%) Calendar method, n (%) Intrauterine device, n (%) Vaginal ring or patch, n (%) Spermicide, n (%) No method, n (%) Not sexually active, n (%) No answer, n (%) Total, n (%)
Psychology
Medicine
Pharmacy
141 108 22 27
(30.8) (23.6) (4.8) (5.9)
33 11 5 9
(36.7) (12.2) (5.6) (10.0)
53 35 22 8
(24.3) (16.1) (10.1) (3.7)
36 21 14 3
(27.9) (16.3) (10.9) (2.3)
27 36 11 1
13 4 4 0 49 79 11 458
(2.8) (0.9) (0.9) (0.0) (10.7) (17.2) (2.4) (100)
1 1 1 0 4 20 5 90
(1.1) (1.1) (1.1) (0.0) (4.4) (22.2) (5.6) (100)
4 1 0 1 23 65 6 218
(1.8) (0.5) (0.0) (0.5) (10.6) (29.8) (2.8) (100)
4 10 4 1 20 14 2 129
(3.1) (7.8) (3.1) (0.8) (15.5) (10.9) (1.6) (100)
9 (8.3) 5 (4.9) 36 (3.3) 3 (2.8) 0 (0.0) 19 (1.7) 1 (0.9) 0 (0.0) 10 (0.9) 1 (0.9) 0 (0.0) 3 (0.3) 10 (9.3) 10 (9.8) 116 (10.5) 7 (6.5) 14 (13.7) 199 (18.0) 2 (1.9) 5 (4.9) 31 (2.8) 108 (100) 102 (100) 1105 (100)
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Economics
Law
Textiles and leather
(25.0) (33.3) (10.2) (0.9)
41 25 2 0
Total
(40.2) 331 (30.0) (24.5) 236 (21.4) (2.0) 76 (6.9) (0.0) 48 (4.3)
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Table 4 Perceptions of COC beneficial and adverse effects among the non-medical students in relation to students of medicine.
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Perceived additional effect of COCs Safe and effective OR 95% CI p-value Improve quality of life OR 95% CI p-value Have a lot of side effects OR 95% CI p-value Control acne OR 95% CI p-value May interfere with future fertility OR 95% CI p-value May cause cancer OR 95% CI p-value Unnatural OR 95% CI p-value May cause weight gain OR 95% CI p-value Dangerous for health OR 95% CI p-value Reduce dysmenorrhoea OR 95% CI p-value Cause hirsutism OR 95% CI p-value
Medicine (ref.) (n ⫽ 458)
Pharmacy (n ⫽ 90)
Psychology (n ⫽ 218)
Economics (n ⫽ 129)
Law (n ⫽ 108)
Textiles and leather (n ⫽ 102)
1.00
0.32 0.16–0.60 ⬍ 0.001
0.68 0.47–0.99 ⬍ 0.03
0.64 0.47–1.15 0.16
1.08 068–1.70 0.70
1.01 0.62–1.61 0.96
1.00
0.10 0.002–0.63 ⬍ 0.007
0.63 0.32–1.18 0.13
0.49 0.18–1.12 0.08
0.59 0.21–1.37 0.20
0.72 0.28–1.61 0.42
1.00
1.61 0.86–2.88 0.09
0.47 0.25–0.84 0.08
0.42 0.18–0.88 0.01
0.57 0.25–1.17 0.11
0.89 0.44–1.70 0.73
1.00
1.00 0.48–1.94 0.993
0.59 0.33–1.03 0.056
0.60 0.28–1.18 0.13
1.03 0.53–1.90 0.91
079 0.37–1.55 0.48
1.00
1.87 0.89–3.71 0.056
1.02 0.55–1.84 0.92
0.49 0.16–1.21 0.11
0.09 0.002–0.57 0.004
2.03 1.03–3.86 ⬍ 0.02
1.00
0.41 0.09–2.89 0.39
0.34 0.03–1.56 0.14
0.29 0.006–2.00 0.20
0.34 0.008–2.39 0.29
0.36 0.008–2.54 0.32
1.00
0.62 0.06–2.74 0.53
0.91 0.31–2.39 0.84
0.65 0.12–2.35 0.50
0.52 0.05–2.27 0.38
0.83 0.15–3.00 0.78
1.00
0.59 0.26–1.22 0.14
1.28 0.74–2.17 0.32
0.98 0.55–1.68 0.95
1.84 1.09–3.06 0.12
1.31 0.73–2.29 0.30
1.00
0
0.54 0.21–1.24 0.12
0.57 0.17–1.54 0.25
0.54 0.13–1.60 0.26
0.14 0.003–0.87 0.26
1.00
0.69 0.39–1.18 0.16
0.45 0.31–0.66 ⬍ 0.001
0.58 0.35–0.94 ⬍ 0.02
0.58 0.33–0.96 ⬍ 0.02
1.01 0.62–1.63 0.94
1.00
2.89 1.15–6.81 ⬍ 0.006
0.88 0.32–2.15 0.77
1.32 0.46–3.39 0.53
1.12 0.32–3.20 0.82
0.46 0.05–1.97 0.294
Note: p ⬍ 0.05 is statistically significant; confidence interval (CI) was computed using the Fisher exact test.
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medical students most frequently correctly answered the positive statement that COCs may ‘improve quality of life’, but this finding was significant only compared with pharmacy students (OR 0.10; 95% CI 0.002–0.63; p ⬍ 0.007). Medical students were also significantly better informed about the positive additional effect of COCs in reducing dysmenorrhoea than were their colleagues from economics (OR 0.58; 95% CI 0.35–0.94; p ⬍ 0.02), law (OR 0.58; 95% CI 0.33–0.96; p ⬍ 0.02) and psychology (OR 0.45; 95% CI 0.31–0.66; p ⬍ 0.001). Significant misperceptions about the contraceptive pill were that it ‘causes hirsutism’ (stated by pharmacy students; OR 2.89; 95% CI 1.15–6.81; p ⬍ 0.006) and that it ‘may interfere with future fertility’ (stated by textiles and leather students; OR 2.03; 95% CI 1.03– 3.86; p ⬍ 0.02). DISCUSSION
Interpretation of the findings Our study was conducted among a large sample of female students of reproductive age. They may be considered a representative group of female Romanian students who are future specialists, opinion leaders and policy-makers. We investigated their attitudes towards contraception (a modern problem) and motherhood (a traditional issue). Regarding attitudes, we noticed in our respondents a delayed age at first sexual intercourse but an expected high rate of those who were sexually active. A similar number of declared contraceptive users was coupled with a low level of use of modern reliable contraceptives. There was a negative perception about hormonal contraceptives among our respondents, reflected by: (i) the high rate of contraceptive non-users (over 20%); (ii) among users, the high rate of use of unreliable methods; (iii) the low rate of participants who expressed an interest in regular use of extended COC regimens for menstrual suppression or postponement; and (iv) a high degree of non-acceptance of the aforementioned possibility. These findings are important, as it is currently known that the levels of knowledge and understanding as well as the personal opinions/perceptions of health care providers and opinion leaders are very important factors which may influence people’s attitudes towards contraception and, ultimately, their contraceptive
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choices. We assumed that students in medicine and pharmacy, as future health care providers, would be better informed about hormonal contraception and fertility issues than their colleagues from non-medical faculties. This was the case for medical students, but, surprisingly, not for future pharmacists, who proved to be the opposite. Motherhood was contemplated by the majority of students. Nevertheless, we found unexpectedly high rates of respondents who were undecided (8.1%) or who stated that they would not want to have children in the future (6.3%). These findings contradict traditional Romanian family values. Strengths and weaknesses of the study and future research This study has produced reliable data concerning educated young women’s attitudes and perceptions towards contraception and childbearing in Romania. Such information has not hitherto been published. Our study has brought to light presumed deficiencies in secondary and higher education curricula regarding contraception and reproductive health information which must be addressed. A further strength of our study was the extensive and detailed questionnaire that provided insights into young women’s awareness and perceptions regarding their potential fertility and their use and beliefs towards contraception. These perceptions, attitudes and behaviours regarding fertility ultimately shape some of their life decisions. A limitation of our study was the lack of information regarding attitudes towards modern, reliable contraceptive methods other than COCs. The absence of students from other faculties, such as teacher training, media and art, who might have an important impact on general public opinion and/or on the public education system, may be considered a drawback. We should also accept that due to the very personal and sensitive aspects investigated in the questionnaire, some of the answers regarding sexual activity and contraceptive use may not be completely accurate. Nevertheless, we consider that the large number of participants and the diversity of age, subject speciality, marital status, etc., in the study group may mitigate this. The present study did not include similarly aged young women without higher education, nor similar groups of young men. Future research could address
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these issues. A potential valuable development of the study would also involve young women who have already become mothers or who have had significant obstetric history such as abortion or miscarriage. The awareness and knowledge of our adolescent population about sexually transmitted diseases is another important area for future investigation.
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Differences in results in relation to other studies A review of recent literature showed remarkable differences regarding age at first sexual intercourse. Our results resemble the findings of Shindel et al.3 and Larsson and Tyden4, but our study participants were significantly older at first sexual intercourse by comparison with other investigators’ results in Europe and beyond5–8. Present findings about contraceptive behaviour among university students are comparable to data from other studies conducted in several countries between 2006 and 2011 which reported rates of sexually active female students ranging from 47.6–78% and of contraceptive users ranging from 25.4–100%4,6–14. Our results regarding the sexually active female student population are similar to those reported by Larsson and Tyden4 and Virtala et al.13. Conversely, we found a lower rate of contraceptive users in comparison with other researchers4,6,9,10,13–17. According to several studies into female university students’ contraceptive choices, COCs are one of the most popular methods of contraception, with use rates ranging between 13.6% and 80%3,4,6,8,9,15–17. As COCs were used by only 21.4% in our study group, our results could be interpreted as low level usage. In line with reports from other investigators4,8,10, 12,18,19, one of the most sensitive points of our research was that some of the women who would be considered educated were relatively uneducated regarding the benefits and risks of hormonal contraception in particular, and reproductive health in general. Attitudes towards menstrual suppression or postponement induced by extended COC regimens were significantly different from those found by Szarewski in a pan-European market research study carried out in 2009 among a representative sample of women from 18 European countries20. Our findings are similar to those reported by Sedlecky et al.12, and are way below 46
the 70% rate of interest in extended COC regimens reported by Greig et al.16 Delayed motherhood has become a common trend, especially among women with higher education13, probably due to the length of time it takes to complete postgraduate studies. The results of the present study are in line with those of other investigators as regards 25 to 29 years being the optimal age to start a family, as well as the majority’s intention to have two children12,13,21. In our research, the most important factors which influenced childbearing decisions were not traditional Romanian cultural values such as marriage and family support, or modern issues of career and financial independence, but good health, having a job and having a stable relationship with a partner. The degree of importance assigned to various social, economic and personal factors differs to some extent in other studies13,21, where the most important statements were: feeling sufficiently mature; being in a stable relationship with a partner with whom to share the responsibility; and having completed educational studies. Unlike our study, which found high rates of students who did not want to have children in the future or were undecided, the authors of similar papers reported rates of less than 1% in Serbia12, 2.7% in Sweden21 and 5.9% in Finland13. Relevance of the findings: Implications for policy-makers Our research highlighted the need for both institutional reproductive health education for students and increased family planning activities oriented towards evidence-based education and information and targeting the entire adolescent population. CONCLUSIONS
The present study adds to the European picture reflecting the sexual and reproductive health care situation of young educated women. It highlights the social, educational and medical implications for future specialists who will work in areas involving family planning and contraception. It also indicates the need for more research into patterns of contraceptive use among larger populations of all categories of young people. Our study confirms the working hypothesis that medical students are significantly better informed and
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have more positive attitudes and perceptions than other categories of students about most aspects of the physiology of the female reproductive system and contraception. Surprisingly, we found that the least informed and educated respondents were pharmacy students. Students’ attitudes and perceptions regarding contraception in general, COCs in particular, and motherhood need to be improved through evidence-based information. In many cases we ascertained how poor knowledge generated misperceptions and negative attitudes about contraception and reproductive health, as well as misconceptions relating to COCs and to the possibility of menstrual suppression through the use of hormonal contraceptive methods. In light of previous and current findings, compulsory reproductive health education and information for high school and university students are needed. Family planning and reproductive health services should deliver better and more accurate information about contraception to improve knowledge and use among young women and men.
AC K N OW L E D G E M E N T S
We are indebted to Sarah Randall for revising the manuscript. We are also grateful to Michelle Shedlin, from New York University College of Nursing, who revised the questionnaire; to the statisticians of the Central Statistical Institute, Szeged, Hungary, who established a large part of the Excel database; and to Lucian Boiculese, from the Department of Medical Informatics and Biostatistics at Grigore T. Popa University of Medicine and Pharmacy, for reviewing the statistical analysis. Declaration of interest: The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The authors are grateful to the European Society of Contraception and Reproductive Health for its financial support of the present study.
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sexual function score: A study in German female medical students. Contraception 2010;82:155–9. 16. Greig AJ, Palmer MA, Chepulis LM. Hormonal contraceptive practices in young Australian women (ⱕ 25 years) and their possible impact on menstrual frequency and iron requirements. Sexual Reproductive Healthcare 2010;1:99–103. 17. Rowen TS, Smith JF, Elsenberg ML, et al. Contraceptive usage patterns in North American medical students. Contraception 2011;83:459–65. 18. Bryden PJ, Fletcher P. Knowledge of the risks and benefits associated with oral contraception in a university-aged
sample of users and non-users. Contraception 2001;63: 223–7. 19. Patel CJ, Kooverjee T. Abortion and contraception: Attitudes of South African university students. Health Care Women International 2009;30:550–68. 20. Szarewski A.Women’s perceptions and attitudes towards menstrual bleeding. Gynaecology Forum 2011;16: 17–19. 21. Tydén T, Svanberg AS, Karlström PO, et al. Female university students’ attitudes to future motherhood and their understanding about fertility. Eur J Contracept Reprod Health Care 2006;11:181–9.
S U P P L E M E N T A RY M A T E R I A L AVA I L A B L E O N L I N E
Supplementary Appendix to be found online at http:// informahealthcare.com/doi/abs/10.3109/13625187. 2015.1066495
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ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal homepage: http://www.tandfonline.com/loi/iejc20
Female Romanian university students’ attitudes and perceptions about contraception and motherhood Iolanda Elena Blidaru, Gheorghe Furau & Demetra Socolov To cite this article: Iolanda Elena Blidaru, Gheorghe Furau & Demetra Socolov (2016) Female Romanian university students’ attitudes and perceptions about contraception and motherhood, The European Journal of Contraception & Reproductive Health Care, 21:1, 39-48, DOI: 10.3109/13625187.2015.1066495 To link to this article: http://dx.doi.org/10.3109/13625187.2015.1066495
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Female Romanian university students’ attitudes and perceptions about contraception and motherhood
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Iolanda Elena Blidaru∗, Gheorghe Furau† and Demetra Socolov∗ ∗Department of Obstetrics and Gynaecology, Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania, and †Department of Obstetrics and Gynaecology, Arad University, Arad, Romania
ABSTRACT
Objectives The aim of our study was to investigate the knowledge, perceptions and attitudes of female Romanian university students, as possible future opinion leaders, about contraception and motherhood, by assessing their level of contraceptive use, opinions and knowledge with regard to combined oral contraceptives (COCs). Methods A knowledge, attitudes and practice questionnaire was conducted among 1105 female university students aged 19 to 30 years. The participants were recruited from six faculties at universities in Iasi and Arad, Romania. The study protocol was approved by the university ethics committees. Statistical analyses included percentages, χ2 tests and Fisher’s exact test. Results Two-thirds of respondents were in a relationship or married. Average age at first sexual intercourse was 18.6 years. Two out of three (69%) students identified themselves as sexually active. The same percentage showed a positive attitude towards contraception and stated that they used it. The most commonly used contraceptive methods were condoms, COCs and withdrawal. The students’ perceptions of the benefits and adverse effects of COCs were analysed. Half of the students had heard about extended COC regimens, but only 24% showed interest in using them regularly. A large proportion of pharmacy and non-medical students appeared to have poor knowledge about contraception and reproductive health, which generated misperceptions and negative attitudes. Two-thirds of the participants considered 25 to 29 years to be the optimal age for starting a family, and 85.5% intended to have children in the future. Conclusions Medical students, but not pharmacy students, showed higher levels of knowledge. Improvement of students’ knowledge, perceptions and attitudes towards general contraceptive use, COCs and childbearing is needed. Evidence-based information is required to address poor knowledge about the physiology of reproduction, misconceptions relating to COCs, and the possibility of menstrual suppression using hormonal contraceptive methods. Compulsory reproductive health education for students is desirable.
K E Y WO R D S
Childbearing; Combined oral contraception; Contraceptive use; Family planning in Romania; Female university students; Reproductive health knowledge
Correspondence: Gheorghe Furau, Department of Obstetrics and Gynecology, Emergency Clinical County Hospital of Arad, Vasile Goldis Western University of Arad, 4 Romei Street, 310118 Arad, Romania. Tel: ⫹ 40 722 483640. E-mail: [email protected]
© 2015 The European Society of Contraception and Reproductive Health DOI: 10.3109/13625187.2015.1066495
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I N T RO D U C T I O N
Between October 1966 and December 1989, due to the demographic policy established during the communist era by Romanian ex-president Nicolae Ceausescu, abortion on demand and use of modern contraceptive methods were banned by law and severely punished. The result was a significant increase in maternal mortality to 147 per 100,000 live births, due to the large number of illegal abortions. In 1989, unsafe abortions reached a peak of 169 per 100,000 live births1. Legal abortions were rarely permitted, and only in women who had already delivered five children, were older than 45 years of age or who had serious maternal health conditions. After December 1989, this law was abolished, and the abortion rate, mostly comprising at that time legal ‘on demand’ abortions, attained a peak of almost one million in 1990. This highlighted the need for education about contraception and its use. Consequently, since 1990, a network of family planning centres has been set up and governmental and non-governmental family planning programmes have been introduced with the purpose of providing mass education and direct access to contraception. Nevertheless, in spite of the current recorded increase in contraceptive use, there are still many unwanted pregnancies that end in legal abortions or unwanted births2. This is probably caused by the lack of information and education about contraception. Reproductive health education is not a compulsory topic in school curricula, universities and other learning communities. Much of this type of education is carried out on a voluntary basis. Using a scientific approach to identify gaps in knowledge about family planning and reproductive health could be a starting point for establishing appropriate policies to bring about improvement in reproductive health.
OBJECTIVES
The aim of this study was to investigate the level of knowledge and the prevalence of positive and negative individual perceptions and attitudes regarding contraception in general, combined oral contraceptives (COCs) in particular, and childbearing. This was achieved by measuring the responses of a group of medical and non-medical female university students to a specific questionnaire. Their high educational status created expectations of a higher level of knowledge 40
and understanding in this area than may be found among the general population. Beliefs regarding COCs were considered by analysing the opinions of the whole sample of welleducated young women on contraceptive efficacy, side effects and the possibility of menstrual suppression using extended COC regimens. Certain differences in knowledge between medical students and other academic students were then examined. Our assumption was that many of these students would become future opinion leaders, and some of them even policy-makers, and they need to be accurately informed and educated. Our investigation would provide insight into gaps in academic curricula in the area of family planning and modern contraception.
METHODS
Study population and design Our cross-sectional study was conducted at universities in Iasi and Arad, Romania. It included 1105 female undergraduates from the faculties of medicine, pharmacy, psychology, textiles and leather, economics, and law. These faculties were chosen in order to show the differences in knowledge between medical and other students. Due to the randomised selection of the group and the sample size, participants in the survey may be considered representative of female Romanian students in the same disciplines and of the same age. The sample size was statistically calculated for each academic centre by considering the total number of students, the sex distribution per faculty and the year of study. We accepted a margin of error of less than 5% for estimating the population size, resulting in a sample of about 500 students per academic centre. In our study, every ninth female student from Iasi and every sixth female student from Arad registered at the above-mentioned universities was invited to participate. Those who accepted completed a consent form and a study-specific questionnaire. The study protocol was approved by the ethics committees of Grigore T. Popa University of Medicine and Pharmacy, Iasi, and Vasile Goldis Western University, Arad. The following inclusion criteria were used: female sex, a high educational level represented by attendance at one of the above-mentioned faculties, consent to participate in the study, and completion of at least 19
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out of 22 questions in the questionnaire. The age range of the students was 19 to 30 years. Our study excluded students who were outside this age range, who refused to sign the informed consent form or whose questionnaires were incomplete. Consequently, 1105 participants were selected (93% of the 1188 distributed questionnaires: 641 from Iasi and 547 from Arad) and 83 were excluded, which represented a 6.9% rejection rate.
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Study questionnaire After signing the consent form, the participants filled in the anonymous questionnaire, which took about 30 min, in the presence of an investigator. The data collected in Romania represent partial results from a larger simultaneous study conducted in six academic centres in three countries (Romania, Hungary and Serbia), entitled ‘Women’s experience and attitudes regarding menstruation, contraception and childbearing’, which was partly funded by the European Society of Contraception and Reproductive Health. The questionnaire was a study-specific, validated, self-administered knowledge, attitudes and practice survey comprising 33 questions, common to all three countries. The questions covered four areas of interest: (i) socioeconomic and educational data; (ii) menstrual profile; (iii) sexual and contraceptive behaviour; (iv) knowledge and intentions with regard to childbearing. For our paper we assessed 22 questions (see Appendix to be found online at http://informahealthcare.com/ doi/abs/DOI:10.3109/13625187.2015.1066495). The first four questions outlined the inclusion criteria and the demographic characteristics of the subgroups (age, residency, area of study, marital status), and the rest allowed us to investigate the following dependent variables: • Knowledge related to the menstrual cycle; results were split into correct and incorrect answers (questions 12, 15, 16 and 19).
• Individual perceptions regarding regular menstrual bleeding, menstruation-related disorders, beneficial and adverse effects of COCs, optimal age for having a first child (questions 5, 7, 8, 11, 14 and 21); results were interpreted as positive (true) or negative (false). • Attitudes toward contraception use, menstrual suppression induced by extended COC regimens and childbearing (questions 6, 9, 10, 13, 17, 18, 20 and 22); part of the results could be classified into positive and negative outcomes. The Excel database was completed in the county statistical office of Szeged, Hungary. Statistical analysis was performed using SPSS software, version 17.0 (SPSS, Chicago, IL, USA), and Epi Info 7.1.4.0 (http:// wwwn.cdc.gov/epiinfo/7/index.htm). Percentages were calculated and χ2 tests performed using SPSS statistics. The confidence level for the odds ratio (OR; Fisher’s exact test, 95% CI) was computed using Epi Info. The significance level for p was set at 0.05.
R E S U LT S
Results regarding the total sample of students Our study group included 1105 female students aged 19 to 30 years (average age 22.6 ⫾ 3.0 years, median age 22 years), enrolled in the faculties of medicine, pharmacy, psychology, textiles and leather, economics, and law from the university cities of Iasi (605 participants) and Arad (500 participants). The distribution of students per faculty (Table 1) reflects our intention to balance the number of students from medicine and pharmacy (n ⫽ 548) with those from non-medical faculties (n ⫽ 557), starting with the assumption that the former would be better informed and educated about the issues under discussion. The sociodemographic features of the group revealed that most respondents were in a stable but unofficial relationship (48.7%); 14.8% were married
Table 1 The students’ distribution per faculty. University Iasi, n Arad, n Total, n
Medicine Pharmacy 242 216 458
90 0 90
Psychology 171 47 218
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Economics Law 0 129 129
0 108 108
Textiles and leather 102 0 102
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and the rest were single. Almost all were living in urban areas (95%).
The level of knowledge concerning the menstrual cycle in the whole study group may be considered insufficient given that fewer than one out of 10 (9%) of the participants knew that it is not necessary to have a monthly menstrual bleed in order to be healthy (question 15) and only 14% knew that methods interfering with the menstrual cycle did not harm future fertility (question 16). Menstrual suppression induced by extended COC regimens was known by only 53.6% (n ⫽ 592) of our respondents, half of whom, namely 45.8% (n ⫽ 271), were medical students (question 12). Furthermore, we found a noticeable lack of knowledge among all participants regarding the fact that maximum fertility occurs in the middle of the menstrual cycle, as only half of students (n ⫽ 561) knew about this (question 19).
disorders (question 5). Such complaints were reported by 967 students (87.5%), dysmenorrhoea being by far the most prominent complaint (Figure 2). Half of those with complaints had adopted a positive attitude and become temporary COC users. They stated that COCs eased their symptoms (question 7), which represents a positive perception. Almost two-thirds of the students said they would prefer less frequent menstrual bleeding (61%) (question 10). Several positive perceptions were behind this attitude: fewer menstrual problems (n ⫽ 340, 30.8%), better hygiene (n ⫽ 251, 22.7%) and improved quality of life (n ⫽ 194, 17.6%) (question 11). However, even though more than half of the participants in the study declared they would prefer fewer menstrual periods, two-thirds (n ⫽ 662) had negative perceptions and would not accept extended use of a COC (question 13). The main reasons given were fear of adverse effects and fear of infertility (Table 2) (question 14). We noticed that one-third of students did not answer this question, which we believed was most likely due to lack of knowledge.
Perceptions
Sexual attitudes and sexual/contraceptive practice
Our respondents’ perceptions concerning the beneficial and adverse effects of COCs are shown in Figure 1 (question 8). The figure shows that about one-third considered COCs to be safe and effective and was aware that COC use reduces dysmenorrhoea. Weight gain, fear of numerous side-effects and of interference with future fertility were the three most common negative perceptions about COCs in the study group. The present investigation revealed a large range of individual perceptions about menstrual cycle-related
Our investigation into sexual attitudes and sexual/contraceptive practice revealed that age at first intercourse was between 13 and 30 years (average 18.6 ⫾ 2.3 years, median 18 years) (question 17). At the time of the investigation, 68.7% (n ⫽ 759) of respondents declared they were sexually active and an equal number reported they were contraceptive users (question 9). We noticed a clear preference for barrier methods, namely condoms, followed by COCs (Table 3). The negative perceptions about COCs were
Figure 1 The students’perceptions about the positive and negative side effects of the oral contraceptives in the study group.
Figure 2 Symptoms associated with the menstrual cycle reported by the students.
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Knowledge
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Table 2 Reasons provided for the non-acceptance of suppressed menstruation by oral contraceptives. Reason
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Fear of pregnancy, % Fear of infertility, % Fear of adverse effects, % It is unnatural, % I think it’s dangerous, % No answer, %
Medicine
Pharmacy
Psychology
10.5 14.2 28.8 9.6 0.9 36.0
4.4 15.6 28.9 6.7 6.7 37.8
5.0 22.9 24.3 12.4 3.2 32.1
reflected in the fact that despite almost two-thirds reporting they would prefer less frequent menstrual bleeding only 24.1% (n ⫽ 266) stated that they were interested in using a daily low-dose COC without the pill-free interval for as long as they wanted. Moreover, one in 10 of the respondents (9.2%) would accept this opportunity only for special occasions such as exams, summer holidays or parties. The positive attitude towards motherhood was manifested by the majority of respondents (85.5%) who stated their intention to have children in the future, while 6.3% stated the contrary, and 8.1% were undecided (question 18). More than half of the participants (50.5%) stated that they might want to have two children. Equal numbers (14.4%) said they would like to have one child or three children, and a few (6.3%) considered having more than three children (question 22). Two-thirds of the participants (68%) positively perceived 25 to 29 years as the optimal age for having a first child (question 21).
Economics
Law
7.8 13.2 32.6 10.9 2.3 33.3
Textiles and leather
12.0 8.3 26.9 8.3 0.0 44.4
5.9 9.8 32.4 9.8 2.9 39.2
Attitudes toward childbearing were also investigated by ranking its importance among 13 socioeconomic and personal goals scored by the participants as follows: 1 ⫽ very important, 2 ⫽ not so important, 3 ⫽ not important at all (question 20). Our results revealed that, for our respondents, having good health, a job and being in a stable relationship with a partner were the top three most important factors associated with the dependent variable ‘childbearing’. Results comparing perceptions about COC use among subgroups of students When analysing perceptions about COC use among the six faculty profiles certain differences became obvious (Table 4). Oral contraceptive pills were positively perceived to be ‘safe and effective’ by significantly more medical students than by pharmacy students (OR 0.32; 95% CI 0.16–0.60; p ⬍ 0.001) and psychology students (OR 0.68; 95% CI 0.47–0.99; p ⬍ 0.03). Also,
Table 3 The contraceptive methods regularly used by the students in the entire study groups. Contraceptive method regularly used Condom, n (%) COCs, n (%) Interruption, n (%) Combined method: condom ⫹ COCs, n (%) Calendar method, n (%) Intrauterine device, n (%) Vaginal ring or patch, n (%) Spermicide, n (%) No method, n (%) Not sexually active, n (%) No answer, n (%) Total, n (%)
Psychology
Medicine
Pharmacy
141 108 22 27
(30.8) (23.6) (4.8) (5.9)
33 11 5 9
(36.7) (12.2) (5.6) (10.0)
53 35 22 8
(24.3) (16.1) (10.1) (3.7)
36 21 14 3
(27.9) (16.3) (10.9) (2.3)
27 36 11 1
13 4 4 0 49 79 11 458
(2.8) (0.9) (0.9) (0.0) (10.7) (17.2) (2.4) (100)
1 1 1 0 4 20 5 90
(1.1) (1.1) (1.1) (0.0) (4.4) (22.2) (5.6) (100)
4 1 0 1 23 65 6 218
(1.8) (0.5) (0.0) (0.5) (10.6) (29.8) (2.8) (100)
4 10 4 1 20 14 2 129
(3.1) (7.8) (3.1) (0.8) (15.5) (10.9) (1.6) (100)
9 (8.3) 5 (4.9) 36 (3.3) 3 (2.8) 0 (0.0) 19 (1.7) 1 (0.9) 0 (0.0) 10 (0.9) 1 (0.9) 0 (0.0) 3 (0.3) 10 (9.3) 10 (9.8) 116 (10.5) 7 (6.5) 14 (13.7) 199 (18.0) 2 (1.9) 5 (4.9) 31 (2.8) 108 (100) 102 (100) 1105 (100)
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Economics
Law
Textiles and leather
(25.0) (33.3) (10.2) (0.9)
41 25 2 0
Total
(40.2) 331 (30.0) (24.5) 236 (21.4) (2.0) 76 (6.9) (0.0) 48 (4.3)
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Table 4 Perceptions of COC beneficial and adverse effects among the non-medical students in relation to students of medicine.
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Perceived additional effect of COCs Safe and effective OR 95% CI p-value Improve quality of life OR 95% CI p-value Have a lot of side effects OR 95% CI p-value Control acne OR 95% CI p-value May interfere with future fertility OR 95% CI p-value May cause cancer OR 95% CI p-value Unnatural OR 95% CI p-value May cause weight gain OR 95% CI p-value Dangerous for health OR 95% CI p-value Reduce dysmenorrhoea OR 95% CI p-value Cause hirsutism OR 95% CI p-value
Medicine (ref.) (n ⫽ 458)
Pharmacy (n ⫽ 90)
Psychology (n ⫽ 218)
Economics (n ⫽ 129)
Law (n ⫽ 108)
Textiles and leather (n ⫽ 102)
1.00
0.32 0.16–0.60 ⬍ 0.001
0.68 0.47–0.99 ⬍ 0.03
0.64 0.47–1.15 0.16
1.08 068–1.70 0.70
1.01 0.62–1.61 0.96
1.00
0.10 0.002–0.63 ⬍ 0.007
0.63 0.32–1.18 0.13
0.49 0.18–1.12 0.08
0.59 0.21–1.37 0.20
0.72 0.28–1.61 0.42
1.00
1.61 0.86–2.88 0.09
0.47 0.25–0.84 0.08
0.42 0.18–0.88 0.01
0.57 0.25–1.17 0.11
0.89 0.44–1.70 0.73
1.00
1.00 0.48–1.94 0.993
0.59 0.33–1.03 0.056
0.60 0.28–1.18 0.13
1.03 0.53–1.90 0.91
079 0.37–1.55 0.48
1.00
1.87 0.89–3.71 0.056
1.02 0.55–1.84 0.92
0.49 0.16–1.21 0.11
0.09 0.002–0.57 0.004
2.03 1.03–3.86 ⬍ 0.02
1.00
0.41 0.09–2.89 0.39
0.34 0.03–1.56 0.14
0.29 0.006–2.00 0.20
0.34 0.008–2.39 0.29
0.36 0.008–2.54 0.32
1.00
0.62 0.06–2.74 0.53
0.91 0.31–2.39 0.84
0.65 0.12–2.35 0.50
0.52 0.05–2.27 0.38
0.83 0.15–3.00 0.78
1.00
0.59 0.26–1.22 0.14
1.28 0.74–2.17 0.32
0.98 0.55–1.68 0.95
1.84 1.09–3.06 0.12
1.31 0.73–2.29 0.30
1.00
0
0.54 0.21–1.24 0.12
0.57 0.17–1.54 0.25
0.54 0.13–1.60 0.26
0.14 0.003–0.87 0.26
1.00
0.69 0.39–1.18 0.16
0.45 0.31–0.66 ⬍ 0.001
0.58 0.35–0.94 ⬍ 0.02
0.58 0.33–0.96 ⬍ 0.02
1.01 0.62–1.63 0.94
1.00
2.89 1.15–6.81 ⬍ 0.006
0.88 0.32–2.15 0.77
1.32 0.46–3.39 0.53
1.12 0.32–3.20 0.82
0.46 0.05–1.97 0.294
Note: p ⬍ 0.05 is statistically significant; confidence interval (CI) was computed using the Fisher exact test.
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medical students most frequently correctly answered the positive statement that COCs may ‘improve quality of life’, but this finding was significant only compared with pharmacy students (OR 0.10; 95% CI 0.002–0.63; p ⬍ 0.007). Medical students were also significantly better informed about the positive additional effect of COCs in reducing dysmenorrhoea than were their colleagues from economics (OR 0.58; 95% CI 0.35–0.94; p ⬍ 0.02), law (OR 0.58; 95% CI 0.33–0.96; p ⬍ 0.02) and psychology (OR 0.45; 95% CI 0.31–0.66; p ⬍ 0.001). Significant misperceptions about the contraceptive pill were that it ‘causes hirsutism’ (stated by pharmacy students; OR 2.89; 95% CI 1.15–6.81; p ⬍ 0.006) and that it ‘may interfere with future fertility’ (stated by textiles and leather students; OR 2.03; 95% CI 1.03– 3.86; p ⬍ 0.02). DISCUSSION
Interpretation of the findings Our study was conducted among a large sample of female students of reproductive age. They may be considered a representative group of female Romanian students who are future specialists, opinion leaders and policy-makers. We investigated their attitudes towards contraception (a modern problem) and motherhood (a traditional issue). Regarding attitudes, we noticed in our respondents a delayed age at first sexual intercourse but an expected high rate of those who were sexually active. A similar number of declared contraceptive users was coupled with a low level of use of modern reliable contraceptives. There was a negative perception about hormonal contraceptives among our respondents, reflected by: (i) the high rate of contraceptive non-users (over 20%); (ii) among users, the high rate of use of unreliable methods; (iii) the low rate of participants who expressed an interest in regular use of extended COC regimens for menstrual suppression or postponement; and (iv) a high degree of non-acceptance of the aforementioned possibility. These findings are important, as it is currently known that the levels of knowledge and understanding as well as the personal opinions/perceptions of health care providers and opinion leaders are very important factors which may influence people’s attitudes towards contraception and, ultimately, their contraceptive
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choices. We assumed that students in medicine and pharmacy, as future health care providers, would be better informed about hormonal contraception and fertility issues than their colleagues from non-medical faculties. This was the case for medical students, but, surprisingly, not for future pharmacists, who proved to be the opposite. Motherhood was contemplated by the majority of students. Nevertheless, we found unexpectedly high rates of respondents who were undecided (8.1%) or who stated that they would not want to have children in the future (6.3%). These findings contradict traditional Romanian family values. Strengths and weaknesses of the study and future research This study has produced reliable data concerning educated young women’s attitudes and perceptions towards contraception and childbearing in Romania. Such information has not hitherto been published. Our study has brought to light presumed deficiencies in secondary and higher education curricula regarding contraception and reproductive health information which must be addressed. A further strength of our study was the extensive and detailed questionnaire that provided insights into young women’s awareness and perceptions regarding their potential fertility and their use and beliefs towards contraception. These perceptions, attitudes and behaviours regarding fertility ultimately shape some of their life decisions. A limitation of our study was the lack of information regarding attitudes towards modern, reliable contraceptive methods other than COCs. The absence of students from other faculties, such as teacher training, media and art, who might have an important impact on general public opinion and/or on the public education system, may be considered a drawback. We should also accept that due to the very personal and sensitive aspects investigated in the questionnaire, some of the answers regarding sexual activity and contraceptive use may not be completely accurate. Nevertheless, we consider that the large number of participants and the diversity of age, subject speciality, marital status, etc., in the study group may mitigate this. The present study did not include similarly aged young women without higher education, nor similar groups of young men. Future research could address
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these issues. A potential valuable development of the study would also involve young women who have already become mothers or who have had significant obstetric history such as abortion or miscarriage. The awareness and knowledge of our adolescent population about sexually transmitted diseases is another important area for future investigation.
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Differences in results in relation to other studies A review of recent literature showed remarkable differences regarding age at first sexual intercourse. Our results resemble the findings of Shindel et al.3 and Larsson and Tyden4, but our study participants were significantly older at first sexual intercourse by comparison with other investigators’ results in Europe and beyond5–8. Present findings about contraceptive behaviour among university students are comparable to data from other studies conducted in several countries between 2006 and 2011 which reported rates of sexually active female students ranging from 47.6–78% and of contraceptive users ranging from 25.4–100%4,6–14. Our results regarding the sexually active female student population are similar to those reported by Larsson and Tyden4 and Virtala et al.13. Conversely, we found a lower rate of contraceptive users in comparison with other researchers4,6,9,10,13–17. According to several studies into female university students’ contraceptive choices, COCs are one of the most popular methods of contraception, with use rates ranging between 13.6% and 80%3,4,6,8,9,15–17. As COCs were used by only 21.4% in our study group, our results could be interpreted as low level usage. In line with reports from other investigators4,8,10, 12,18,19, one of the most sensitive points of our research was that some of the women who would be considered educated were relatively uneducated regarding the benefits and risks of hormonal contraception in particular, and reproductive health in general. Attitudes towards menstrual suppression or postponement induced by extended COC regimens were significantly different from those found by Szarewski in a pan-European market research study carried out in 2009 among a representative sample of women from 18 European countries20. Our findings are similar to those reported by Sedlecky et al.12, and are way below 46
the 70% rate of interest in extended COC regimens reported by Greig et al.16 Delayed motherhood has become a common trend, especially among women with higher education13, probably due to the length of time it takes to complete postgraduate studies. The results of the present study are in line with those of other investigators as regards 25 to 29 years being the optimal age to start a family, as well as the majority’s intention to have two children12,13,21. In our research, the most important factors which influenced childbearing decisions were not traditional Romanian cultural values such as marriage and family support, or modern issues of career and financial independence, but good health, having a job and having a stable relationship with a partner. The degree of importance assigned to various social, economic and personal factors differs to some extent in other studies13,21, where the most important statements were: feeling sufficiently mature; being in a stable relationship with a partner with whom to share the responsibility; and having completed educational studies. Unlike our study, which found high rates of students who did not want to have children in the future or were undecided, the authors of similar papers reported rates of less than 1% in Serbia12, 2.7% in Sweden21 and 5.9% in Finland13. Relevance of the findings: Implications for policy-makers Our research highlighted the need for both institutional reproductive health education for students and increased family planning activities oriented towards evidence-based education and information and targeting the entire adolescent population. CONCLUSIONS
The present study adds to the European picture reflecting the sexual and reproductive health care situation of young educated women. It highlights the social, educational and medical implications for future specialists who will work in areas involving family planning and contraception. It also indicates the need for more research into patterns of contraceptive use among larger populations of all categories of young people. Our study confirms the working hypothesis that medical students are significantly better informed and
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have more positive attitudes and perceptions than other categories of students about most aspects of the physiology of the female reproductive system and contraception. Surprisingly, we found that the least informed and educated respondents were pharmacy students. Students’ attitudes and perceptions regarding contraception in general, COCs in particular, and motherhood need to be improved through evidence-based information. In many cases we ascertained how poor knowledge generated misperceptions and negative attitudes about contraception and reproductive health, as well as misconceptions relating to COCs and to the possibility of menstrual suppression through the use of hormonal contraceptive methods. In light of previous and current findings, compulsory reproductive health education and information for high school and university students are needed. Family planning and reproductive health services should deliver better and more accurate information about contraception to improve knowledge and use among young women and men.
AC K N OW L E D G E M E N T S
We are indebted to Sarah Randall for revising the manuscript. We are also grateful to Michelle Shedlin, from New York University College of Nursing, who revised the questionnaire; to the statisticians of the Central Statistical Institute, Szeged, Hungary, who established a large part of the Excel database; and to Lucian Boiculese, from the Department of Medical Informatics and Biostatistics at Grigore T. Popa University of Medicine and Pharmacy, for reviewing the statistical analysis. Declaration of interest: The authors declare no conflicts of interest. The authors alone are responsible for the content and writing of the paper. The authors are grateful to the European Society of Contraception and Reproductive Health for its financial support of the present study.
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S U P P L E M E N T A RY M A T E R I A L AVA I L A B L E O N L I N E
Supplementary Appendix to be found online at http:// informahealthcare.com/doi/abs/10.3109/13625187. 2015.1066495
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