Introduction

In today’s modern world, the choice to access safe family planning measures is a human right and according to the United Nations, it is a central part of new globalization and urbanization trend to promote gender equality, the empowerment of women but more so it is a big step towards reduction of poverty (“Elimam, Abdullah, Al-Banawi, Bokhari, & Abla, 2014). However, due to one reason or another such as the lack of adequate information, women around the world do not have access to safe and modern methods to avoid unwanted pregnancies (“Consequences of unmet need,” 2013). In many of the cases, unmet needs affect women who are sexually active and wish to remain active but without the risks of having another child. For some, it may be a question of delaying the next birth or avoiding it entirely (“Consequences of unmet need,” 2013). However, their behaviors differ from their desires as they do not take or follow up on their contraceptive medication or precautionary measures leading to a lapse in the numbers (“Consequences of unmet need,” 2013). At times the fault may be in the lack of support from their partners or community, in other instances it has been the religious or governmental hindrances that have affected the changes hindering the process. Irrespective of the cause, it has been a major hurdle especially for the women in the Kingdom of Saudi Arabia. For some time studies and research has been conducted in several cities of the Kingdom with the aim of understanding why it is difficult to reduce the numbers of people with unmet needs. The core reasons have been found to be ignorance on the use of contraceptives and resistance from the people in using them (Sedgh et al, 2007). This paper will seek to assess literature on family planning and highlight some of the key challenges the Saudi Arabian Kingdom is having in decreasing the unmet needs of women and couples in family planning. It will also provide some recommendations that have been found to have potential to be effective to families around the world that are non-evasive and safe.The studies done in the various cities yielded a number of results the first being that the Saudi Arabian women have limited information concerning contraceptives which leaves them prone to misconceptions as they lack the right understanding about the concept. Furthermore, it was found that the rate of contraceptive use has reduced significantly over the years but in the country, the Eastern provinces showed more potential for use of contraceptives amongst the younger generation of Saudi women.

Country Profile of the Kingdom of Saudi Arabia

The Kingdom of Saudi Arabia is part of the Arabic Middle Eastern countries with a population of approximately 30 million people in an area of 2.24 million sq. Km. The population growth rate is placed at an average of 2.3% per annum and the age dependency ratio is placed at 4.4%. The country is Arab speaking where Islam is the major religion and life expectancy is around 73 years for men and 76 years for women. The economy of Saudi Arabia is based on oil and it possess 18% of the petroleum distributed on the global platform (“Saudi Arabia; Facts and Figures,” 2015).
Rationale/Statement of problem with justifications

The 20th century has brought with it a number of changes to various industries and fields particularly to the economic and medical arena. There has been a rise in the need for efficient and appropriate adoptions of family planning. Family planning refers to the ability of the couple to assess their situations and decide on the number of children they want or can manage to sustain comfortably. It also refers to the spacing of the birth of the children all aimed at reducing and ultimately preventing the growing number of unintended pregnancies, abortions, deaths and illnesses related to pregnancy and/or childbirth (Gribble 2012) ( Appendix 1). Aside from the health benefits, family planning and in particular spacing has given women around the world an opportunity to participate in income generation whether in employment or as entrepreneurs. This has been a positive effect as couples can now plan and decide when they are ready to have children (Sedgh, et al. 2007). They have also been more vocal and present in their families, community and in the Kingdom as a whole through empowerment and gender equality programs.

Across the world, there are about 222 million women who wish to utilize contraceptives but due to a lack of access to the medicine or other family planning services their needs are left unattended (Marie Stopes International 2013). The biggest hurdles for the Saudi Arabian population in accepting and practicing the use of contraceptives have been due to their misconceptions about the family planning practice. The major barriers have ranged from religious, social and cultural beliefs or practices which the population feels they would be going against by practicing family planning. The rates of contraceptives use has been relatively low and the number is yet to increase with the latest global campaigns advocating for them as a way to curb medical issues and the alarming population growth rates (Appendix 2). Compared to other Muslim countries, their participation has been low and the family acceptance and implementation is similarly not encouraging. This trend is especially true for the Saudis in the rural areas who lack access to knowledge, medical facilities or council but most of all their lifestyles dictate that it is the norm to handle the issue of birth in a modern way. Their traditional beliefs and practices still dominate as their main basis for decision making where a contraceptive or its use to them is wrong according to their religion and against nature. Various studies have shown this is a weakness that can be advocated to the failure or neglect of the religious leaders in the discussion both by the government and the medical fraternity (Cooper and Yue 2008).

Socially the role of women was seen to revolve around being a wife and a mother and as such, they were invested in giving birth. The society also portrayed a woman as virtuous if she had children and one who has few or no children was seen to be missing something. Additionally, women in the Saudi Kingdom which is predominantly Muslim in religion is such that the woman is under the control of the man and therefore resistance from the men meant they could not take contraceptives (Population Reference Bureau 2012). Furthermore, the low educational investment of the society to a woman’s education left a majority of women illiterate. Due to this aspect, they had no knowledge of what contraceptives are nor their use or benefits to their families and to them as individuals. In Saudi Arabia, the desire of the people is to have large families has been a real and constant challenge as people also have reservations of using contraceptives due to worry it may cause permanent infertility. The society and people believe children are a gift and thus they resist taking measures to prevent or slow their fertilities (Appendix 3). The fear of side effects has also been a problem but the biggest hurdle so far has been a little or no access to the medications or measures for a number of the Saudis irrespective of their need to use them (Mordor Intelligence 2015).

Methods and Justification of Methods

The methodology adopted for the study was quantitative where it was conducted involving female respondents only. It was conducted at a number of medical family clinics in different cities within Saudi Arabia both in the urban cities and in the rural areas with equal respondents from each center. The methods utilized were those of questionnaires and interviews using a structured list of questions designed to adequately assess the research objectives. The dependent variable investigated was the access and use of contraceptives in reducing unmet needs of family planning for the women while the socioeconomic factors were all independent for example education levels.

Search term Inclusion Criteria Exclusion Criteria
Family Planning ,Contracptive, Unmet need , Family Planning in KSA cities Family Planning outside KSA
Contraceptive use In KSA Contraceptive In KSA Contraceptive use outside KSA
Unmet need for Family Planning Unmet need for Family Planning in KSA cities (Jeddah, Alkhobar, Taif, Al-Madinah, Al-Qaseem, Abha) Unmet need for Family Planning outside KSA cities
Country KSA Middle east countries and African countries
Languages Articles written in English Articles not written in English
Publication Articles published within the last 30 years (1986- 2016) Articles published before 1986

Table 1: Indication of literature review search criteria, inclusion and exclusion.

The investigative methods were appropriate as they catered to all angles and dynamics of the women’s external and internal environment that is in respect to their culture, religion, community or societal stand but most of all it captured their own personal beliefs and understandings about contraception. The methods have been proven in other areas of research and are recognized by researchers globally as being efficient, unbiased and accurate. They were the best options as they helped expose reality rather than assumptions as a database would have or fallacious behavior as would have been the case with observation.
Results and Presentation of Data
The studies done in the various cities yielded a number of results the first being that the Saudi Arabian women have limited information concerning contraceptives which leaves them prone to misconceptions as they lack the right understanding about the concept. Furthermore, it was found that the rate of contraceptive use has reduced significantly over the years but in the country, the Eastern provinces showed more potential for use of contraceptives amongst the younger generation of Saudi women. The Western Province had mixed results where despite the limited knowledge on contraceptives and their use, a majority of women were willing and had intentions to use contraceptive methods in the near future.

It is noted that regardless of the city, awareness regarding contraception among women in Saudi Arabia is determined to be quite low. A study on emergency contraception concluded that only 6.2% of the women from Riyadh who took part in the study had knowledge of emergency contraceptives and only 2% have ever used contraceptives (Syed et al, 2015). This figures show that contraception use is very low in Saudi Arabia. In some cases, some of the women in Saudi Arabia have taken the contraceptives for appearance purposes. Some of them believed that contraceptives help in curing acne, and they do not necessarily taking them for family needs (“Young Saudis taking oral contraceptives for ‘better looks’,” n.d.). This might explain the reason behind the sales of contraceptives, which stood at SR108 million in 2013 (Al-Mukhtar, 2014). However, different studies have revealed relatively higher use of contraceptives among women in other different cities. In Abha and Qassim region, the rate of emergency contraceptive use was noted to be at 27% and 44% respectively (Mahboub et al, 2014). However, this is relatively low compared to expected standards. Within the same study, Al Khobar recorded 74.8% and Taif recorded 34.1% of contraceptive use (Mahboub et al, 2014). This is a fair representation for Al Khobar though there is still more work to be done to ensure 100% penetration. Taif needs extensive campaign and sensitization to improve the numbers. Contraceptive prevalence in Saudi Arabia was 31.8% in 1996 but it has fallen and was recorded at 23.8% in 2007. These figures show that attitudes and use of contraceptives are on the decline over the years. Even though it can be argued that the low use of contraceptives is largely influenced by the Islam religion, there are no studies that prove that. Another study conducted on primary care centers in Al-Qassim accentuated the fact that knowledge on contraception is extremely low based on the fact that more than half of the participants barely understood how to access and use contraception (Al-Sheesha, 2010).
Discussion

The maternal mortality ratio which is a measure of the maternal deaths in a country or region assesses the risks of a pregnancy on the life of a woman. It has however been criticized for its lack of accounting of the risks of a pregnancy in respect to fertility and population explosion (Appendix 4). The medical fraternity and the government has been encouraged to use more media and digital avenues so as to reach more people in a shorter period of time as indicated by studies in clinics in Al-Qassim (Al Sheeha 2010). In a number of cities there have been a lot of improvements in the society and the medical health of the people targeted to enhance reproductive health so that the women can have appropriate and safe access to various methods of family planning. They have also been campaigns to empower women and couples on the use of contraceptives. Studies in Taif region in KSA in a gynecologist outpatient clinic found that almost half of the respondents had three or more living children. However, the majority of the respondents had adopted the use of contraceptives particularly the oral kind, intrauterine devices and injectable hormonal contraceptives. Moreover, the biggest hurdle for the women in using family planning was found to be religious beliefs (Albezrah 2015). Other research was done in cities that were previously neglected for instance Abha with an objective of finding the rate of contraceptive use in women in their centers and the preferred methods of contraception. 27% of the respondents were found to use contraceptives with the most common form being the oral pill but overall the knowledge of the contraceptives and their benefits was very low (Farheen 2013). Further studies have been conducted in the city of Al-Khobar where the focus was on perceptions of women towards spacing of their child births where the results were most of the respondents had two or more children in a time span of ten years despite a majority preferring a spacing of more than two years. The research also focused on the reasons most influencing to decisions to space and use contraception which were mainly due to employment and education opportunities. Furthermore, the majority of the respondent reported to be aware of the benefits to their physical well-being and thus used oral contraception to regulate their fertility (Rasheed and Al-Dabal 2007). The status in Riyadh, Saudi Arabia in the period of the 70s to the 80s was such that maternal mortality was approximately 52 for every 100,000 births. However the trend has been reducing gradually over the last few years (Appendix 5).

The high rate of the deaths has primarily been attributed to the failure of the pregnant mothers to seek medical care during their terms leading to vulnerabilities to infections and other associated diseases. Antenatal care is considered instrumental when it comes to improving infant and maternal death. However, a survey data conducted in Jeddah indicates that more than 73% of pregnant women only initiate antenatal care after the first trimester (Alsahafi et al., 2016). Some of the women do not bother to seek antenatal care at all. The reasons that the respondents provided included the notion that they were very busy, some claimed that antenatal care is not important, transport and financial limitations were also highlighted as main reasons. This situation is replicated in other cities in Saudi Arabia where pregnant mothers do not take antenatal care seriously. As a result it is expected that death during childbirth, for both the child and the mother is at a very high rate within the entire country of Saudi Arabia.The lack of knowledge was a core factor that added to the high deaths as the women were ignorant of the benefits or available options of family control. Different literature and research has shown that in the Saudi society the women who are more mature or older have higher mortality. Similarly, women with low incomes and who have little or no education have also been found to have higher cases of high mortality rates. In a majority of the cases, the low quality of medical care and service were found to be leading reasons for the high number of maternal and neonatal deaths in almost 73%of the cases. Along with substandard medical service provisions, a number of respondents identified the challenges they had in having their family planning needs met as a core reason for their high mortality rate as they were left vulnerable to unwanted pregnancies and no access to family planning plans or procedures such as contraceptives. Furthermore, caesarean section is not mostly preferred in Saudi Arabia and insisting on natural methods subjects mothers to a a higher risk. For example, in Jeddah, caesarean section rate is approximated to be at 22.4% (Altaweli et al., 2014). In Riyadh, it is placed at 19.05% and in Mecca it was indicated to be 38% (Al Rowaily et al., 2014). Despite the high population growth rates, the country has been effective in reducing the number of pregnancies in the young adolescent population mostly due to reduced fertility (Appendix 6) (Al-Kadri, et al. 2014).

One of the major barriers to the use of contraceptives in Saudi Arabia is mainly based on faith and culture. The culture in which the large part of the population subscribes to is designed in a manner that makes them believe that they are not allowed to use contraceptives. This explains the reason why unintended pregnancies occur across different socio-economic backgrounds. In addition, the concept of poverty also plays a major role whereby, women cannot afford reliable and effective contraceptives on a long term basis. Availability is also an issue as the supply of contraceptives can be extremely minimal in some areas of Saudi Arabia. The most notable barrier is based on the aspect that most of the women do not understand or acknowledge the use of contraceptives (Syed, 2015).

The concept of unmet family needs has been an issue of contention for decades and its urgency has become more dire now for agencies around the world than anywhere else. This growing need has been due to the rapid population growth rate being experienced around the world and Saudi Arabia as well (Appendix 7). The United Nations analysis showed that in for the hundred thousand years it took the population of the world to reach one billion, the growth rate now is worrying as in two hundred years or less the population growth rate has have increased sevenfold to approximately 7.3 billion (Appendix 8). The massive increase has been attributed to increased fertility rates across the board for men and women, urbanization, the survival of a majority of people to the reproduction age and rampant migrations. The United Nations Population Fund is one of the agencies tasked with management of the world’s population and their main objectives have been in educating the public and nations on how to push their citizens to build sustainable economies through having wanted pregnancies, safe births and empowerment of the young (United Nations Population Fund 2015). From the total world population, the growth rate has been found to be 1.13% with a majority of the population dwelling in the urban areas. The current fertility rates globally stand at 2.5 and the median age for the population is at 29.9.

Compared to the global statistics, the Saudi Arabian population is 0.4% of the total population with a population growth rate of 1.96% annually and a fertility rate of about 2.85. The population’s median age is 28 and the rate of migrations into the country is similarly on the rise (United Nations 2015).
There are various evidences of family planning methods

Education programs and curriculums have had a big impact on the reduced number of unmet needs for a majority of women and the Saudi population. Recent developments and advocacies for equal education opportunities for both the girls and boys have opened up new avenues of information useful to enhancing their well-being and awareness on family planning (Roudi-Fahimi and Moghadam 2003).
The government has been more motivated in their campaigns to raise awareness on the family planning avenues available to the public and by increasing their presence in both rural and urban centers so that the people have more access to contraceptives and family planning guidance centers (Appendix 9).
The levels of training for the medical employees have improved where they are more efficient and effective in the delivery of their services (Mersal and Keshk 2012).

Recommendations

Expansion of family planning and family care services to the rural areas. In Saudi Arabia the largest regions and people affected by inefficient and inadequate family planning knowledge and services are those in the rural regions. There needs to be a more focused approach to these populations as they are the most resistant to change especially that which directs them in a way they believe their culture does not condone or allow.
Involve leaders in the campaign to eliminate cases of unmet family planning incidences particularly the political and religious leaders. Religious leaders are a pivotal part of the family planning campaign as they can help raise awareness as to the needs for the contraception and other methods. Research has also shown that they have the power to reaffirm to the masses that a decision to manage their family size through family planning is not a contradiction to their religious beliefs but a means to enhance their lives and health.
Utilize more media campaigns to increase awareness on the methods of family planning and their pros and consparticluarly contraceptive use which is marred by a number of misconceptions. Technology has advanced and the Saudi people too are adapted to using media devices such as the television and newspapers or the internet (Al Sheeha 2010).
The government needs to strive to bridge the gap between the poor and the wealthy as the poor or lower income families have been found to have more children. Their low access to resources and knowledge needs to be curbed and remedied if family planning policies and programs are to have an impact. Furthermore, the cost of the contraceptives and family planning is high and they are not able to afford it even though they need it (Population Reference Bureau 2012).

The situation in Saudi Arabia is changing and more of the population are becoming more aware and gaining more access to family planning services and contraceptives. The rise in the adoption of the measures has been attributed to the change in the lifestyles and rules and regulations of the country that are now more flexible to the emancipation of women and their empowerment. Women now have access to education and are allowed to work both factors that have been vital in encouraging the use of family planning measures (Al Sheeha 2010). Furthermore, the change in the countries socio demographic structures and patterns have seen a majority of the population move to the urban centers which are more exposed to family planning and more open to the adoption of the methods. The challenges within the Kingdom in relation to family planning and unmet needs is still a reality but a lot of positive steps have been made and from evidence from a number of literature and studies shows that it is anticipated a positive growth will be seen in the future.

Appendices

Appendix 1

Appendix 2

Contraceptive prevalence rate

Appendix 3

Appendix 4

Appendix 5

Appendix 6

Adolescent Fertility Rates

Appendix 7

Appendix 8

Appendix 9

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