Introduction
Ovulation in reproductive age women is a natural physiological process and an indicator of fertility [
1]. The ovulatory cycle has three phases, egg formation (follicular), egg release (ovulation) and luteal. Ovulation is the most important event i.e., break-up of follicular and release of mature egg into the fallopian tube [
2‐
4], it represents fertile window in the ovarian cycle [
5]. The knowledge of the ovulatory cycle (KOC) is the basis of the natural family planning (NFP) methods [
6]. Lack of correct KOC in sexually active women is likely to lead to unintended pregnancies in the absence of modern contraceptive use [
7‐
10]. Thus correct KOC is important for women of reproductive age, both for planning of conception or avoiding unintended pregnancies and unsafe abortions [
9,
11‐
13].
KOC has not received much attention in research on women’s reproductive health. However, recently, studies on the subject have reported that the prevalence of KOC among women is low. In India, only 11% of young women (age 15–24 years) had correct KOC [
14]. Another study from Turkey on a young population also established that only 50% women had correct KOC and 40% of young people had correct KOC in the sample [
15]. Similarly, studies from the global north reported low prevalence of adequate KOC among childbearing-age women [
1,
16,
17]. Likewise, previous studies from Africa have shown low prevalence of adequate KOC among women; only 8.3% women of childbearing age in sub-Saharan Africa had correct knowledge of their fertile window, based on data from Demographic and Health surveys (2008–2017) [
18], while this prevalence was estimated at 23.3% in Ethiopia [
19].
Several studies have explored community and individual levels factors associated with correct KOC among women of childbearing age. These factors include women’s age, place of residence, region, religion, women’s education, husband/partner’s education, occupational status, wealth index, marital status, contraceptive use, menstruating in last 6 weeks, and being pregnant [
18‐
24]. Further, existing studies revealed that exposure to mass media family planning messages and being visited by fieldworker are positively associated with women’s adequate KOC [
18,
25‐
27].
Understanding the prevalence and determinants of correct KOC could help a country to overcome the problem. In the context of Haiti, a country characterized by a low prevalence of modern contraception use (23.4%), a high rate of unmet need for contraception (42.1%) and a large number of unwanted pregnancies (n = 413,000 in 2016) which are largely associated with socio-cultural, religious and economic factors [
24,
25], no study to the best of the authors’ knowledge has focused on KOC level among women of reproductive age. In order to partially fill this gap, this paper aims to assess the prevalence of correct KOC and its determinants among women of childbearing age in Haiti.
Results
Socio-economic and demographic characteristics of the study participants
Table
1 summarises the characteristics of the study participants. Slightly more than 40.0% (41.8%) of women were young (less than 25 years), 15.7% were aged 25–29 years, 14.0% were 30–34 years, 11.5% were in the 35–39-year age group, and 16.9% were aged 40 years and above. The vast majority (90.8%) were Christians; more than half (53.2%) were from rural areas and 25.3% came from “Aire Métropolitaine de Port-au-Prince” region. Around a third of them (32.0%) were in the poor wealth index category, 43.7% were not working, and 43.5% had primary education or less.
Table 1
Socio-economic and demographic profiles of women of childbearing age in Haiti
Age |
Less than 25 years | 6012 | 41.8 |
25–29 | 2258 | 15.7 |
30–34 | 2016 | 14.0 |
35–39 | 1650 | 11.5 |
40 and above | 2435 | 16.9 |
Place of residence |
Urban | 6731 | 46.8 |
Rural | 7640 | 53.2 |
Region |
Aire Métropolitaine de Port-au-Prince | 3632 | 25.3 |
Reste-Ouest | 2285 | 15.9 |
Grand Sud | 1708 | 11.9 |
Grand Nord | 2778 | 19.3 |
Artibonite | 2090 | 14.5 |
Centre | 918 | 6.4 |
Grand'Anse/Nippes | 959 | 6.7 |
Wealth index |
Poor | 4596 | 32.0 |
Middle | 2772 | 19.3 |
Rich | 7003 | 48.7 |
Currently working |
Yes | 8091 | 56.3 |
No | 6280 | 43.7 |
Religion |
No religion | 1134 | 7.9 |
Christian | 13,055 | 90.8 |
Voodoo or others | 182 | 1.3 |
Education level |
Primary or less | 6258 | 43.5 |
Secondary | 7068 | 49.2 |
Higher | 1045 | 7.3 |
Marital status |
Never in union | 5823 | 40.5 |
In union | 7402 | 51.5 |
Widowed/divorced/separated | 1146 | 8.0 |
Number of living children |
No children | 5990 | 41.7 |
1–2 | 4586 | 31.9 |
3 or more | 3795 | 26.4 |
Husband/partner's education level |
Primary or less | 3558 | 24.8 |
Secondary | 3051 | 21.2 |
Higher | 693 | 4.8 |
Don’t know | 101 | 0.7 |
No partner | 6969 | 48.5 |
Knowledge of any contraceptive method |
Knows modern method | 14,351 | 99.9 |
Knows no method | 20 | 0.1 |
Current use by method type |
No method | 10,909 | 75.9 |
Traditional method | 263 | 1.8 |
Modern method | 3199 | 22.3 |
Exposure to FP messages (medias) |
Yes | 3929 | 27.3 |
No | 10,442 | 72.7 |
Visited by fieldworker in last 12 months |
Yes | 991 | 6.9 |
No | 13,380 | 93.1 |
Total | 14,371 | 100.0 |
Over half (51.5%) of the women were in union, and about 60.0% had at least one child with 26.4% having 3 or more children. Almost all of the participants had knowledge of modern contraceptive methods whilst only 22.3% reported using a modern method during sexual intercourse. Nearly a quarter (24.8%) declared that their partner had primary education or less, 26.0% reported that their partner had secondary level or higher, and 48.5% didn’t have partner. Less than 30.0% of them had been exposed to mass media family planning (FP) messages in last few months preceding the survey, and 6.9% had been visited by a fieldworker.
Association between socio-economic and demographic characteristics and KOC
Table
2 depicts the bivariable associations between KOC and socio-economic and demographic characteristics. Overall, the proportion of women who reported having correct knowledge of ovulatory cycle was 24.1% (95% CI = 23.4–24.8). The results indicated that participants’ responses on KOC varied markedly. The lowest proportion of correct KOC was among women aged 40 and above (19.1%), while the highest proportions were among those in the 25–29 (27.6%) and 30–34 (27.8%) age groups. Approximately 30.0% of urban women were knowledgeable about ovulatory cycle compared to 19.7% in rural areas. Correct KOC was most common in “Aire Métropolitaine de Port-au-Prince” region (30.2%) and least common in “Centre” (19.0%). Similarly, correct KOC prevalence was higher among women who had higher education level (52.7%), from rich households (30.3%) and currently working (24.8%).
Table 2
Bivariable association between KOC and socio-economic and demographic characteristics
Age | 0.000 |
Less than 25 years | 1383 (23.0) | 4629 (77.0) | |
25–29 | 624 (27.6) | 1634 (72.4) | |
30–34 | 560 (27.8) | 1456 (72.2) | |
35–39 | 426 (25.8) | 1224 (74.2) | |
40 and above | 466 (19.1) | 1969 (80.9) | |
Place of residence | 0.000 |
Urban | 1950 (29.0) | 4781 (71.0) | |
Rural | 1509 (19.7) | 6131 (80.3) | |
Region | 0.000 |
Aire Métropolitaine de Port-au-Prince | 1097 (30.2) | 2535 (69.8) | |
Reste-Ouest | 498 (21.8) | 1787 (78.2) | |
Grand Sud | 420 (24.5) | 1288 (75.5) | |
Grand Nord | 641 (23.1) | 2137 (76.9) | |
Artibonite | 425 (20.3) | 1665 (79.7) | |
Centre | 174 (19.0) | 744 (81.0) | |
Grand'Anse/Nippes | 204 (21.3) | 755 (78.7) | |
Wealth index | 0.000 |
Poor | 737 (16.0) | 3859 (84.0) | |
Middle | 601 (21.7) | 2171 (78.3) | |
Rich | 2121 (30.3) | 4882 (69.7) | |
Currently working | 0.014 |
Yes | 2010 (24.8) | 6081 (75.2) | |
No | 1449 (23.1) | 4831 (76.9) | |
Religion | 0.000 |
No religion | 175 (15.4) | 959 (84.6) | |
Christian | 3245 (24.9) | 9810 (75.1) | |
Voodoo or others | 39 (21.3) | 143 (78.7) | |
Education level | 0.000 |
Primary or less | 933 (14.9) | 5325 (85.1) | |
Secondary | 1975 (27.9) | 5093 (72.1) | |
Higher | 551 (52.7) | 494 (47.3) | |
Marital status | 0.000 |
Never in union | 1522 (26.1) | 4301 (73.9) | |
In union | 1682 (22.7) | 5720 (77.3) | |
Widowed/divorced/separated | 255 (22.3) | 891 (77.7) | |
Number of living children | 0.000 |
No children | 1608 (26.8) | 4382 (73.2) | |
1–2 | 1139 (24.8) | 3447 (75.2) | |
3 or more | 712 (18.7) | 3083 (81.3) | |
Husband/partner's education level | 0.000 |
Primary or less | 573 (16.1) | 2985 (83.9) | |
Secondary | 799 (26.2) | 2251 (73.8) | |
Higher | 291 (42.0) | 402 (58.0) | |
Don't know | 19 (19.0) | 81 (81.0) | |
No partner | 1777 (25.5) | 5193 (74.5) | |
Current use by method type | 0.000 |
No method | 2507 (23.0) | 8402 (77.0) | |
Traditional method | 94 (35.7) | 169 (64.3) | |
Modern method | 858 (26.8) | 2341 (73.2) | |
Exposure to FP messages (medias) | 0.000 |
Yes | 1314 (33.4) | 2615 (66.6) | |
No | 2145 (20.5) | 8297 (79.5) | |
Visited by fieldworker in last 12 months | 0.000 |
Yes | 303 (30.6) | 688 (69.4) | |
No | 3156 (23.6) | 10,224 (76.4) | |
Total | 3459 (24.1) | 10,912 (75.9) | |
Nearly a quarter (24.9%) of Christian respondents had correct KOC and this proportion was 15.4% and 21.3% among non-religious women and voodoo adherents, respectively. The results also showed that women who were not in union (26.1%) had a higher prevalence of correct KOC than those who were in union (22.7%) or widowed/divorced/separated (22.3%). Women with no children had a prevalence of correct KOC of 26.8%, while those who had 3 or more children had a prevalence of 18.7%. Slightly more than 40.0% of women whose partners had higher education level reported having correct KOC compared to 16.1% among those whose partners had primary education or less. In addition, correct KOC was most common among respondents who used traditional contraceptive methods (35.7%) and least common among those who declared using no method (23.0%). As expected, correct KOC prevalence was higher among women who had been exposed to mass media FP messages (33.4%) and visited by a fieldworker (30.6%) than their counterparts who had not been exposed to mass media FP messages (20.5%) and not been visited by a fieldworker (23.6%). In summary, it should be noted that a statistically significant association was found between all selected covariates and correct KOC (p < 0.05).
Factors associated with correct KOC
In the binary logistic regression, place of residence, respondent’s education level, wealth index, currently working, husband/partner’s education level, contraceptive use, exposure to mass media FP messages, and fieldworker visit were statistically significant predictors of correct KOC at
p-value < 0.05 (Table
3). Urban women had higher odds (AOR = 1.10; 95% CI 1.01–1.21) of having correct KOC compared to rural women. The odds of correct KOC were higher among women who attended secondary (AOR = 1.95; 95% CI 1.75–2.17) and higher level (AOR = 4.58; 95% CI 3.81–5.49) compared to those with primary level or less. Similarly, participants whose partners had secondary (AOR = 1.20; 95% CI 1.05–1.37) and higher education (AOR = 1.30; 95% CI 1.05–1.62) were more likely to have correct KOC than their counterparts with primary education or less. We also found that women from rich households were 1.2 times more likely to have correct KOC (AOR = 1.24; 95% CI 1.14–1.35) compared to those from poor households. Participants who currently worked had 1.1 greater odds (AOR = 1.13; 95% CI 1.03–1.25) of having correct KOC than those who were not currently working. Participants who reported using no contraceptive method (AOR = 0.82; 95% CI 0.74–0.90) had lower odds of having correct KOC compared with those who declared using modern method. In addition, women who had been exposed to mass media FP messages had 1.7 greater odds (AOR = 1.67; 95% CI 1.53–1.83) of having correct KOC than their counterparts who had not been exposed to mass media FP messages. Likewise, women who had been visited by a fieldworker were 1.5 times more likely (AOR = 1.51; 95% CI 1.30–1.75) to have correct KOC than those who had not been visited.
Table 3
Multi-variable association (binary logistic regression) between KOC and socio-economic and demographic characteristics
Age |
Less than 25 years | − 0.0565 | 0.95 | 0.80–1.12 |
25–29 | − 0.0274 | 0.97 | 0.83–1.14 |
30–34 | 0.0409 | 1.04 | 0.90–1.22 |
35–39 | 0.1021 | 1.11 | 0.94–1.30 |
Ref = 40 and above | | | |
Place of residence |
Urban | 0.0997 | 1.10* | 1.01–1.21 |
Ref = Rural | | | |
Region |
Reste-Ouest | 0.0977 | 1.10 | 0.94–1.29 |
Grand Sud | 0.1261 | 1.13 | 0.99–1.30 |
Grand Nord | 0.0126 | 1.01 | 0.91–1.13 |
Artibonite | − 0.0429 | 0.96 | 0.83–1.11 |
Centre | − 0.0884 | 0.92 | 0.77–1.10 |
Grand'Anse/Nippes | − 0.0841 | 0.92 | 0.81–1.04 |
Ref = Aire Métropolitaine de Port-au-Prince | | | |
Education level |
Secondary | 0.6669 | 1.95*** | 1.75–2.17 |
Higher | 1.5208 | 4.58*** | 3.81–5.49 |
Ref = Primary or less | | | |
Wealth index |
Middle | 0.0702 | 1.07 | 0.97–1.19 |
Rich | 0.2158 | 1.24*** | 1.14–1.35 |
Ref = Poor | | | |
Currently working |
Yes | 0.1252 | 1.13** | 1.03–1.25 |
Ref = No | | | |
Religion |
No religion | − 0.1472 | 0.86 | 0.72–1.04 |
Vodoo or others | 0.0851 | 1.09 | 0.72–1.66 |
Ref = Christian | | | |
Marital status |
In union | − 0.0921 | 0.91 | 0.76–1.10 |
Widowed/divorced/separated | 0.0695 | 1.07 | 0.86–1.33 |
Ref = Never in union | | | |
Number of living children |
No children | 0.0712 | 1.07 | 0.89–1.30 |
1–2 | 0.0092 | 1.01 | 0.89–1.15 |
Ref = 3 or more | | | |
Husband/partner's education level |
Secondary | 0.1813 | 1.20** | 1.05–1.37 |
Higher | 0.2639 | 1.30** | 1.05–1.62 |
Don't know | − 0.2780 | 0.7573 | 0.40–1.42 |
Ref = Primary or less | | | |
Current use by method type |
No method | − 0.2027 | 0.82*** | 0.74–0.90 |
Traditional method | 0.1703 | 1.19 | 0.89–1.59 |
Ref = Modern method | | | |
Exposure to FP messages (medias) |
Yes | 0.5141 | 1.67*** | 1.53–1.83 |
Ref = No | | | |
Visited by fieldworker in last 12 months |
Yes | 0.4114 | 1.51*** | 1.30–1.75 |
Ref = No | | | |
Discussion
The aim of this study was to assess the level of correct KOC and its determinants among women of childbearing age in Haiti, using the 2016/17 HDHS. Several significant findings are revealed in this study. First, we found that the overall proportion of women of childbearing age in Haiti having correct KOC was estimated at 24.1% (95% CI 23.4–24.8), two times higher than in the Dominican Republic (12.0%) [
31]. This could be partly explained by the fact that women in the Dominican Republic have more access to modern FP information and services, and use natural FP methods less than Haitian women [
32,
33]. Second, place of residence, respondent’s education level, wealth index, currently working, husband/partner’s education level, contraceptive use, exposure to mass media FP messages, and fieldworker visit were identified as determinants of correct KOC.
This study found that education level was positively and significantly associated factor with correct KOC. Women with higher education status were more likely to have correct KOC compared to those with primary education or no education. Similarly, higher education level of husband/partner contributes to women’s correct KOC. Consistent with findings from previous studies [
16,
34,
35], this could be explained by the fact that individuals with higher education level are literate and better informed on topics related to reproductive health [
36,
37]. Moreover, when a husband/partner has higher education, they are more open to discussions about sexual health with their partners, which could enhance the level of women's knowledge of the ovulatory cycle [
32,
33].
Urban women were more knowledgeable than rural women, which is supported by prior studies [
18,
38,
39]. This might be due to a variety of reasons. Urban women in Haiti have greater access to sexual and reproductive health information and services [
40,
41]. Besides, they are better educated than their rural counterparts [
29], which would allow them to better comprehend information about the ovulatory cycle [
7].
It was also revealed that exposure to mass media FP messages significantly predicted correct KOC. Women who had been exposed to mass media FP messages had greater odds of having correct KOC than women who had not been exposed. Wolde et al. [
20] reported similar findings in Ethiopia. During the last decades, the mass media has been considered as a powerful tool for communication [
36]. Additionally, studies have shown that mass media remains a vital source of sexual information and can raise awareness, increase knowledge, and influence individual behaviours and attitudes [
36,
42]. This observation underscores the importance for the Haitian government to provide electricity to more households in Haiti in order to allow these messages to reach more women, especially those in rural areas. Further, consistent with findings from studies in Bangladesh [
22] and Ethiopia [
32], we found that being visited by a fieldworker increases the likelihood of correct KOC. The possible explanation for this finding is that women who had been visited by fieldworkers had the possibility to have adequate information on ovulatory cycle, and inquire about their specific sexual and reproductive health issues.
Wealth index and currently working were other significantly associated factors with women’s correct KOC. The odds of having correct KOC was higher among women from rich households and those who were currently working compared to women from poor households and without income-generating activities, respectively. These results are in line with several studies [
7,
18,
20,
22,
32,
43] that suggested that women from wealthy households and working women are more likely to afford sexual health services compared with their counterparts from poor households and without income-generating activities. Furthermore, our data indicated that women from rich households and currently working were in significantly higher proportions, living in urban areas, with a higher education level, exposed to mass media FP messages, and receiving visit by a fieldworker than those from poor households and without income-generating activities, respectively, which could positively influence their correct KOC level.
In agreement with a recent study in Malawi [
44], our results indicated that women who used modern contraceptive methods were more likely to have correct KOC than those who used no method. It is possible that women who use modern contraception have knowledge of their ovulatory cycle and use modern contraception to avoid unintended pregnancy [
40,
41].
Study strengths and limitations
To the best of the authors’ knowledge, this is the first study to assess the level of correct KOC and its determinants among women of childbearing of age in Haiti using the 2016/17 HDHS (nationally representative DHS data). Further, the findings are based on adequate statistical power (data were weighted for the sampling probabilities) and took into account the complex sampling procedures in the analysis. Although this study contributes to the literature on knowledge of ovulatory cycle, it has some limitations. First, the study used exclusively a quantitative research design. Future studies using qualitative methods will provide a more nuanced understanding of the factors associated with correct KOC. Second, due to the cross-sectional study design, we could not infer causality in the relationships between the exposure variables and the outcome. Third, due to the self-reported nature of the DHS surveys, the data may be subject to recall bias. Finally, failure to control for known and unknown potential confounding factors due to data limitations could have resulted in an over- or under-estimation of the associations between the socioeconomic and demographic variables assessed with KOC.
Implications of the findings
Knowledge of ovulatory cycle is an important factor in fertility awareness and decision-making [
32]. This is especially important in the context of Haiti, characterized by low contraceptive prevalence and high unmet need for modern contraception [
24,
45]. Promoting correct KOC through education and media outreach may be helpful strategies for enhancing fertility decision-making and, subsequently, increasing contraceptive use, including modern methods, as well as fertility-based methods such as natural family planning methods, which depend on accurate KOC.
Conclusion
Prevalence of correct knowledge of ovulatory cycle (KOC) is low among women of childbearing age in Haiti. Women from rural and poor backgrounds, without income-generating activities, with lower education, not using contraception, not exposed to mass media FP messages, not visited by fieldworker and with less educated spouses/partners lack the adequate knowledge of ovulatory cycle. It should also be noted that there is a deep and long-lasting lack of public investment in education in Haiti. Despite of a significant growth in the number of children having access to primary/secondary school, in the last decades, the quality has not grown the same. There are a lot of unskilled persons teaching. This could also partly explain low prevalence of correct KOC. Thus, priority should be accorded to increasing the knowledge of ovulatory cycle among childbearing age women, especially women with unmet need for contraception (who are neither using traditional nor modern contraception methods). These findings showed that policies should be developed to increase the knowledge about women’s menstrual and ovulatory cycle, especially for women from at risk demographic groups.
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