Use of Contraceptives by Roma Women from Plovdiv Region

Introduction: The share of unwanted pregnancies and voluntary abortions among women from Central and Eastern Europe is still quite high


INTRODUCTION
The share of unwanted pregnancies and voluntary abortions among women from Central and Eastern Europe is still quite high [1] , and Bulgaria is no exception to this statistic. Bulgaria is among the EU countries with the largest Roma population. It is inhabited by several ethnic groups of which Roma is one of the most numerous ranking third after Bulgarians and Turks. This determines the influence of this ethnic group on the demographic indicators of the country. [2] The sexual culture of the spouses and their attitude to the birth rate are built under the influence of a complex set of medico-social, psychological, economic and biological factors. Conservative attitudes and traditional gender norms limit women's ability to engage in safer sexual behaviour, contribute to a lack of sexual health education, and impede access to health services. [3] Roma women experience even more inequalities in women's health due to ethnic discrimination and racism. [4][5][6] This leads to adverse consequences and effects on the sexual and reproductive health of these women. Use of contraceptives by Roma women and the factors that affect it have not been sufficiently studied. [3] The influence of ethnic characteristics that are observed in terms of reproductive behaviour must also be taken into account. They are expressed in the early onset of sexual life, short proto-and intergenetic interval, a large number of pregnancies, a high rate of abortions at will. In some families, the influence of the husband and his mother is very strong, as they impose their will on the use of contraception. A study of the awareness of Roma population of contraceptive methods and means arouses scientific interest. Knowledge of contraceptive methods and means, the frequency of their use, as well as the factors influencing them were investigated.

AIM
The aim was to study the use of contraceptive methods and means of Roma women from Plovdiv region in Bulgaria and the factors influencing them.

MATERIALS AND METHODS
A pilot survey was conducted through a structured, anonymous interview. The survey was conducted in 2019 among 70 women of Roma origin at Plovdiv University Hospital, Vessela Obstetric Gynecology Unit with St Mina Hospital, Plovdiv, and Community Center for Children and Families, Plovdiv. We studied the reproductive behaviour, the knowledge of contraceptive methods and means, and the frequency of their use among Roma women, as well as the factors influencing them.

Statistical analysis
Descriptive analysis, the Spearman's correlation analysis, and non-parametric methods for testing variables that do not have a normal distribution were used in the statistical analysis. The data were analysed using SPSS ver. 23. We accepted a level of statistical significance α=0.05.

Socio-demographic characteristics of the studied contingent
The mean age of the studied contingent was 30.83±12.51 years (range 15-75 years). The respondents living in a town were 54 (77.14%). Sixteen Roma women (22.85%) reported a village as their place of residence. Roma women were divided into five groups by educational level. The largest share belonged to Roma women with primary education (48.57%), followed by those with secondary education (31.43%). The women who never attended school were 17.14%. There were no women with basic education in the sample, and the percentage of women with a higher education diploma was only 2.85%.

Reproductive behaviour, contraception
The majority of Roma women start having sexual contacts at the age of 14 (20.58%), followed by those at 15 (14.70%), and 16 (13.23%). The mean age for this indicator was 16.91±3.69 years. The Kruskal-Wallis test showed that there was a strong correlation between the educational level of Roma women and the years of beginning their sexual contacts (p<0.001). A statistically significant relationship was found between the place of residence and the age at which Roma women start having sex (p=0.003). More than half of the surveyed women (69.56%) did not know a means of protection against STDs, and 23.18% indicated a condom as such.
The largest share of Roma women indicated interrupted intercourse as a method of preventing unwanted pregnancy (54.41%), and 22.05% did not know how to prevent pregnancy.
Only 21.73% of the sample used contraceptives regularly, 39.13% of the women did not use contraceptives, and 39.13% used them rarely.
No statistically significant relationship was found between the level of education of Roma women and the frequency of contraceptive use (p=0.639). The statistical analysis found no relationship between the financial condition of Roma women and the frequency of contraceptive use (p=0.069). Roma women reported that family was the main source (53.96%) of information on the means of preventing unwanted pregnancies, friends -22.22%, and school -22.22% were also significant sources, and 14.28% received information from a healthcare professional.
No statistically significant relationship was found between the educational level of Roma women and their willingness to recommend contraception to their children (p=0.515). A relationship was not found between financial security and the tendency of Roma women to advise children on the use of contraceptives (p=0.348). The largest percentage of women (30.76%) indicated insufficient information on the types of contraceptives as the reason for not using contraception. Other reasons were fear for their health (28.84%), no worries about getting pregnant (19.23%), and their husband did not want to use contraception (15.38%).

DISCUSSION
Child marriages, low sexual culture, and low level of education among Roma women determine a reproductive behaviour typical for this ethnos. There is an early onset of sexual activity, low frequency of contraceptive use, a high rate of unwanted pregnancies. In their study of early marriages among Serbian Roma girls, Hotchkiss et al. [7] report that child marriages are more common in the rural areas. Such data is available in a UNICEF report on the access of Bulgarian Roma to education. [8] We confirmed these findings in our study, which revealed a relationship between residence and years of marriage. We confirmed the tendency observed among Roma women, regarding the receiving education. Most Roma girls never attended school or dropped out of the educational system at an early stage. In her monograph, Sandeva [9] emphasizes that one of the crucial problems for Roma women is the low level of education. Education is a factor influencing the age at which sexual intercourse begins. Gipson and Upchurch [10] obtained similar results in 2017. The authors argued that women with higher education were more likely to delay their first sexual intercourse. Lower levels of education are also a risk factor for early marriages among Roma, according to a study by Hotkis and Gotha [7] and a 2016 UNICEF report [8] . A serious problem of the Roma ethnic group is the low sexual culture, typical for families that respect the traditions of the community. It is a prerequisite for early sexual intercourse, high and early birth rate. In this way, a "vicious circle of negative factors" is formed -low education and sexual culture, early sexual life, early family formation, and high birth rate. [11] It is the low health culture that determines the fact that most Roma women do not know how to protect themselves from STDs and unwanted pregnancies. However, some of the women interviewed in our study pointed a condom as a means of preventing STDs. Gunovska [11] also concludes that young Roma are uninformed about the means of prevention of sexually transmitted diseases. Djonic et al. [12] also find low condom use among young Roma. Knowledge about the means and methods of contraception among Roma is extremely limited. One-thirds of them did not know how to prevent unwanted pregnancies; half of the respondents indicated interrupted intercourse as the main method of contraception. In her monograph, Taneva reveals interrupted sexual intercourse and a condom as preferred methods of contraception. [13] Similar data were obtained by Sandeva and Kuzmanov. [14] Their results show that condoms, interrupted intercourse, and birth control pills are the preferred methods to prevent unwanted pregnancies. In 2018, King et al. [3] found that Roma men did not like condoms and rarely used them. They also found that interrupted intercourse was the preferred method of contraception, as well as methods with a long-term contraceptive effect, namely intrauterine pessaries and clips that are placed on the fallopian tubes. [3] Similar data are found in Semerdzhieva's dissertation. [15] According to the author, the largest percentage of Roma women use intrauterine devices, and the second most used method is interrupted sexual intercourse. In 2020, Sandeva [9] described that Roma women still used voluntary abortion as a method of contraception.
In their report on the Roma families, Voicu and Popescu [16] confirmed that the lack of education had an impact on the low frequency of contraceptive use. They view low levels of education, early marriages, and childhood pregnancies as key factors leading to a "vicious circle of housework that absorbs Roma women from an early age". Despite our expectations that education and financial status are factors that influence the frequency of contraceptive use, this has not been confirmed statistically. King et all. [3] obtained different results from ours and concluded that education and financial security were important factors for the use of contraceptives by Roma women in Western Europe. Semerdzhieva [15] proves that the use of contraception increases with the increase of the educational level, which is contradictory to the data we obtained. We found that the family is the main source of information on the use of contraception by Roma women. Logar et al. [5] obtained the same results and proved that the family had a special role in the Roma community, especially when it comes to reproductive health issues. The Roma women, interviewed in the study by Logar et al. [5] , share that they draw information on contraception from their mothers. Taneva and Kirkova [17] also describe the influence of mothers on the reproductive behaviour of their daughters. We find similar results in Taneva's dissertation. [18] Despite the low share of Roma women who use contraception, some of them would recommend their children to be protected from unwanted pregnancies. This is an optimistic fact, which suggests wider use of contraception among young Roma, as the main factor for reproductive behaviour is the mother. Roma women are concerned about the health and well-being of their children, but often do not have enough health culture to advise them for the proper reproductive behaviour. Logar et al. [5] argue that despite the strong concerns about their children's health, Roma women are often unable to distinguish between dangerous conditions and often do not understand the causes of health problems. As leading reasons for their unwillingness to use contraception, Roma point to insufficient information on the types of contraceptive methods and means, fear for health, lack of concern about pregnancy, prohibition by the husband, prohibition by the mother-in-law. Sedlecky & Rašević [19] received similar data. In their study, a large share of women cited pressure from their spouses or families as a reason not to use contraception. There is gender discrimination in the Roma ethnic group, with the status of women increasing with age. In their study on the use of modern contraception, King et al. [3] discuss gender inequality among Roma in Serbia and Macedonia. A paper by Mrhálek et al. [20] , which is a part of the research project "The current position of Roma women in the family and in society", describes the role of men as dominant in the family. Women are discriminated against and do not take decisions about their reproductive behaviour, the number of children in the family, and the use of contraception.

CONCLUSIONS
Our study revealed some trends in the reproductive behaviour of Roma women, which are largely determined by their ethnic characteristics, the influence of the family, and gender inequality existing in the ethnic group. Early marriages, early sexual intercourse, low health culture, low level of education and family influence are factors influencing Roma women' propensity to use contraception. A low rate of contraceptive use and a high rate of unwanted pregnancies were found. The education of Roma women is not a priority for this ethnic group and most of them remain uneducated. The low level of education and health culture leads to a lack of knowledge about reproductive health, the types of contraceptives, and the benefits from their use. Roma women have little knowledge of the various ways to prevent unwanted pregnancies, which is one of the main reasons for the low frequency of contraceptive use. Roma women receive information about contraceptive methods mainly from their mothers. The main contraceptive method used by the Roma is interrupted intercourse. There is still sex discrimination in the Roma ethnic group and men have a strong influence on decisions about contraceptive use. Prohibition by a spouse or mother-in-law is given by Roma as a reason for not using contraception.