Study design: A population based cross-sectional descriptive study was carried out in the urban field practice area of the Urban Health Training Centre attached to Sree Balaji Medical College and Hospital, Bharath University, Chennai, Tamil Nadu, India, during October 2016 to February 2017.

Sample size: The sample size for the study was calculated based on a previous study done by Pegu B et al., where 38% of the women were found to be using contraceptives [18]. Using the formula,

the sample size was calculated to be 290 with a relative precision of 15%. The sample size calculated was rounded off to 300.

Inclusion criteria: The inclusion criteria for the study were married females of reproductive age group irrespective of their parity residing in the study area, who were apparently healthy and willing to participate in the study.

Exclusion criteria: The exclusion criteria for the study were married females not belonging to the reproductive age group and who were not willing to participate in the study.

Sampling technique: Simple random sampling method was used to identify the study subjects. There were 621 eligible couples registered under the Anakaputhur Health Centre. From among them, the required sample size 300 was identified by computer generated random number.

Data collection: The data collection was done by the study team, which included the interns who were undergoing training at the Urban Health Training Centre. The study subjects identified by simple random sampling were interviewed by the interns by visiting their homes. The data collection tool comprised of a pretested, validated, structured questionnaire, prepared in the local language, which comprised of background information, questions on knowledge and practice regarding small family norm and contraceptive usage. Details on usage of contraceptive and reasons behind the practice were asked. The questionnaire consisted of five questions on knowledge and nine questions on practice. Those who have answered correctly three out of the five knowledge questions are considered to have adequate knowledge about small family norm.

Contraceptive usage: In this study, it refers to the measures adopted by married and sexually active women to space or prevent pregnancies (does not want to have a child or another child in the next two years or at all) as a consequence of sexual intercourse.

Practice: In this study practice refers to the use of any contraceptive methods.

Ethical clearance and informed consent: The study was carried out after obtaining the requisite approval from the Institutional Ethical Committee. The participants were briefed about the study purpose and informed consent was obtained prior to the data collection.

All the data collected were entered into the Microsoft excel. The data analysis was carried out using SPSS software version 17.0. The level of knowledge and practice of contraceptives was calculated by using percentages. Prevalence of contraceptive usage and reasons behind not using contraceptives was calculated using percentages. Association between sociodemographic characteristics and knowledge and practice about small family norm was analysed using odds ratio and 95% confidence interval. The p-value less than 0.05 are considered as statistical significant and was calculated by using chi-square test.

The background characteristics of the study participants are given in [Table/Fig-1].

Level of knowledge about the small family norm among the study group is presented in [Table/Fig-2].

The percentages of married women who use contraceptives and reasons behind the married women not using contraceptives are shown in [Table/Fig-3].

The practice of contraception among the study group is given in [Table/Fig-4].

Association between education status and knowledge about small family norm is represented in [Table/Fig-5]. There was strong statistically significant association between the level of knowledge about small norm and education status with odds ratio of 3.12 (95% CI- 1.66-5.89) and a p-value of 0.0002.

Association between the number of children in families and eligible couples practicing small family norm is shown in [Table/Fig-6]. Among the study group 81.5% of the eligible couple were practicing small family norm with 2 or less children in the families. The couple protection rate was found to be 78% i.e., the eligible couples who were using contraceptives. The association was found to be statically significant with odds ratio of 2.21 (95% CI- 1.22 -4.01) and a p-value of 0.009.

Association between educational status and eligible couples practicing small family norm is shown in [Table/Fig-6]. Among the study population 84.5% of the literate women uses contraceptive and 43.8% of the illiterate women uses contraceptives. There was a strong statistical association between the educational status and eligible couples practicing small family norm with odds ratio of 7.02 (3.61-13.65) and a p-value less than 0.05.

This study on assessing the knowledge and practice of small family norm and use of contraceptives has given a new insight into the neglected problem. This study tried to identify the proportion of population adopting small family norms, the type of contraception preferred, the felt needs of the study group, motivating factors for those adopting small family norms and reasons for those not adopting small family norms and also to assess the satisfaction level of those who availed the governments family welfare services.

Age group: In this study, 48% of the females belonged to 35-40 years of age; followed by 38% who belonged to 26-34 years age group and 14% belonged to less than 25 years of age. In most of the similar studies done elsewhere, majority of the females studied belonged to the 20-35 years of age group as evidenced by the results of Onokerhoraye AG and Dudu JE (54.4%), Uma K (47.63%), Renjhen P et al., (48%), Vishwakarma K et al., (41.8%), Pegu B et al., (48%), Dagar N and Bhardwaj U (46.6%), Lakkawar N et al., (40.8%) [3,8,9,17-20].

Number of children: Nearly 78% of the females have two or less than two children in this study. In a study by Pegu B et al., 24% of the women had two children and 11% of the women had one child, which shows a big difference when compared to this study [18]. In a study by Uma K, it was found that 37.1% of women had 2 children while 27.6% had one child [8]. In another study by Lakkawar N et al., 48.8% of women had less than or equal to two children [20]. Almost all the studies compared here had a lesser percentage of small family when compared to this study.

Education status: The education status of the mothers in the study group shows that 16% were illiterates, while 12% had graduate or diploma level education. A total of 46% mothers studied up to secondary school level. The illiteracy rates in this study were found to be almost similar to the findings of other studies done elsewhere by Onokerhoraye AG et al., (17.1%), Uma K (18.7%), Renjhen P et al., (18.7%), Jahan U et al., (10.4%), Vishwakarma K et al., (17.2%) and Lakkawar N et al., (14.8%) [3,8,9,16,17,20]. In some studies done by Pegu B et al., (26.5%), Dagar N and Bhardwaj U (53.3%), AK Biswas AK et al., (51.6%) and Prasad RV et al., (25%), the illiteracy rates were comparatively high [18,19,21,22]. While, in a study done by Johnson O and Ekong I the illiteracy rate was only 5% [23].

In this study, 72% of the mothers said they had heard about the idea of small family norm and about 70% of them informed that they know how small family norm is practiced. In a study by Renjhen P et al., 98% of the study subjects had heard of small family norm, which was similar to a study by Uma K, where 90% of the women had heard of the term [8,9]. In a study by Johnson O and Ekong I 88.5% of the women had heard of small family norm [23]. Compared to this study, participants of all the other studies have a higher percentage of awareness about the small family norm.

Nearly 68% of the mothers studied said small family norm means a family with 2 or less children. In a study by Renjhen P et al., 92.2% of the study participants said it means a ‘small and happy family’ and 19.4% said it is to ‘avoid and space pregnancy’ [9]. Whereas, in a study by Jahan U et al., only 26.3% said it is to ‘avoid and space pregnancy’ [16]. Compared to these two studies, the women subjects in this study have somewhat clearly understood the concept behind the small family norm.

The source of information on small family norm came from multiple sources like friends/relatives, health workers and mass media. Almost 65% came to know about it from health worker, 57% from friends or relatives and 68% through media similar to other studies done elsewhere [3,18,20,22-24]. In studies by Uma K, Renjhen P et al., and Jahan U et al., the major source of information was through media [8,9,16].

Almost 78% of the married women of reproductive age group use contraceptive and 22% of the them do not use contraceptives which was similar to a study done by Onokerhoraye AG et al., [3]. Studies done by Jahan U et al., showed a prevalence of contraceptive usage of 62.9%, AK Biswas AK et al., showed 61.9% and Prasad RV et al., showed 61.2%, which were comparatively less when compared to this study [16,21,22]. Whereas the studies by Renjhen P et al., Johnson O et al., Srivastav A et al., Kaushal SK et al., showed a huge difference in the usage of contraceptives with 48.5%, 53.58%, 51.7% and 42.3% respectively [9,23,24,25]. Surprisingly, in a study by Uma K, the prevalence of contraceptive usage was found to be 93.4% [8].

The main reasons for those not following contraceptive measures among 22% of the study group in this study were: 39% did not use contraceptives due to religious reasons, 35% due to lack of awareness and 26% due to family compulsions. The reasons predominantly quoted by other studies are lack of knowledge; desire to have more children, fear of side effects and religious beliefs etc. In other studies, most of the study subjects did not respond to this question nor did they disclose the reason [3,8,9,16,22,23,26].

Nearly, 52% of the women have undergone permanent contraception method while 26% opted for temporary measures. In a study by AK Biswas et al., 44.9% had undergone permanent contraceptive method and 17% used temporary contraceptive method [21].

Among those who used temporary contraception, about 77% was using barrier methods (condoms) while only 23% used IUCD. Usage of barrier method (condoms) were more in studies done by Jahan U et al., Pegu B et al., Nayak A et al., [16,18,27]. Whereas, most of the study subjects used oral contraceptive pills in studies conducted by Uma K, Renjhen P et al., Johnson O and Ekong I, Kaushal SK et al., [8,9,23,25]. In a study Onokerhoraye AG and Dudu JE, injectable contraceptives topped the list with 42.3% [3].

In this study, the economic reasons were the main felt need for adopting small family norm among 48% of the women while compulsions due to varied reasons motivated 22% of the women to accept small family norm. In most of the other studies people used contraceptives because it was comfortable and easy to use, easily available and was available free of cost [8,9,16]. A good majority of the study group got contraceptives from government hospitals while the others got it from health workers and shops/pharmacy which were similar to study findings by Uma K, Renjhen P et al., Jahan U et al., [8,9,16].

Among those women who were not using any contraceptives at the time of the study, everyone were willing to use contraceptives in the future, 55% preferred to have temporary contraception while 45% preferred to follow permanent contraceptive method in the near future. In a study by Renjhen P et al., 44.6% were willing to use contraceptives in the future, which was similar to the study by Uma K [8,9]. In a study by Jahan U et al., 27.2% were found to be willing to use contraceptives in the future [16].

Use of family planning methods by married women in this study was 78%, which was higher than the current usage in Tamil Nadu according to the NFHS-4 survey. The use of family planning methods in Tamil Nadu according to NFHS-4 data is 53.2% totally, with 54.1% usage in urban areas [15]. There is a difference of approximately 23.9% in the use of contraceptives while comparing this study to NFHS-4 data. Though there is a decrease in the current usage of family planning methods, women in this area are well aware and using the family planning methods appropriately. However, the adoption of small family norm among the families should be enhanced more in the general population to achieve a net reproductive rate of 1, so as to lead an economically and socially productive life.

Importance and future scope of the study: This study on small family norm leads us to implement family welfare services according to the needs of the community in future. Implementation of such programs must be followed by monitoring and good evaluation systems. In view of the population explosion problem which plagues our county, this kind of studies on larger population groups can be carried out to assess the utilisation levels of family planning services, which will help to enhance the propagation of effective contraceptive usage.

Recommendations: Awareness about small family norm and suitable contraceptive usage should be enhanced through various strategies under the family welfare programs.

Increasing the awareness levels among the partners and participatory approach of both the partners is necessary to enhance contraceptive usage.

The sustained efforts by health workers will be a motivation for the couples to use contraceptives to ensure the success of small family norm.

The study done in the urban field practice area of our institution covering about 45,562 populations and with 621 eligible couples registered could have been planned to cover larger population groups, to understand the situation better. Increasing the sample size and covering a wider geographical area could have made this study more valuable. Another limitation was this study did not investigate the attitude of the married women, towards their contraceptive usage.

This study outcome shows that almost 78% of the married females in the reproductive age group follow small family norms and about 68% of the mothers knew that small family norm means a family with 2 or less children. However, according to NFHS-4 data for Tamil Nadu, only 53.2% were found to be using family planning methods. This shows the gap existing in the system, which needs to be bridged by creating awareness and motivating the public about the available family planning services and to meet their unmet needs of contraception. People should be encouraged to come forward to accept family welfare measures for the sake of themselves, their families and the country as a whole.