CONSENT FORM
Dear participant,
My name is Kudi Deline Owu, a level 400 student from Covenant Institute for Business and
Technology Bamenda. I am carrying out a research on "Knowledge, Practice and Factors
Influencing the use of Family Planning Methods Among Post-Partum Women at Akum
Holy Family Hospital". I kindly request that you complete the following questions related to
the above topic. The information collected will be used solely for academic purposes. Please sign
the consent form below if you agree to my request. Thanks for your comprehension.
I the undersigned…………………………………………………………..have been invited to
participate in this study titled "Knowledge, Practice and Factors Influencing the use of
Family Planning Methods Among Post-Partum Women at Akum Holy Family Hospital" by
Miss Kudi Deline Owu, Principal Investigator.
I have read attentively and understood the Information Notice.
I have understood the objectives of the study.
The risks and benefits linked to the study have been presented.
I had sufficient time to ask questions for clarification of any information that can
motivate my participation and clear answers were given.
I also understood that my participation in this research is voluntary, thus, I am free to
accept or refuse to participate in this study, and refuse my consent at any given moment.
In view of the aforementioned, I voluntarily accept to participate in this study.
Principal Investigator Participant
Signature ………………… Signature ……………..………
Name ……………………… Name ………………….………
Date ………………………. Date …………………….…….
QUESTIONNAIRE
SECTION A: SOCIO-DEMOGRAPHIC DATA
1) Age of respondent a)15- 25 years b) 26-35 years d) 36 and above
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2) Marital Status a) Married b) Single c) Divorced
3) Level of education a) None b) Primary c) Secondary d) Tertiary
4) Employment status a) unemployed b) self-employed c) privately employed d) civil
servant
5) Religion: a) Christian b) Muslim c) Orthodox
SECTION B: KNOWLEDGE OF POST PARTUM WOMEN ON FAMILY PLANNING
6) Have you ever heard of family planning before? a) Yes b) No
7) If yes to question 6 above, where did you hear about it? a) Hospital b) Friends c) TV and
social media d) Schools
8) Which contraceptive/family planning methods do you know? (Tick all that apply)
I-NATURAL METHODS
a) Lactation amenorrhea method (LAM)
b) Coitus interrupts
c) Periodic abstinence
II-Traditional methods
a) Salt water/ strong alcohol/lime juice
b) Use of local concoctions/ herbal preparations
III- Modern methods
a) Progesterone Only Pills (POL)
b) Combine Oral contraceptive
c) Intrauterine Device (IUD)
d) Injectable Depot
e) Implants
f) Sterilization
g) Male Condoms
h) Female Condoms
i) Vasectomy
j) diaphragm
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9) According to you what is contraception/family planning?
a) Limiting and spacing deliveries
b) Preventing labor
c) Preventing STI
d) Preventing poverty
SECTION C: PRACTICE OF FAMILY PLANNING
10) Are you using contraceptive method/family planning method?
a) Yes b) No
11) Which of the following contraceptive methods are you practicing? (Tick all that apply)
I-NATURAL METHODS
d) Lactation amenorrhea method (LAM)
e) Coitus interrupts
f) Periodic abstinence
II-Traditional methods
c) Salt water/ strong alcohol/lime juice
d) Use of local concoctions/ herbal preparations
III- Modern methods
k) Progesterone Only Pills (POL)
l) Combine Oral contraceptive
m) Intrauterine Device (IUD)
n) Injectable Depot
o) Implants
p) Sterilization
q) Male Condoms
r) Female Condoms
s) Vasectomy
t) diaphragm
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12) For how long have you been on this (these) methods? a) less than 1 year b) 1 year and above
13) Where do you receive advice on the type of family planning method to user?
a) From Hospitals
b) From traditional Doctors
c) From my friends / family members / media
14) How many children do you have? a) 1-3 b) 4-6 c) 7 And above
SECTION D: FACTORS HINDERING THE PRACTICIES OF FAMILY PLANNING
15) What are the problems you face when using family planning methods?
a) Having heavy or mild bleeding
b) Mood changes
c) Increase in weight
d) Irregular menses
e) I don’t face any problems
16) Do you think that contraceptive methods /family planning methods can lead to infertility?
a) Yes b) No
17) Does your religion/culture permit contraception/family planning? a) yes b) no
18) Was this your first pregnancy? a) Yes (primigravida) b) No (multigravida)
19) What is your most used mode of delivery? a) Vaginal delivery b) CS (Operation)
