- Open access
- Published: 07 November 2023
Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review
- Ashraf Nabhan ORCID: orcid.org/0000-0003-4572-2210 1 ,
- Rita Kabra 2 ,
- Alyaa Ashraf 3 ,
- Fatma Elghamry 3 ,
- James Kiarie 2 &
Family Planning Research Collaborators
BMC Women's Health volume 23 , Article number: 574 ( 2023 ) Cite this article
1787 Accesses
8 Altmetric
Metrics details
Demand generation aims to increase clients’ desire to use family planning. The aim of this work was to systematically summarize strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning.
We searched electronic bibliographic databases from inception to October 2022. We included quantitative, qualitative, and mixed methods reports on demand generation strategies in family planning, regardless of country, language, publication status, or methodological limitations. We assessed abstracts, titles and full-text papers according to the inclusion criteria, extracted data, and assessed methodological quality of included reports. We used the convergent integrated approach and a deductive thematic synthesis to summarize demand generation themes and subthemes. We used the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators). We used GRADE-CERQual to assess our confidence in the findings.
Forty-six studies (published 1990–2022) were included: forty-one quantitative, one qualitative, and four mixed methods). Three were from one high-income country, and forty three from LMIC settings. Half of reports were judged to be of unclear risk of bias. There were unique yet interrelated strategies of scaling-up demand generation for family planning. Interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. Demand-side financing approaches probably increase awareness of contraceptives and the use of modern contraceptive methods among poor clients. Multifaceted Demand generation approaches probably improve adoption, coverage and sustainability of modern methods use. Factors that influence the success of implementing these strategies include users knowledge about family planning methods, the availability of modern methods, and the accessibility to services.
Conclusions
Demand generation strategies may function independently or supplement each other. The myriad of techniques of the different demand generation strategies, the complexities of family planning services, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in increasing and sustaining family planning utilization.
Trial Registration
Systematic review registration: Center for Open Science, osf.io/286j5
Plain English summary
Family planning could prevent one third of maternal deaths by allowing women to delay motherhood, avoid unintended pregnancies and subsequent abortions. Demand generation is one of the critical factors for increasing coverage and sustainability of family planning programs. Demand generation activities aim to increase clients’ desire to use family planning by changing their attitudes or perceptions about FP or increasing their awareness or knowledge about FP methods and also by improving access to contraceptive services. Many demand generation activities also aim to shift social and cultural norms to affect individual behavior change. Scaling up demand generation and ensuring that demand for family planning is satisfied is essential for achieving universal access to reproductive health-care services. We systematically searched for and summarized reports of strategies to scale up demand generation for family planning. Available evidence shows that interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. The effect of new media is uncertain. Demand-side financing approach probably increase awareness of contraceptives and the use of modern contraceptive methods among poor women. The most apparent factors influencing the success of implementing these strategies include knowledge about family planning methods, especially regarding side effects and health concerns, the availability of modern contraceptive methods, and the accessibility to family planning services.
Peer Review reports
Improving the effectiveness of family planning (FP) programs is critical for empowering women and adolescent girls, improving human capital, reducing dependency ratios, reducing maternal and child mortality, and achieving demographic dividends particularly in low- and middle-income countries. Family planning could prevent one third of maternal deaths by allowing women to delay motherhood, avoid unintended pregnancies and subsequent abortions [ 1 , 2 ].
One of the driving forces for increasing coverage and sustainability of family planning programs is demand generation. Demand generation strategies encompass three categories: interpersonal communications, mass media, and innovative financing approaches. Demand generation activities aim to increase clients’ desire to use family planning by changing their attitudes or perceptions about FP or increasing their awareness or knowledge about FP methods and also by improving access to contraceptive services. Many demand generation activities also aim to shift social and cultural norms to affect individual behavior change [ 3 , 4 ].
Implementing demand generation strategies and ensuring that demand for family planning is satisfied are essential for achieving universal access to reproductive health-care services, as called for in the 2030 Agenda for Sustainable Development [ 5 ]. Scaling up is defined as deliberate efforts to increase the impact of health service innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis [ 6 , 7 , 8 , 9 ].
Therefore, as part of its family planning strategy, the WHO has commissioned this systematic review of scaling up demand generation in family planning.
The overall aim of the review was to describe and assess the quality of the evidence on scaling up demand generation in family planning. The review has the following objectives:
to identify, appraise and synthesize research evidence regarding the approaches or strategies to scale up demand generation in FP for improving adoption, coverage, and sustainability;
to identify, appraise and synthesize research evidence on the barriers to and facilitators of scaling up demand generation for family planning.
We conducted a systematic review, following the JBI methodology for mixed methods systematic reviews (MMSR) [ 10 ] and methods suggested by the Cochrane Effective Practice and Organisation of Care (EPOC) Review Group [ 11 ].
The protocol, available as a preprint [ 12 ], was registered in the Center for Open Science platform ( https://doi.org/10.17605/OSF.IO/286J5 ).
We reported the review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 13 ].
Criteria for considering studies for this review
Types of participants.
We included all types of participants who are the target of scaling up demand generation for FP.
Phenomena of interest
We included studies where the focus is scaling up demand generation for FP.
Types of interventions
For this review, we considered demand generation strategies under the following categories: interpersonal communications, mass media, and innovative financing approaches [ 3 ].
We considered implementation research outcomes mainly adoption (the intention, initial decision, or action to try to employ an intervention; also known as Uptake, Utilization, Intention to use), coverage (the degree to which the population that is eligible to benefit from an intervention actually receives it), and sustainability (the extent to which an intervention is maintained; also known as maintenance, Continuation) [ 14 , 15 ].
Barriers and facilitators (factors that influence demand generation)
The approach to the factors affecting demand generation to scale up FP was based on the SURE (Supporting the Use of Research Evidence) framework [ 16 ]. We considered the factors affecting implementation at all levels namely recipients of care, providers of care, other stakeholders (including other healthcare providers, community health committees, community leaders, program managers, donors, policymakers and opinion leaders), health system constraints, and social and political constraints.
The factors were finally grouped by the categories of health system building blocks (HSBB). HSBB is an analytical framework used by WHO to describe health systems, disaggregating them into 6 core components, with people in the center, (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) Medical products, vaccines and technologies (access to essential medicines), (v) financing, and (vi) leadership and governance [ 17 ].
Types of studies
We included primary quantitative studies, qualitative studies, process evaluation studies, policy analysis studies, and case studies. Mixed method studies were only considered if data from the quantitative or qualitative components can be clearly extracted.
We excluded editorials, commentaries, proposals, conference abstracts and systematic reviews. We also excluded reports that lacked a clear methodology section.
There was no restriction on length of study follow-up, language of publication, or country of origin.
Literature search
The search strategy aimed to locate both published and unpublished studies. We searched bibliographic databases for peer reviewed publications as well as grey literature. We searched the following electronic bibliographic databases (from inception to 15th September 2022): MEDLINE, PubMed, Scopus, the Cochrane Library, and Global Index Medicus, World Health Organization ( www.globalindexmedicus.net ).
We also searched gray literature using the search engines and websites of relevant organizations. We hand searched citations in included articles.
Search strategy
The search terms were developed in consultation with the other authors using a combination of keywords and Medical Subject Headings (MeSH). The search strategy will be first developed in Pubmed format and was adapted to the other databases. The search strategies for various platforms are available in an open access repository [ 18 ].
We will use the following terms ((Implementation Science[MeSH Terms]) OR (“Health Services Needs and Demand”[MeSH Terms]) OR (“demand generation” [Text Word]) OR (“demand side” [Text Word])) AND ((Family Planning Services[MeSH Terms]) OR (contraception[MeSH Terms]) OR (contracept*[Text Word]) OR (“family planning”[Text Word]) OR (“birth control”[Text Word]) OR (“birth spacing”[Text Word])). We aimed at sensitivity rather than precision since we opted to minimize false negative results.
Management of search results
All search results were imported into Jabref v5. Duplicate search results were identified by the software and were eliminated after being revised by the authors, using a method that enables retaining unique citations without accidentally excluding false duplicates.
Data collection
Study selection.
We developed a study selection form based on our eligibility criteria. After removal of duplicates, two review authors independently piloted the study selection form with a small random sample of studies to assess understanding of eligibility criteria and ease of use of the form. Two review authors independently screened all titles/abstracts and full text to identify the relevant studies. Discrepancies between review authors regarding study eligibility were resolved by consensus or, when required, with a third party. We used the PRISMA flowchart to describe the process of study selection.
Data extraction
Two review authors independently extracted characteristics from the included studies: study title, first author, year of publication, country of study, the country’s economic status (low-, middle-, or high-income), study type and design. We extracted the demand generation strategies mentioned in each study, the target of the demand generation activity, implementation outcome evaluated in each study, and barriers and facilitators. We resolved any disagreement in the data collection process through discussion and consensus between the two reviewers and, if needed, with a third party.
Quality assessment
For each included study, the methodological quality were described using the corresponding Mixed-Methods Appraisal Tool (MMAT) criteria [ 19 , 20 ]. Two independent reviewers assessed the quality of included studies using MMAT, with a third independent reviewer to be used in case of any discrepancies. We accepted that there is no ‘gold standard’ approach for assessing the methodological quality of primary qualitative studies, but believe that MMAT fits the context of this synthesis [ 19 , 20 ].
We did not exclude studies based on methodological limitations, but rather will use the findings to assess the confidence in the findings.
Data synthesis
We used the convergent integrated approach. The quantitative data was then converted into “qualitized data.” This involved transformation into textual descriptions or narrative interpretation of the quantitative results in a way that answers the review questions [ 10 ].
We grouped articles according to categories of demand generation, as defined above. We used a deductive thematic synthesis using the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators).
Appraisal of confidence in the review findings
We used GRADE-CERQual to assess the confidence that can be placed in each review finding [ 21 ] based on four components: methodological limitations of included studies, coherence of the review findings, adequacy of the data contributing to a review finding, and relevance of the included studies to the review question. After assessing each of the four components, we made a judgement about the overall confidence in the evidence supporting each review finding. All findings start as high confidence and were then graded down if there are important concerns regarding any of the four components. We judged confidence as high, moderate, low, or very low. The final assessment was based on consensus among the review authors. We presented summaries of the findings and our assessments of confidence in these findings in the Summary of findings Table [ 21 ].
Researchers’ reflexivity
We maintained a reflexive stance throughout the stages of the review process, from study selection to data synthesis. The team discussed the Progress regularly and explored critically every step of the work. As a review team, we all have clinical backgrounds. In addition, three review authors have received advanced training in implementation science (AN, RK, JK) and are well versed in relevant theory. Based on our collective and individual experiences (as clinicians, academics and researchers), we anticipated the findings of our review to reveal a combination of organisational, professional and individual factors influencing the demand generation for family planning. We, as a team, remained mindful of our presuppositions and support each other to minimize the risk of these skewing the synthesis or the interpretation of the findings. We kept a reflexive journal throughout the review process in which to document and reflect on progress and decisions made [ 11 ].
The flow of identification, screening, and including 46 reports is depicted in Fig. 1 .
PRISMA Flowchart
Characteristics of included studies
The 46 included studies used Quantitative (41/46, 89.13%), Qualitative (1/46; 2.17%), and Mixed methods (4/46; 8.70%). The studies were reported from 23 countries from all regions and from Low (Ethiopia, Gambia, Madagascar, Malawi, Mali, Rwanda, Uganda, Yemen,Zambia), Lower middle (Cambodia, Cameroon, Egypt, Ghana, India, Iran, Kenya, Nepal, Nigeria, Pakistan, Senegal, Tanzania), Upper middle (Turkey) and High income (USA) countries, Table 1 .
Methodological quality
For each included study, the methodological quality was described using the corresponding MMAT criteria. We judged 14 studies (30.43%) to be of low risk of bias, 10 studies (21.74%) to have a high risk of bias, and 22 studies (47.83%) to have an unclear risk of bias. We did not exclude studies based on methodological limitations, but rather used the findings to assess the confidence in the findings.
Findings of the review
We used a convergent integrated approach and a deductive thematic synthesis of the different approaches to scale up demand generation for family planning and the factors influencing implementation.
Strategies of demand generation in family planning
The review identified unique yet interrelated strategies of scaling-up demand generation for family planning, Table 2 .
Interpersonal communications included 16 reports: [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. These included diverse approaches: home visits, one-on-one discussion, small group discussions, lectures, workshops. Community events included street plays and dramas, caravan road shows, community drama/puppet shows, sports competitions, beauty contests, bicycle races, public entertainment events, population weekends, and religious leaders’ speeches. This category included counselling and referral.
Mass- and mid- media included Television, Radio, Wall paintings, Leaflets, Posters, Booklets, Brochures, Newspaper and magazines. New media included mobile messages and social media namely Facebook (advertisements or page) in 8 reports, [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 ].
Demand-side financing strategies included small cash incentives and vouchers in 7 reports [ 46 , 47 , 48 , 49 , 50 , 51 , 52 ].
Reports used a multifaceted approach, namely Interpersonal communications plus Mass media in 12 reports [ 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 ], Interpersonal communications plus Financing in 2 reports: [ 65 , 66 ], and a bundle of Interpersonal communications plus Mass media plus Financing in one report [ 67 ].
Effect of demand generation strategies
The effect of demand generation strategies were grouped by either reports of unique strategies, Table 3 or multifaceted strategies, Table 4 .
Interpersonal communications strategies contributed to 67.39% (31/46) of the reports either independently (Table 3 ) or as part of a bundle (Table 4 ) to generate demand for FP.
Factors influencing demand generation for family planning
The health system building blocks frame work was used for the synthesis of factors that influence demand generation for family planning.
Knowledge about family planning methods, especially regarding side effects and health concerns [ 32 , 42 , 56 , 57 ].
Woman’s preference and acceptability [ 42 , 57 ].
Engagement of partners in discussing family planning [ 25 , 57 ].
Interest to discuss family planning [ 39 , 42 ].
Motivation to use family planning [ 22 ].
Reach of mass media [ 44 , 54 ].
Social acceptability to approach unmarried women to discuss contraception [ 25 ].
Traditional and religious beliefs regarding the number of children [ 24 ].
Affordability of family planning services [ 25 ].
Financial benefits associated with practicing family planning [ 35 ].
Health workforce
Providers’ age, gender, and religion [ 25 , 35 ].
Family planning nurses and community healthcare workers sharing sound knowledge [ 56 ].
Number of Health workforce, especially female healthcare workers [ 24 , 32 ].
Leadership and governance
Concurrent multiple demand generation programs within the same area in need [ 25 ].
Consistency of implementing family planning programs [ 25 ].
Degree of reliance on donor driven management and funding [ 25 ].
Endorsement of family planning by the government [ 56 ].
Integration of community-based health workers into healthcare system [ 25 ].
Integration of non-governmental organizations trained field workers into the healthcare system [ 25 ].
Medical products
Availability of modern contraceptive methods [ 24 , 32 , 35 , 54 ].
Number of methods available to women [ 54 ].
Service delivery
Accessibility to family planning services [ 24 , 35 , 54 ].
Ease of use of the family planning method [ 55 ].
Summary of the evidence
Demand-side unmet need (lack of demand for contraception), compared with supply-side unmet need, is responsible for the vast majority of total unmet need, ranging from 69 to 84% of unmet need [ 68 ]. This implies that a significant proportion of nonusers, irrespective of their age or level of education, consciously and knowingly decide against using modern family planning methods, even when they are not actively seeking to conceive [ 68 , 69 , 70 ]. Therefore, it was imperative to critically summarize best available evidence to understand what and how demand generation strategies can help for improving family planning services and reducing unmet need.
In the current review, demand generation strategies in cross-cutting themes were identified within the included studies. Available evidence suggests that scaling up demand generation using interpersonal communication strategies can increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Demand generation through mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. The effect of new media is uncertain. Demand-side financing approach probably increases awareness and use of modern contraceptive methods among poor women. The results are in agreement with previous reviews that examined demand generation strategies and how these might improve adoption and coverage of family planning methods [ 71 , 72 , 73 ].
Our results indicate that demand generation strategies may function independently or supplement each other. Each theme seems to improve certain aspect contributing to scaling up family planning. Evidence for sustainability is insufficient and this remains an important issue for countries striving to maintain a reduction in unmet needs and improvement of contraceptive prevalence rates. The need for integration with health system is critical for family planning to be institutionalized and therefore sustainable [ 74 ].
The heterogeneity in the designs of studies assessing demand-side interventions and the lack of evidence on indicators used to measure the outcomes of such interventions make it difficult to draw overall conclusions about the strategies that can be scaled up. These issues have been observed, yet remain an resolved challenge [ 63 ].
There is lack of reports on social media (one platform in two reports) and cellular phone technology (two reports) for demand generation in family planning. Social media allows users to connect in a virtual network or community, facilitating reach and usability of shared information. Types of social media include social networks (e.g., Facebook, Twitter), video sharing (e.g., YouTube), photo-sharing platforms (e.g., Instagram), or messaging apps (e.g., WhatsApp, Telegram). In each of these types, the over-arching characteristics include: connections and relationship-building, speedy delivery, and not limited by geography. This issue is extremely important in the currrent era since there is evidence that incorporating social media features into social behavior change activities has been shown to contribute positively to their success [ 75 ].
In the current synthesis of barriers to the success of demand generation strategies included knowledge about family planning methods, especially regarding side effects and health concerns. The significance of providing precise information to individuals for making informed health decisions cannot be overstated [ 76 ]. The discussion of an individual’s lack of demand for contraceptive methods that health providers consider advantageous always necessitates a consideration of health literacy. The significance of health literacy is important, specifically in relation to the prevalence of “myths and rumors” as justifications for the non-utilization of contraceptives [ 77 , 78 ]. Women’s concerns regarding the potential adverse effects of contraceptives on their bodies are valid. These valid concerns are conceptualized as a demand-side rationale for abstaining from contraceptive use. Particularly for those women whose inclination to avoid pregnancy is weak, the urge to avert contraceptive side effects may emerge as a more persuasive impetus, thereby culminating in non-utilization of contraceptives [ 79 ]. Although the concerns regarding the adverse effects of contraception is frequently associated with myths and misconceptions, an examination of women’s views revealed that individuals who attribute their non-use to health concerns are more likely to have previously used modern contraceptive method [ 80 ]. In the current era, it is critical to scrutinize the systematic exclusion of women’s voices from the debate concerning their bodies and families.
Limitations
Although we took every effort to minimize the potential for biases in the review process, sources of potential bias may exist. First, while our searches were comprehensive, there is a possibility that some relevant studies were missed for assessment by the review since the results of some programs may have not been made public.
Second, a potential bias in reviews in this area is the adoption of clear criteria for what constitutes a standalone demand side strategy, which is never the case.
Third, each theme of demand-generation contains a diversity of possible processes, content, and operational environments. Because these variables are often not controlled across studies, it is difficult to rigorously determine the situations in which specific strategies work best. Despite this, the strengths of different strategies in different circumstances can still be realized.
Finaly, information regarding the processes of demand generation strategies in the included reports were not described in sufficiently informative details.
Demand generation strategies may function independently or supplement each other. Each category possibly improves certain aspect contributing to improving awareness, adoption, and use of modern contraceptive methods. Evidence for sustainability is insufficient. The myriad of techniques of the different demand generation strategies, the complexities of programs, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in scaling up demand generation thus increasing use and sustaining family planning services.
Availability of data and materials
All data generated or analysed during this study are included in this published article and its supplementary information files.
Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, Group CRAC. Selected major risk factors and global and regional burden of disease. Lancet (London England). 2002;360:1347–60.
Article PubMed Google Scholar
Chola L, McGee S, Tugendhaft A, Buchmann E, Hofman K. Scaling up family planning to reduce maternal and child mortality: the potential costs and benefits of modern contraceptive use in South Africa. Plos One. 2015;10:e0130077.
Article PubMed PubMed Central Google Scholar
Mwaikambo L, Speizer IS, Schurmann A, Morgan G, Fikree F. What works in family planning interventions: a systematic review. Stud Fam Plann. 2011;42:67–82.
UNFPA. Towards the development of a UNFPA programmatic guidance for demand generation in family planning. New York: UNFPA; 2014.
United Nations, Department of Economic and Social Affairs, Population Division. Family planning and the 2030 agenda for sustainable development: Data booklet. New York: United Nations; 2019.
Simmons R, Fajans P, Ghiron L, editors. Scaling up health service delivery: from pilot innovations to policies and programmes. Geneva: World Health Organization; 2007.
World Health Organization. Practical guidance for scaling up health service innovations. World Health Organization; 2009.
Google Scholar
Simmons R, Ghiron L, Fajans P, Newton N. Nine steps for developing a scaling-up strategy. Geneva: World Health Organization; 2010.
Starbird E, Norton M, Marcus R. Investing in family planning: key to achieving the sustainable development goals. Glob Health Sci Pract. 2016;4:191–210.
Lizarondo L, Stern C, Carrier J, Godfrey C, Rieger K, Salmond S, et al. Chapter 8: Mixed methods systematic reviews. In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis. JBI. 2020. Available from: https://synthesismanual.jbi.global . https://doi.org/10.46658/JBIMES-20-09 .
Glenton C, Bohren MA, Downe S, Paulsen EJ, Lewin S, on behalf of Effective Practice and Organisation of Care (EPOC). EPOC Qualitative Evidence Syntheses: Protocol and review template v1.3. EPOC Resources for review authors. 2022. https://doi.org/10.5281/zenodo.5973704 .
Nabhan A, Kabra R, Kiarie J. Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review protocol, 19 December 2022, PREPRINT (Version 1) available at Research Square. https://doi.org/10.21203/rs.3.rs-2388905/v1 .
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Reviews. 2015;4:1.
Article Google Scholar
Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Implementation research: what it is and how to do it. BMJ (Clinical Research ed). 2013;347:f6753.
PubMed Google Scholar
Peters D, Tran N, Adam T. Implementation research in health: a practical guide. Geneva: World Health Organization; 2013.
The SURE Collaboration. SURE Guides for Preparing and Using Evidence-Based Policy Briefs: 5. Identifying and addressing barriers to implementing policy options. Version 2.1 [updated November 2011]. The SURE Collaboration. 2011. Available from: www.evipnet.org/sure .
de Savigny D, Adam T, editors. Systems thinking for health systems strengthening. Geneva: Alliance for Health Policy and Systems Research; 2009.
Nabhan A. Search strategy: demand generation. figshare. 2022. https://doi.org/10.6084/M9.FIGSHARE.20152928.V4 .
Pluye P, Gagnon M-P, Griffiths F, Johnson-Lafleur J. A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews. Int J Nurs Stud. 2009;46:529–46.
Hong QN, Fàbregues S, Bartlett G, Boardman F, Cargo M, Dagenais P, et al. The Mixed Methods Appraisal Tool (MMAT) version 2018 for information professionals and researchers. Educ Inf. 2018;34(4):285–91.
Lewin CAM-K, Simon AND, Glenton. Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). PLoS Med. 2015;12:1–18.
Akman M, Tüzün S, Uzuner A, Başgul A, Kavak Z. The influence of prenatal counselling on postpartum contraceptive choice. J Int Med Res. 2010;38:1243–9.
Article CAS PubMed Google Scholar
Daniel EE, Masilamani R, Rahman M. The effect of community-based reproductive health communication interventions on contraceptive use among young married couples in Bihar, India. Int Fam Plan Perspect. 2008;34:189–97.
Dureab F, Bawazir AA, Kuelker R. The effects of community-based reproductive health workers on the utilization of family planning services in Yemen. Int Invention J Med Med Sci. 2015;2:56–61.
Hackett K, Henry E, Hussain I, Khan M, Feroz K, Kaur N, et al. Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study. BMJ Open. 2020;10:e039835.
Henry EG, Hackett KM, Bawah A, Asuming PO, Agula C, Canning D, et al. The impact of a personalized, community-based counselling and referral programme on modern contraceptive use in urban Ghana: a retrospective evaluation. Health Policy Plann. 2021;35:1290–9.
Katz KR, West CG, Doumbia F, Kane F. Increasing access to family planning services in rural Mali through community-based distribution. Int Fam Plan Perspect. 1998;24:104.
Luck M, Jarju E, Nell MD, George MO. Mobilizing demand for contraception in rural Gambia. Stud Fam Plann. 2000;31:325–35.
Mahamed F, Parhizkar S, Raygan Shirazi A. Impact of family planning health education on the knowledge and attitude among yasoujian women. Global J Health Sci. 2012;4:110–8.
Pradhan E, Canning D, Shah IH, Puri M, Pearson E, Thapa K, et al. Integrating postpartum contraceptive counseling and IUD insertion services into maternity care in Nepal: results from stepped-wedge randomized controlled trial. Reprod Health. 2019;16:69.
Prata N, Weidert K, Fraser A, Gessessew A. Meeting rural demand: a case for combining community-based distribution and social marketing of injectable contraceptives in tigray, Ethiopia. PLoS One. 2013;8:e68794.
Article CAS PubMed PubMed Central Google Scholar
Ruark A, Kishoyian J, Bormet M, Huber D. Increasing family planning access in Kenya through engagement of faith-based health facilities, religious leaders, and community health volunteers. Global Health Sci Pract. 2019;7:478–90.
Saeed GA, Fakhar S, Rahim F, Tabassum S. Change in trend of contraceptive uptake–effect of educational leaflets and counseling. Contraception. 2008;77:377–81.
Schwandt HM, Creanga AA, Danso KA, Adanu RMK, Agbenyega T, Hindin MJ. Group versus individual family planning counseling in Ghana: a randomized, noninferiority trial. Contraception. 2013;88:281–8.
Shattuck D, Kerner B, Gilles K, Hartmann M, Ng’ombe T, Guest G. Encouraging contraceptive uptake by motivating men to communicate about family planning: the Malawi male motivator project. Am J Public Health. 2011;101:1089–95.
Soliman MH. Impact of antenatal counselling on couples’ knowledge and practice of contraception in mansoura, Egypt. East Mediterr Health J 1999;5:1002–13.
Terefe A, Larson CP. Modern contraception use in Ethiopia: does involving husbands make a difference? Am J Public Health. 1993;83:1567–71.
Agha S. Intention to use the female condom following a mass-marketing campaign in Lusaka, Zambia. Am J Public Health. 2001;91:307–10.
Agha S, van Rossem R. Impact of mass media campaigns on intentions to use the female condom in tanzania. Int Fam Plan Perspect. 2002;28:151.
Babalola S, Folda L, Babayaro H. The effects of a communication program on contraceptive ideation and use among young women in northern Nigeria. Stud Fam Plann. 2008;39:211–20.
Byker T, Myers C, Graff M. Can a social media campaign increase the use of long-acting reversible contraception? Evidence from a cluster randomized control trial using facebook. Contraception. 2019;100:116–22.
Dehlendorf C, Fox E, Sharma AE, Zhang J, Yang S, Centola D. Birth control connect: a randomized trial of an online group to disseminate contraceptive information. Contraception. 2020;101:376–83.
Kofinas JD, Varrey A, Sapra KJ, Kanj RV, Chervenak FA, Asfaw T. Adjunctive social media for more effective contraceptive counseling: a randomized controlled trial. Obstet Gynecol. 2014;123:763–70.
Piotrow PT, Rimon JG, Winnard K, Kincaid DL, Huntington D, Convisser J. Mass media family planning promotion in three Nigerian cities. Stud Fam Plann. 1990;21:265–74.
Rogers EM, Vaughan PW, Swalehe RM, Rao N, Svenkerud P, Sood S. Effects of an entertainment-education radio soap opera on family planning behavior in tanzania. Stud Fam Plann. 1999;30:193–211.
Ali M, Azmat SK, Hamza HB, Rahman MM, Hameed W. Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan. BMC Health Serv Res. 2019;19:200.
Bajracharya A, Veasnakiry L, Rathavy T, Bellows B. Increasing uptake of long-acting reversible contraceptives in Cambodia through a voucher program: evidence from a difference-in-differences analysis. Global Health Science and Practice. 2016;4(Suppl 2):109–21.
Burke E, Gold J, Razafinirinasoa L, Mackay A. Youth Voucher program in Madagascar increases access to voluntary family planning and STI services for young people. Global Health Sci Pract. 2017;5:33–43.
IFPS Technical Assistance Project. Sambhav: Vouchers make high-quality reproductive health services possible for india’s poor. Haryana: Futures Group, ITAP Gurgaon; 2012.
Mozumdar A, Aruldas K, Jain A, Reichenbach L. Understanding the use of India’s national health insurance scheme for family planning and reproductive health services in uttar pradesh. Int J Health Plann Manag. 2018;33:823–35.
Obare F, Warren C, Njuki R, Abuya T, Sunday J, Askew I, et al. Community-level impact of the reproductive health vouchers programme on service utilization in Kenya. Health Policy Plann. 2013;28:165–75.
Stevens JR, Stevens CM. Introductory small cash incentives to promote child spacing in India. Stud Fam Plann. 1992;23:171–86.
Achyut P, Benson A, Calhoun LM, Corroon M, Guilkey DK, Kebede E, et al. Impact evaluation of the urban health initiative in urban uttar pradesh, India. Contraception. 2016;93:519–25.
Benson A, Calhoun LM, Corroon M, Lance P, O’Hara R, Otsola J, et al. Longitudinal evaluation of the tupange urban family planning program in Kenya. Int Perspect Sex Reprod Health. 2017;43:75–87.
Benson A, Calhoun L, Corroon M, Gueye A, Guilkey D, Kebede E, et al. The Senegal urban reproductive health initiative: a longitudinal program impact evaluation. Contraception. 2018;97:439–44.
Corey J, Schwandt H, Boulware A, Herrera A, Hudler E, Imbabazi C, et al. Family planning demand generation in Rwanda: government efforts at the national and community level impact interpersonal communication and family norms. PLoS One. 2022;17:e0266520.
Krenn S, Cobb L, Babalola S, Odeku M, Kusemiju B. Using behavior change communication to lead a comprehensive family planning program: the Nigerian urban reproductive health initiative. Global health. Sci Pract. 2014;2:427–43.
Lemani C, Kamtuwanje N, Phiri B, Speizer IS, Singh K, Mtema O, et al. Effect of family planning interventions on couple years of protection in Malawi. Int J Gynaecol Obstet. 2018;141:37–44.
Lutalo T, Kigozi G, Kimera E, Serwadda D, Wawer MJ, Zabin LS, et al. A randomized community trial of enhanced family planning outreach in rakai, uganda. Studies in family planning. Stud Fam Plan. 2010;41:55–60.
Okigbo CC, Speizer IS, Corroon M, Gueye A. Exposure to family planning messages and modern contraceptive use among men in urban Kenya, Nigeria, and Senegal: a cross-sectional study. Reproductive Health. 2015;12:63.
Plautz A, Meekers D. Evaluation of the reach and impact of the 100. Reprod Health. 2007;4:1.
Sebastian MP, Khan ME, Kumari K, Idnani R. Increasing postpartum contraception in rural India: evaluation of a community-based behavior change communication intervention. Int Perspect Sex Reproductive Health. 2012;38:68–77.
Speizer IS, Corroon M, Calhoun L, Lance P, Montana L, Nanda P, et al. Demand generation activities and modern contraceptive use in urban areas of four countries: a longitudinal evaluation. Global Health Science and Practice. 2014;2:410–26.
Wu W-J, Tiwari A, Choudhury N, Basnett I, Bhatt R, Citrin D, et al. Community-based postpartum contraceptive counselling in rural Nepal: a mixed-methods evaluation. Sex Reproductive Health Matters. 2020;28:1765646.
Agha S. Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention. Int J Equity Health. 2011;10:57.
Azmat SK, Khurram Azmat S, Shaikh BT, Tasneem Shaikh B, Hameed W, Mustafa G, et al. Impact of social franchising on contraceptive use when complemented by vouchers: a quasi-experimental study in rural Pakistan. PLoS ONE. 2013;8:e74260.
Hameed W, Azmat SK, Ishaque M, Hussain W, Munroe E, Mustafa G, et al. Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of pakistan: results of a 24-month prospective client follow-up. Health Res Policy Syst. 2015;13(Suppl 1):53.
Senderowicz L, Maloney N. Supply-side versus demand-side unmet need: implications for family planning programs. Popul Dev Rev. 2022;48:689–722.
RamaRao S, Jain AK. Aligning goals, intents, and performance indicators in family planning service delivery. Stud Fam Plann. 2015;46:97–104.
Senderowicz L. I was obligated to accept: a qualitative exploration of contraceptive Coercion. Soc Sci Med. 2019;239:112531.
Ali M, Farron M, Azmat SK, Hameed W. The logistics of voucher management: the underreported component in family planning voucher discussions. J Multidisciplinary Healthc. 2018;11:683–90.
Eva G, Quinn A, Ngo TD. Vouchers for family planning and sexual and reproductive health services: a review of voucher programs involving Marie Stopes international among 11 Asian and African countries. Int J Gynecol Obstet. 2015;130:E15-20.
Bellows NM, Bellows BW, Warren C. Systematic review: the use of vouchers for reproductive health services in developing countries: systematic review. Tropical Med Int Health. 2010;16:84–96.
Sebert Kuhlmann A, Gavin L, Galavotti C. The integration of family planning with other health services: a literature review. Int Perspect Sex Reprod Health. 2010;36:189–96.
Elaheebocus SMRA, Weal M, Morrison L, Yardley L. Peer-based social media features in behavior change interventions: systematic review. J Med Internet Res. 2018;20:e20.
Littlejohn KE. It’s those pills that are ruining me. Gend Soc. 2013;27:843–63.
Farmer DB, Berman L, Ryan G, Habumugisha L, Basinga P, Nutt C, et al. Motivations and constraints to family planning: a qualitative study in Rwanda’s Southern Kayonza District. Global Health: Sci Pract. 2015;3:242–54.
Mushy SE, Tarimo EAM, Fredrick Massae A, Horiuchi S. Barriers to the uptake of modern family planning methods among female youth of Temeke District in Dar Es Salaam, Tanzania: a qualitative study. Sex Reprod Healthc. 2020;24:100499.
Rocca CH, Ralph LJ, Wilson M, Gould H, Foster DG. Psychometric evaluation of an instrument to measure prospective pregnancy preferences. Med Care. 2019;57:152–8.
Sedgh G, Hussain R. Reasons for contraceptive nonuse among women having Unmet need for Contraception in developing countries. Stud Fam Plann. 2014;45:151–69.
Download references
Acknowledgements
Family Planning Research Collaborators: Alyaa Ashraf (Faculty of Medicine, Ain Shams University, Egypt), Emry Atwa (Faculty of Medicine, Ain Shams University, Egypt), Samhaa Bahnasy (Faculty of Medicine, Ain Shams University, Egypt), Marwa Elgendi (Faculty of Medicine, Ain Shams University, Egypt), Fatma Elghamry (Faculty of Medicine, Ain Shams University, Egypt), Amal Elshabrawy (Faculty of Medicine, Ain Shams University, Egypt), Salma Eltayeb (Faculty of Medicine, Ain Shams University, Egypt), Sara Galal (Faculty of Medicine, Ain Shams University, Egypt), Rita Kabra (World Health Organization, Switzerland), James Kiarie (World Health Organization, Switzerland), Mariam Kodsy (Faculty of Medicine, Ain Shams University, Egypt), Nada Makram (Faculty of Medicine, Ain Shams University, Egypt), Nourhan Mostafa (Faculty of Medicine, Ain Shams University, Egypt), Ashraf Nabhan (Faculty of Medicine, Ain Shams University, Egypt), Noha Sakna (Faculty of Medicine, Ain Shams University, Egypt), Mohamed Salama (Faculty of Medicine, Ain Shams University, Egypt), Marwa Snosi (Faculty of Medicine, Ain Shams University, Egypt), Nouran Wagih (Faculty of Medicine, Ain Shams University, Egypt), Ahmed Zenhom (Faculty of Medicine, Ain Shams University, Egypt).
This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored program executed by the World Health Organization (WHO) (WHO-SRH/HRP-CFC grant number 2022/1240770-0 ).
Author information
Authors and affiliations.
Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, Egypt
Ashraf Nabhan
Department of Sexual and Reproductive Health including UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
Rita Kabra & James Kiarie
Faculty of Medicine, Ain Shams University, Cairo, Egypt
Alyaa Ashraf & Fatma Elghamry
You can also search for this author in PubMed Google Scholar
- Alyaa Ashraf
- , Emry Atwa
- , Samhaa Bahnasy
- , Marwa Elgendi
- , Fatma Elghamry
- , Amal Elshabrawy
- , Salma Eltayeb
- , Sara Galal
- , Rita Kabra
- , James Kiarie
- , Mariam Kodsy
- , Nada Makram
- , Nourhan Mostafa
- , Ashraf Nabhan
- , Noha Sakna
- , Mohamed Salama
- , Marwa Snosi
- , Nouran Wagih
- & Ahmed Zenhom
Contributions
AN, RK, JK conceived the idea for this review and planned the systematic review methods. AN, FE, AA conducted the review. All members of the Family Planning Research Collaborators performed screening of studies and data extraction. AN, RK, JK collaborated in writing the first draft of this review. All members of the Family Planning Research Collaborators read and approved the final version.The authors alone are responsible for the views expressed in this article, and they do not necessarily represent the decisions, policy, or views of the World Health.
Corresponding author
Correspondence to Ashraf Nabhan .
Ethics declarations
Ethics approval and consent to participate.
Not applicable.
Consent for publication
Competing interests.
The authors declare no competing interests.
Additional information
Publisher’s note.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Reprints and permissions
About this article
Cite this article.
Nabhan, A., Kabra, R., Ashraf, A. et al. Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review. BMC Women's Health 23 , 574 (2023). https://doi.org/10.1186/s12905-023-02735-z
Download citation
Received : 27 January 2023
Accepted : 26 October 2023
Published : 07 November 2023
DOI : https://doi.org/10.1186/s12905-023-02735-z
Share this article
Anyone you share the following link with will be able to read this content:
Sorry, a shareable link is not currently available for this article.
Provided by the Springer Nature SharedIt content-sharing initiative
- Family planning
- Demand generation
BMC Women's Health
ISSN: 1472-6874
- General enquiries: [email protected]
An official website of the United States government
Official websites use .gov A .gov website belongs to an official government organization in the United States.
Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.
- Publications
- Account settings
- Advanced Search
- Journal List
Perceptions of family planning services and its key barriers among adolescents and young people in Eastern Nepal: A qualitative study
Navin bhatt, bandana bhatt, bandana neupane, ashmita karki, tribhuwan bhatta, jeevan thapa, lila bahadur basnet, shyam sundar budhathoki.
- Author information
- Article notes
- Copyright and License information
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: [email protected]
Received 2020 Jun 27; Accepted 2021 May 12; Collection date 2021.
This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Introduction
Family planning methods are used to promote safer sexual practices, reduce unintended pregnancies and unsafe abortion, and control population. Young people aged 15–24 years belong to a key reproductive age group. However, little is known about their engagement with the family planning services in Nepal. Our study aimed to identify the perceptions of and barriers to the use of family planning among youth in Nepal.
A qualitative explorative study was done among adolescents and young people aged 15–24 years from the Hattimuda village in eastern Nepal. Six focus group discussions and 25 in-depth interviews were conducted with both male and female participants in the community using a maximum variation sampling method. Data were analyzed using a thematic framework approach.
Many individuals were aware that family planning measures postpone pregnancy. However, some young participants were not fully aware of the available family planning services. Some married couples who preferred ’birth spacing’ received negative judgments from their family members for not starting a family. The perceived barriers to the use of family planning included lack of knowledge about family planning use, fear of side effects of modern family planning methods, lack of access/affordability due to familial and religious beliefs/myths/misconceptions. On an individual level, some couples’ timid nature also negatively influenced the uptake of family planning measures.
Women predominantly take the responsibility for using family planning measures in male-dominated decision-making societies. Moreover, young men feel that the current family planning programs have very little space for men to engage even if they were willing to participate. Communication in the community and in between the couples seem to be influenced by the presence of strong societal and cultural norms and practices. These practices seem to affect family planning related teaching at schools as well. This research shows that both young men and women are keen on getting involved with initiatives and campaigns for supporting local governments in strengthening the family planning programs in Nepal.
An unmet need for family planning results in unintended pregnancies and illegal abortions. This has major health and social implications and is often the leading cause of maternal and child mortality in low-income countries [ 1 , 2 ]. An estimated 214 million women of reproductive age lack access to contraception resulting in an estimated 67 million unintended pregnancies, 36 million induced abortions, and 76,000 maternal deaths each year [ 3 ]. Family planning (FP) is a key intervention to limit these adverse health outcomes [ 4 – 6 ]. Such interventions can prevent 90% of abortions, 32% of maternal deaths, 20% of pregnancy-related morbidity globally, and reduce 44% of maternal mortality in low-income countries [ 1 , 7 ]. FP reduces adolescent pregnancies, prevents pregnancy-related health risks, and helps to prevent HIV/AIDS [ 8 ]. Access to contraception promotes education, raises the economic status of women, and gradually empowers them resulting in improved health outcomes and better quality of life [ 3 , 5 , 9 , 10 ].
Global data show that only 32% of married women from low-income countries currently use modern contraceptives [ 9 ]. According to the Nepal Demographic Health Survey 2016, the total fertility rate was 2.3 births per woman, which is declining and approaching replacement fertility. This is an important achievement. However, the modern contraceptive prevalence rate (mCPR), which is 43%, is still below the target in Nepal [ 11 ]. Nepal has consistently failed to reach the target of mCPR for the past 20 years. The future projection of mCPR for 2030 is 60% [ 5 ], which may be a distant dream if the barriers and enablers are not identified on time to strengthen the current efforts.
Expanding the coverage and access to effective contraceptive methods are essential to meet the Sustainable Development Goals and to achieve universal access to reproductive healthcare services by 2030 [ 11 , 12 ]. For this, the government of Nepal has started a FP program with a focus on increasing the use of FP services and reducing the unmet need [ 5 , 11 ]. However, various factors negatively influence the delivery of FP services including lack of information, limited awareness of dissemination activities, lack of trained staff, and various cultural and religious factors [ 13 ].
Family planning is a choice for many youth, but they often experience barriers such as negative provider attitudes, long distances to healthcare facilities, and inadequate stock of preferred contraceptives [ 13 , 14 ]. Nepali youth are reluctant to use modern contraceptives due to misconceptions about long-term fertility risks, fear of side effects and overall lack of deeper knowledge [ 15 , 16 ]. Besides, FP decisions are mostly dependent on male household members, including husbands and other elder members [ 17 , 18 ]. Married women whose husbands are away as migrant workers face unique contraceptive challenges. When their husbands return home for a few weeks in a year, these women are not prepared with their contraceptives, which can result in unwanted pregnancies [ 18 ].
The extrapolation of the available literature on FP use among adults from Nepal and elsewhere suggests that youth is an under-researched population when it comes to FP There is also a dearth of evidence on perception and key barriers to the use of FP measures in this population. Hence, this study aims to identify the perceptions of the FP services and barriers to the use of FP among the youth in Nepal to assist policymakers in designing appropriate interventions to strengthen the family planning programs in Nepal.
Material and methods
Ethical considerations.
The study received ethical approval from the Institutional Review Committee of B.P. Koirala Institute of Health Sciences, Dharan, Nepal as per the Undergraduate Research Proposal review process (URPRB/01/015). We obtained informed written consent from all participants aged 18 and above. For minors, we obtained assent from the parents of the participants with the participants’ permission. For those who could not read, the information sheet was read aloud by a volunteer, verbal consent was given, and a thumbprint, in the presence of a witness, was used in place of a signature. To maintain the confidentiality of the information and the privacy of the participants, only selected participants and the moderators attended the sessions. Personal identifiers and locator information were not collected, and any identifying information accidentally mentioned was removed from the text before the analysis.
Study setting
The study was conducted among the participants from Hattimuda village of Morang district in Province One of Nepal. Hattimuda village is a community service area of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. BPKIHS is a public-funded health sciences university, which follows a teaching district concept adopted as a part of its community-based medical education curriculum. BPKIHS also runs a tertiary hospital service for the population of eastern Nepal [ 19 ]. There is a public health facility in Hattimuda village that provides primary health care services including FP services such as the distribution of contraceptives. The nearest secondary and tertiary levels of healthcare services are available 18 kilometers away in Biratnagar, which is the provincial capital and the headquarters of Morang district. According to the 2017/18 annual report of the Department of Health Services, the contraceptive prevalence rate of Morang district is 54.6% [ 5 ] whereas the unmet need for FP in Province One as per the Nepal Demographic Health Survey 2016 is 25% [ 11 ].
Study design
This was a qualitative study with an exploratory design to gather a deeper understanding of the perception of FP and its barriers. Focus group discussions (FGD) and in-depth interview (IDI) methods were used. The overall study lasted from November 2017 to October 2018.
Study population and sampling technique
Adolescents and young people between 15 and 24 years of age from Hattimuda were included in the study. We used the maximum variation sampling method to enroll participants. Pretesting, including one FGD and four IDIs, was conducted among residents in another village of the same district. The pretesting guided the selection of participants for FGDs and IDIs. Accordingly, FGDs were conducted among adolescents and young people, separately for male and female participants to allow for free expression of views during the discussion of potentially sensitive issues. Moreover, the respondents recommended that people at the forefront of the community such as the village leaders, schoolteachers, community health volunteers, religious leaders, youth leaders, and students be selected for the interviews to gather more information. Along with the recommendations from the pretesting, brainstorming was done with community volunteers to generate a list of people who understood the issues of adolescents and young people. More volunteers were added to the list upon the recommendation of the initial respondents. Thus, participants representing diverse backgrounds in terms of gender, profession, education, and social status, were selected. The IDIs were done among 25 prominent people in the community, which included leaders, school teachers, female community health volunteers, healthcare professionals working at the health post and FP service centers, and youth leaders from youth clubs. Health care providers were included in the interviews as their views would be invaluable due to their experience as FP service providers and as witnessing the health issues faced by youth. The teachers are regarded highly for their knowledge and opinions in Nepali communities. So, they were selected for the IDI to provide more insight into the educational barriers to FP and to help in youth mobilization for FP activities. Considering the vital role of local leaders in influencing the implementation and regulation of population-level activities in the village, they were selected for IDI. Six focus groups were conducted with a total of 48 respondents ( Fig 1 ).
Fig 1. Selection of participants.
Data collection
The Focus Group Discussions (FGD) and In-depth interviews (IDI) were conducted by the researchers within the team with prior experience in qualitative research methods. The interview team included an undergraduate medical student, two postgraduate resident doctors, a public health graduate, and a public health academic researcher. Before data collection, an orientation session was conducted for the interviewers using the interview schedule and the topic guide. The IDI guidelines and interview schedules were developed from the literature review and were modified after pretesting. Validation of the tools was ensured by using the Item Objective Congruence (IOC) index and consultation with academics with experience in FP research. Using a semi-structured open-ended questionnaire, the participants were assessed on their knowledge and perceptions regarding sexual and reproductive health (SRH) and FP, SRH problems faced by youth, challenges and barriers to use of FP services, the role of youth in combating the perceived challenges, and suggestions for enhancing the use of services. Data were considered to have reached saturation when the responses from participants became repetitive and/or no new responses were received.
Focus group discussions
A representative group of youth from diverse backgrounds who could provide credible information about practices and factors affecting the use of FP in the community was selected. Separate FGDs were held for girls and boys to allow for free expression. A moderator was responsible for guiding the discussion and a note-taker for taking the notes, including recording non-verbal responses and ensuring the audio recording. A total of 6 FGDs, each containing 8 homogenous participants, were conducted. Each individual participated once in the FGD. Every member of the group could make their contribution to any question posed before proceeding to another question. Each FGD lasted for 60–90 minutes on average. The discussion was done in the Nepali language as preferred by participants and later translated into English during transcription.
In-depth interviews
In-depth interviews with the key stakeholders were conducted using the Interview Schedule after obtaining the informed consent and audio-recorded with participant permission. A total of 25 IDIs were conducted for the average duration of 30–45 minutes, at a location convenient to the participant, which included their homes and offices.
Data management and analysis
A framework method of thematic analysis was used. The analysis included stages of transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting the data into the framework matrix, and interpretation of the data. The data collected from the focus groups and interviews were transcribed verbatim. The notes taken were used as a guide to segregate the responses by different respondents during the discussion. An independent researcher conversant in the Nepali and English languages cross-checked the transcripts for accuracy and preservation of original meaning during translation. Preliminary codes were assigned to the available data and then organized into thematic units that were continually revisited and revised as necessary. To ensure consistency of data and findings, two authors were involved in data analysis and reporting. The recordings were stored and accessed by the research team only and were destroyed after the analysis and final report preparation.
Operational definition
According to UNFPA, all persons within the age of 15–24 years are considered youth [ 20 ].
The baseline characteristics of the participants can be seen in Table 1 .
Table 1. Sociodemographic characteristics of the participants.
The responses from the IDIs and FGDs revealed four broad themes. Within each broad theme were several substantive sub-themes that emerged from the data. The themes and subthemes are summarized in Table 2 below.
Table 2. Perceptions of FP services and its key barriers among youth.
Theme 1: knowledge and perceptions of fp, a) knowledge and sources of information on fp.
Participants demonstrated awareness of some form of FP. However, some knew nothing about it. Health workers were commonly referred to as the sources of information, while some also mentioned peers, radio, television, and books. Male participants openly disclosed their sources of information on FP while some female participants were reluctant to share their sources.
b) Perceptions of FP
Perceptions of FP varied among participants. Some male participants inferred FP measures as women’s business and did not show any interest in talking more about it. Some referred to FP as using condoms during intercourse, while others referred to oral pills and injectable hormones as FP. Some female participants looked at FP as a way of avoiding unwanted pregnancies.
“My sister used to say that she has been using injection (Depo-Provera) to control unwanted pregnancy . I think FP is about the same . ”- 19 years Female , FGD participant
Theme 2: Preference for FP methods and decision-making
Some female participants reported preference for traditional methods of contraception such as coitus interruptus and calendar method over modern methods. These people used modern methods of FP to start with, which they discontinued later due to the side effects. Participants also stated that the health facilities that provide FP services were far, and hence they had no alternative other than natural methods. Male participants hardly mentioned visiting any health facilities for FP purposes.
“Most of our clients who come for it (FP) are women. Even condoms are collected by women. Men rarely come alone or as couples for FP services.” - 35 years old Female, FP service provider, IDI participant
Yet husbands were responsible for the decision-making about FP and choices of methods for most couples. Some participants (both male and females) mentioned that women rather than men should use permanent FP measures. They believed that men being the breadwinner of the family, should not undergo sterilization, for example, as it would make them physically weak.
“Though I love my wife and I am concerned about her. But I have no options. I must work in a factory. I need to lift heavy weights there. All the major house chores are also done by me. These things (sterilization) would make me weak. How can I earn my livelihood then?”- 22 years Male, FGD participant
Some female participants expressed their concerns regarding the use of permanent FP methods. They mentioned that they had already been through various phases of pain, be it during menstruation, pregnancy, or delivery which has made them weak. Thus, they prefer their husbands to undertake any measures.
In contrast, unmarried participants stated that they would rather discuss and decide together with their partners regarding which method to choose in the future. Despite this interest, women were not sure how to engage their husbands in discussion. Some female participants said that they could not persuade their future husbands to use contraceptives as it would be disrespectful, whereas a few male participants believed it was a woman’s responsibility to use FP methods.
“It (FP) is stuff to be done by the women . So , there is no doubt about who would be doing it . Moreover , people would laugh at me if I do it -20 years Male , FGD participant “ Women have already gone through much pain in bringing up and taking care of the children and again keeping this stuff (FP) in their head is unjustifiable . As such, in comparison to the female operative procedure, I have heard that the male one is simple, less time consuming, and does not bring many complications . So, why not we men take the lead on this? ” -25 years Male, Youth leader, IDI participant
Theme 3: Barriers and challenges in the use of FP
A) supply-side barriers and challenges.
Participants indicated that contraceptive services are not always accessible nor affordable in rural areas. Health facilities are far, and many people feel reluctant to travel in a hot climate. Participants who were reluctant to travel said they were doubtful that the health facilities would have the methods in stock even if they managed to walk the distance. Others who were reluctant said they would be unable to afford the contraceptives from a private medical store regularly. A few participants raised the issue of privacy and unavailability of all services at the health centers. Similarly, young males from the community complained that the services at the health post were focused only on mothers and married couples, while the boys and the unmarried people were not given much attention. For this, they suggested changing the term to something other than FP because they believed that FP should include not only those who had families.
Participants expressed their frustration that FP and SRH services in their village had not been running well for more than a year. They felt that the government was not doing anything about it either. Some students expressed the need for an integrated curriculum at school covering every aspect of SRH and FP that would ensure adequate and proper knowledge of such crucial subjects. Despite the students’ desire to learn and understand FP, their teachers are often reluctant to talk about FP in detail. The participants also indicated that family members, in general, forbid girls and women from getting involved in FP awareness activities.
“Though we are eager to learn about those lessons (reproductive organs and health), our teacher skips them. They tell us to read it by ourselves.” -18 years Female, FGD participant
b) Demand-side barriers and challenges
A few participants were confused about which method to choose, how to use it properly and did not even know where to seek FP services locally.
“My husband works abroad. Last year, when he came home during Dashain (festival), we had (intercourse). Later, he returned to his workplace. Meanwhile, I came to know that I was pregnant, after 3 months. I was shocked to hear that. We already had 3 children; 2 of them were unplanned. I did not have enough information about contraceptive measures in this situation. Had I known about them; I would have used them. I had serious trouble travelling to get it aborted.” - 24 years Female, FGD participant
Some female participants expressed their reluctance to use FP methods due to their own or other people’s past experiences and the fear of side effects, including vaginal bleeding, spotting, abdominal pain, nausea, vomiting, headache, acne, and infertility. These female participants expressed the need for a single-use FP method with fewer side effects for women which could be used without their husbands’ consent. The male participants were worried about the risk of unwanted pregnancy due to the breaking of condoms and a few participants also expressed concern that they experienced allergic reactions after the use of condoms. Moreover, they were concerned about not having any alternative methods of contraception other than condoms.
“I have a much bitter experience. I was using Depo injection before. But I started having over bleeding for which I was admitted to the hospital for a few days. Later, I was switched to implants but they also did not suit me. In between I also used pills, but they aggravated my acne and I was feeling nauseated every day. Uff…. I am fed up now. I swear, I won’t ever use any methods.” - 19 years Female, FGD participant “I have heard that keeping these things (Copper-T) in the uterus can cause cancer. Better to avoid it.” - 20 years Female, FGD participant “There aren’t many choices for men. I think using a condom during sex is like tying plastic around the tongue and eating food.” - 21 years Male, IDI participant
Religious and ethnic variation affected use of FP. Participants reported that people belonging to upper caste groups used FP measures more than lower caste groups. Likewise, people who had migrated from the hilly areas used FP services, whereas people from the local ethnic community did not use as they were less aware of it. FP decisions among young people seem to be influenced largely by religious beliefs, stigma, and the perceived role of men and women based on existing social norms. Some participants regarded children as a gift from God and denied using any FP methods. Some believed using FP was going against the law of nature, religion, and culture; thus, they would not avoid childbirth, but rather celebrate every birth. Some indicated that if couples did not have children within 1–2 years of marriage, then people would question the woman’s fertility. Most couples preferred sons to daughters as they believed sons would look after them and their property, while the daughters would be married and sent away, resulting in avoidance of FP measures until they have a son. Some couples even wished to have two sons because if anything unfortunate happened to one, the other son would still be with them to carry the generation forward.
“My aunt gave birth to a son after 5 successive daughters. She is pregnant again this time in the hope to have a son. She says that she cannot trust to have only one son because if anything happens to their only son, then she will have no one to pay tribute after her death.”- 22 years Female, FGD participant
Participants also said that people felt shy talking about FP openly. Female participants also felt uncomfortable asking for contraceptives with male health personnel at the health post. Similarly, teachers felt uncomfortable teaching about reproductive health and FP as their children and relatives could be present as students in the classroom. Participants indicated that some students would laugh and smile, making it difficult for the teachers to run the classroom sessions smoothly.
It was reported by a FP service provider that some men opposed their wives using any FP measures as they perceived that the use of FP measures allowed their wives to become promiscuous when they go abroad for work.
“Some husbands working abroad forbid their wives from using any FP measures because they fear the use of FP measures may provoke a sexual relationship with someone else in their absence”- 30 years Female, Health professional providing medical abortion services, IDI participant
Theme 4: Role of youth and suggestions to improve FP
The youth were interested in getting involved in a “peer to peer education” approach to increase awareness among the community about FP use. This approach would include peer training programs, role-plays/dramas, and counseling sessions to break the key barriers linked with such services. Activities ranging from redesigning the school’s curriculum to strengthening FP services in primary care centers, and from launching mobile outreach clinics to facilitating “spousal communication” were intended to change attitudes and support gender equality in sexual and reproductive health. Participants emphasized forming youth centers and collaborating with other youth clubs in the village. Furthermore, they suggested bringing religious leaders, teachers, doctors, and politicians as advisors of the youth centers would be beneficial as they are influential members of the community.
“I feel bad for my sister who is not given much importance from my parents. She got married against her choice due to her parents’ pressure. Now, they are forcing her to have kids. She is just 15 and if she gets pregnant, what will happen to her health and her child, how can she take care of a baby? I had a long debate with my father yesterday. I have now decided to start a youth club to promote awareness regarding FP and preventing early marriage and teenage pregnancies.” - 23 years Male, FGD participant
Male participants indicated that family planning programs are effective only when men prioritize women’s autonomy. Moreover, they expressed disappointment with the local government for not encouraging the involvement of men in FP programs in their village. To help address this issue, they expressed their interest in supporting the local government in bringing inclusive FP programs to their village.
“For a long time, women have been using those (Contraceptives) by hiding. We are always in fear about what others would say if they came to know about us using it. This can be addressed through male involvement and support.” -24 years Female, FGD participant
This qualitative study provides in-depth information on the understanding and perceptions of youth in Eastern Nepal regarding FP. This study generated findings regarding knowledge and perceptions of rural residents regarding FP and its methods; decision-making and preference among participants; supply-side and demand-side barriers and challenges regarding the use of FP measures; steps that can be taken to improve their use; and the role of youth in increasing FP coverage. Although most participants knew something about FP, a few female participants were completely unaware of it. And while some participants agreed that all married couples should be using FP measures, some unmarried male participants believed that those measures should be exclusively for women. These men said that they would let their wives use them after getting married. Current FP methods for men are either coitus-dependent, such as condoms or withdrawal, or permanent, such as vasectomy. Limited choices for men may have resulted in misconceptions that contraceptives are mostly for women.
Men often claimed to be the sole decision-maker of the family on important matters, including those related to family health and contraception. In most circumstances, men solely decide the FP measure to be used without having a discussion with their partner. This might be one of the reasons why women are bound to adopt a FP method that is not necessarily their choice. Besides, this problem is further reinforced by the limited options of FP methods available for men other than condoms and permanent sterilization. These findings are supported by other studies in South Asia, where family planning measures are mostly considered women’s responsibility [ 21 – 24 ]. Health workers, peers, and mass media were the most common sources of information regarding FP similar to prior studies in India [ 21 , 24 ] and Nepal [ 22 ]. Participants in this study seemed to assign FP responsibility to the other gender in terms of using FP. This could mean that there is a gap in communication within the couples when deciding about FP. There is a need for further research to identify ways to improve communication among couples.
Religious and ethnic variation influence FP use. People belonging to privileged ethnic groups used FP measures more than underprivileged groups. This is despite family planning services being free for all citizens in Nepal. In this study, people who had migrated from hilly regions knew about and used FP services more than those belonging to the ethnic community in the local region. This is an area for further research to understand differences in knowledge and perceptions regarding FP between the population groups. This can be argued as a limitation of the current FP promotion programs, which may not have considered the different needs of people from different religious and ethnic backgrounds [ 25 ]. A few participants reported that their holy scriptures forbade them from using FP methods as they viewed children as a gift from God; any artificial process interrupting pregnancy or preventing the possibility of life is a religious offense for them [ 26 ]. Previous studies from Nepal have shown that this belief has long been rooted in some communities [ 27 – 29 ].
Apart from religious beliefs, fear of side effects, having experienced adverse health consequences after using hormonal contraceptives, and fear of potential infertility in the future are reasons for reluctance using FP methods among women [ 30 ]. Besides, we can speculate that language and cultural barriers, and fear of discrimination especially by male counterparts negatively influence the use of FP measures among some women despite their strong interest in using them. The use of IEC materials in raising awareness and empowering married couples for shared decision-making could help generate demand [ 28 , 29 ]. Local cultural taboos restrict open communication about safer sex measures and sexual health in Nepal, prohibiting young girls and boys from receiving adequate information and guidance regarding sexual and reproductive health and FP [ 31 ].
Most of the married women and men stated that the decision-makers of the family are men. The husband decides whether or not to use contraception, or more specifically, whether or not to let their wives use it. However, unmarried participants expressed their willingness to decide mutually with their spouse regarding FP use in the future [ 21 , 32 ]. Most women in this study seemed comfortable letting their male partners decide on contraceptives. This attitude could be explained by the patriarchal dominance in decision-making [ 19 , 33 , 34 ].
Some men mentioned that condoms inhibit their sexual pleasure, which is why they prefer women to use other methods instead. A study conducted in Far West Nepal and another nationwide study reported similar concerns among men [ 31 , 35 ]. Adolescent girls stated that they were not comfortable talking to a male health worker about FP or to a female worker in the presence of a male health worker, which has also been reported elsewhere [ 36 ]. Some women said that their husbands forbade the use of contraceptives because they thought that contraceptives would allow their wives to become promiscuous and that using FP was a sign of infidelity. This issue, however, was not raised by any men in the study. Some women reported violence as a consequence of using contraceptives without their husband’s consent. Prior qualitative studies also reported that women may suffer domestic violence for opposing their husbands. Studies suggest that a multi-sectoral action involving stakeholders from health, women’s rights, and education sectors is imperative to further research and address this issue [ 29 , 36 , 37 ].
Supply constraints (distance to a provider for getting contraceptives, out of stock, limited choices of contraceptives, unaffordable methods, etc.) could aggravate the unmet need for contraception. These constraints are similar to all regular supplies faced by the health system in Nepal. However, supply-side interventions such as increasing the number of health facilities distributing FP services, policy focusing on consistent operating hours, and full stock of a wide variety of FP methods could largely improve uptake and increase contraceptive coverage [ 18 , 38 ].
Most female participants did not speak up when asked about their perception of the role of men in FP. On the other hand, male participants explained that the role of the youth could be disseminating FP information, conducting awareness campaigns, organizing dramas and role-plays to educate people about the religious and cultural barriers of FP use, etc. With appropriate training, the young men said they would be willing to work for FP advocacy in the community.
Reproductive health leaders and planners should identify men who are willing to share decision-making authority with their wives and devise behavioral change interventions [ 39 ]. Male participation could support the FP programs and also help empower women [ 40 ]. The participants in the study expressed the need for the current FP programs to consider the community members as key stakeholders in planning FP programs. There is a need to further explore possible ways of working with the rural, marginalized communities and hard-to-reach or specific ethnic groups to improve their update of FP services [ 41 ]. There is evidence that mass media messages increase the likelihood of FP use, which could be considered by advocacy and dissemination programs [ 42 ]. Evidence from maternal and newborn health care research shows that interventions that engage men result in more equitable couple communication and shared decision-making. This may be a relatable concept to be considered for FP programs as well [ 43 ].
We urge those in charge of the health and sexual education curriculum to find ways to encourage teachers to give equal attention to these topics, including FP education, as they would to any other. It was reported that teachers were reluctant to teach about FP as they perceived the young students felt discomfort around this topic. Further research to identify innovative youth-friendly methods to teach sexual and reproductive health topics to students may be helpful. Youth groups should be regarded as important stakeholders in the redesign of school health curricula, particularly for their insight into culturally sensitive and otherwise effective ways for delivery. Health professionals, members of local organizations, and community leaders pointed to the necessity of addressing unmet FP needs and the stigma associated with FP use through community education approaches that take into account cultural norms and beliefs [ 44 ]. Interventions focusing on reproductive health education curricula involving school teachers could be considered [ 45 ]. Strengthening health systems, bridging service gaps, improving the integration of contraceptive services and counseling with routine health care are important strategies for increasing contraceptive uptake in eastern Nepal [ 22 ].
Among the study’s limitations was the fact that it was conducted in a single village in eastern Nepal. Our findings might differ if the sample had been drawn from other parts of the country. Although participants spoke fluent Nepali, some phrases used in local dialects could not be perfectly translated into Nepali or English. These responses could have been affected by social desirability as the participants may have felt constrained from speaking freely with people from health institutions. To help reduce these obstacles we held open meetings and drop-in sessions with the support of community youth to disseminate the purpose of the study and build rapport with the young people in the village before we approached them for the study. Moreover, participants were assured anonymity and confidentiality, which may have increased their willingness to participate in the research.
Conclusions
There appear to be information and communication gaps between women and men regarding FP services and programs. The information gap could be addressed by exploring ways to increase information uptake in schools through redesigning the curriculum delivery. Mass media may be used to disseminate appropriate health education regarding FP. Health institutions could consider approaches to create FP information and service centers that are male-friendly. The communication gap may be more deeply rooted in the culture and traditions of Nepalese society. In a mostly patriarchal society, further identification of motivations for men to participate in FP related activities could be challenging. However, it is promising that men may be willing to support their partners for FP decision-making and engage in strengthening FP programs through the “peer to peer” approach via youth-led centers and community clubs. Program managers and policy makers need to take into account the fact that youth are willing to contribute to ongoing FP programs. Doing so would help bridge the information and communication gaps between school education and practice. Innovative research to further explore perceived benefits by youth on the uptake of family planning, sexual and reproductive health services is needed.
Supporting information
Acknowledgments.
We extend our sincere thanks and regards to Dr. Agata Parfieniuk, Kirsty Lunney, and Anu Regmi for their invaluable contributions to the manuscript. We acknowledge the support received from Dr. Meika Bhattachan, Dr. Avinash Kumar Sunny, and Dr. Pawan Upadhyaya during data collection. The authors acknowledge the support received from the BPKIHS and participants for their participation in the study. Special thanks to Dr. Bibisha Baaniya, Dr. Garima Pudasaini, Dr. Soniya Gurung, Dr. Shristi Nepal, Bisha Baaniya, and Arshpreet Kaur for their generous support throughout the study.
Abbreviations
B. P. Koirala Institute of Health Sciences
Family Planning
Focus Group Discussion
In-Depth Interview
Modern Contraceptive Prevalence Rate
Sexual and Reproductive Health
Data Availability
All relevant data are within the manuscript and its Supporting Information files.
Funding Statement
The author(s) received no specific funding for this work.
- 1. Nsubuga H, Sekandi JN, Sempeera H, Makumbi FE. Contraceptive use, knowledge, attitude, perceptions and sexual behavior among female University students in Uganda: A cross-sectional survey. BMC Womens Health. 2016;16(6):1–11. Available from: 10.1186/s12905-016-0286-6 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 2. Bitzer J, Abalos V, Apter D, Martin R, Black A, Machado RB, et al. Targeting factors for change: contraceptive counselling and care of female adolescents. Eur J Contracept Reprod Heal Care. 2016;21(6):417–30. 10.1080/13625187.2016.1237629 [ DOI ] [ PubMed ] [ Google Scholar ]
- 3. Cavallaro FL, Benova L, Owolabi OO, Ali M. A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: What works and what doesn’t? BMJ Sex Reprod Heal. 2019;0:1–16. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 4. Htay MNN, Latt SS, Abas AL, Chuni N, Soe HHK, Moe S. Medical students’ knowledge and perception toward family planning services: A preliminary intervention study. J Educ Heal Promot. 2018;7(137). 10.4103/jehp.jehp_104_18 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 5. Department of Health Services. Annual Report. DoHS. 2019. Available from: https://dohs.gov.np/wp-content/uploads/2019/07/DoHS-Annual-Report-FY-2074-75-date-22-Ashad-2076-for-web-1.pdf
- 6. Sapkota S, Rajbhandary R, Lohani S. The Impact of Balanced Counseling on Contraceptive Method Choice and Determinants of Long Acting and Reversible Contraceptive Continuation in Nepal. Matern child Heal. 2017;21:1713–23. 10.1007/s10995-016-1920-5 [ DOI ] [ PubMed ] [ Google Scholar ]
- 7. EK A-A. Perception of Family Planning Use among Married Men and Women in Anomabu Community. J Contracept Stud. 2018;03(03):1–5. [ Google Scholar ]
- 8. World Health Organizaton. Family planning/Contraception. WHO. 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception [ Google Scholar ]
- 9. Asut O, Gur G, Turk O, Cagin B, Vaizoglu S, Ozenli O, et al. The knowledge and perceptions of the first year medical students of an International University on family planning and emergency contraception in Nicosia (TRNC). BMC Womens Health. 2018;18(149):1–11. 10.1186/s12905-018-0641-x [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 10. Uprety S, Poudel I, Ghimire A, Poudel M, Bhattrai S, Baral D. Knowledge, attitude and practice of family planning among married women of reproductive age in a VDC of Eastern Nepal. J Chitwan Med Coll. 2016;6(15):48–53. [ Google Scholar ]
- 11. Ministry of Health and Population. Nepal Demographic Health Survey. New Era. 2016. Available from: https://www.dhsprogram.com/pubs/pdf/fr336/fr336.pdf 10.1177/1077801216628690 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 12. United Nations Department of Economic and Social Affairs Population Division. Family Planning and the 2030 Agenda for Sustainable Development: Data Booklet. (ST/ESA/ SER.A/429). 2019.
- 13. Mushy SE, Tarimo EAM, Fredrick Massae A, Horiuchi S. Barriers to the uptake of modern family planning methods among female youth of Temeke District in Dar es Salaam, Tanzania: A qualitative study. Sex Reprod Healthc. 2020;24(January):100499. Available from: 10.1016/j.srhc.2020.100499 [ DOI ] [ PubMed ] [ Google Scholar ]
- 14. Ramírez GR, Bravo PE, Vivaldi MIM, Manríquez IP, Pérez TG. Adolescents’ access to contraception: perceptions of health workers in Huechuraba, Chile. Pan Am J public Heal. 2017;41(e77):1–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28614485 10.26633/RPSP.2017.77 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 15. Institute of Reproductive Health. Do myths and misconceptions matter in Nepal? Side-Effects and their effect on Family Planning. 2016. Available from: https://irh.org/do-myths-matter-in-nepal/ [ Google Scholar ]
- 16. Subedi R, Jahan I, Baatsen P. Factors Influencing Modern Contraceptive Use among Adolescents in Nepal. J Nepal Health Research Council. 2018;16(40):251–6 [ PubMed ] [ Google Scholar ]
- 17. Subedi S, Mahato P, Acharya S, Kafle H. Gender roles and practice of decision making on reproductive behavior among couples of Syangja district, Nepal. Int J Reprod Contraception, Obstet Gynecol. 2013;2(3):414–8. [ Google Scholar ]
- 18. Staveteig S, Shrestha N, Gurung S, Kampa KT. Barriers to family planning use in Eastern Nepal: Results from a mixed methods study. United States Agency for International Development (USAID). 2018. Available from: http://dhsprogram.com/pubs/pdf/QRS21/QRS21.pdf [ Google Scholar ]
- 19. Pokharel PK, Budhathoki SS, Upadhyay MP. Teaching District Concept of BP Koirala Institute of Health Sciences: An Inter-Disciplinary Community Based Medical Education and Health Service Delivery Model in Rural Nepal. Kathmandu Univ Med J 2016; 55(3): 294–8. [ PubMed ] [ Google Scholar ]
- 20. Nations United. Definition of youth. 2008. Available from: https://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-definition.pdf [ Google Scholar ]
- 21. Char A., Saavala M., & Kulmala T. Male perceptions on female sterilization: A community-based study in rural central India. International perspectives on sexual and reproductive health . 2009; 35(3): 131–138. 10.1363/ipsrh.35.131.09 [ DOI ] [ PubMed ] [ Google Scholar ]
- 22. Paudel IS, & Budhathoki SS. Unmet needs for family planning in Morang, eastern Nepal. Health Renaissance . 2011; 9(3), 148–151. [ Google Scholar ]
- 23. Ringheim K. Factors that determine prevalence of use of contraceptive methods for men. Stud Fam Plann . 1993;24(2):87–99. [ PubMed ] [ Google Scholar ]
- 24. Aengst JC, Harrington EK, Bahulekar P, Shivkumar P, Jensen JT, Garg B S. Perceptions of nonsurgical permanent contraception among potential users, providers, and influencers in Wardha district and New Delhi, India: Exploratory research. Indian J Pubic Health. 2017; 61(1):3–8 [ DOI ] [ PubMed ] [ Google Scholar ]
- 25. Sharma B, Nam EW. Condom Use at Last Sexual Intercourse and Its Correlates among Males and Females Aged 15–49 Years in Nepal. Int J Environ Res Public Health . 2018;15(3):535. 10.3390/ijerph15030535 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 26. Sundararajan R, Yoder LM, Kihunrwa A, Aristide C, Kalluvya SE, Downs DJ, et al. How gender and religion impact uptake of family planning: results from a qualitative study in Northwestern Tanzania. BMC Women’s Health. 2019. December;19(1):99. 10.1186/s12905-019-0802-6 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 27. Shrestha N, Maharjan U, Arjyal A, Joshi D. Access to family planning services by Muslim communities in Nepal–barriers and evidence gaps. (2016). Available from; https://www.herd.org.np/uploads/frontend/Publications/PublicationsAttachments1/1480652411-Muslims%20brief%20final%20June%202016.pdf [ Google Scholar ]
- 28. Mishra MK. Ethnic Disparities in Contraceptive Use and its Impact on Family Planning Program in Nepal. NJOG. 2011; 6(2): 14–19 [ Google Scholar ]
- 29. Sapkota D, Adhikari SR, Bajracharya T and Sapkota VP. Designing Evidence-Based Family Planning Programs for the Marginalized Community: An Example of Muslim Community in Nepal. Front . Public Health . 2016; 4:122. 10.3389/fpubh.2016.00122 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 30. Goncalves H, Souza AD, Tavares PA, Cruz SIH, Behague DP. Contraceptive medicalisation, fear of infertility and teenage pregnancy in Brazil Culture. Health and Sexuality. 2011; 13(2):201–215. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 31. Dahal G., Hennink M. & Hinde A. Risky sexual behaviour among young men in Nepal. Southampton Statistical Sciences Research Institute, University of Southampton, Southampton. 2005. Available from; http://eprints.soton.ac.uk/id/eprint/14213 [ Google Scholar ]
- 32. Anguzu R, Tweheyo R, Sekandi JN, Zalwango V, Muhumuza C, Tusiime S, et al. Knowledge and attitudes towards use of long acting reversible contraceptives among women of reproductive age in Lubaga division, Kampala district, Uganda. BMC research notes . 2014; 7(1), 153. 10.1186/1756-0500-7-153 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 33. Eliason S, Baiden F, Quansah-Asare G, Graham-Hayfron Y, Bonsu D, Phillips J, et al. Factors influencing the intention of women in rural Ghana to adopt postpartum family planning. Reprod Health . 2013; 10(1):34. 10.1186/1742-4755-10-34 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 34. Oyediran KA, Ishola GP, & Feyisetan BJ. Factors affecting ever-married men’s contraceptive knowledge and use in Nigeria. Journal of biosocial science . 2002; 34(04):497–510. [ DOI ] [ PubMed ] [ Google Scholar ]
- 35. Bam K, Thapa R, Newman MS, Bhatt LP, Bhatta SK Sexual Behavior and Condom Use among Seasonal Dalit Migrant Laborers to India from Far West, Nepal: A Qualitative Study. PLoS ONE. 2013; 8(9): e74903. 10.1371/journal.pone.0074903 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 36. Dansereau E., Schaefer A., Hernández B. et al. Perceptions of and barriers to family planning services in the poorest regions of Chiapas, Mexico: a qualitative study of men, women, and adolescents. Reprod Health . 2017; 14: 129. 10.1186/s12978-017-0392-4 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 37. Bhandari GP, Premarajan KC, Jha N, Yadav BK, Paudel IS, Nagesh S. Prevalence and determinants of unmet need for family planning in a district of eastern region of Nepal. Kathmandu Univ. Med. J. 2006; 4(2): 203–210. [ PubMed ] [ Google Scholar ]
- 38. Silumbwe A, Nkole T, Munakampe MN, Milford C, Cordero JP, Kriel Y, et al. Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia. BMC Health Serv Res. 2018;18(390):1–11. 10.1186/s12913-018-3136-4 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 39. Adongo PB, Tapsoba P, Phillips JF, Tabong PT, Stone A, Kuffour E, et al. The role of community-based health planning and services strategy in involving males in the provision of family planning services: a qualitative study in Southern Ghana. Reprod Health . 2013; 10(36):1–15. 10.1186/1742-4755-10-36 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 40. Sternberg P, Hubley J: Evaluating men’s involvement as strategy in sexual and reproductive health promotion. Health Promot Int. 2004;19(3):389–396. 10.1093/heapro/dah312 [ DOI ] [ PubMed ] [ Google Scholar ]
- 41. Shrestha DR, Shrestha A, Ghimire J. Emerging challenges in family planning programme in Nepal. J Nepal Health Res Counc. 2012;10(21):108–12. [ PubMed ] [ Google Scholar ]
- 42. Ajaero CK, Odimegwu C, Ajaero ID, Nwachukwu CA. Access to mass media messages, and use of family planning in Nigeria: a spatio-demographic analysis from the 2013 DHS. BMC Public Health. 2016;16:427. 10.1186/s12889-016-2979-z [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 43. Tokhi M, Comrie-Thomson L, Davis J, Portela A, Chersich M, Luchters S. Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions. PLoS One . 2018;13(1):e0191620. Published 2018 Jan 25. 10.1371/journal.pone.0191620 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 44. Bankole A, Malarcher S. Removing barriers to adolescents’ access to contraceptive information and services. Stud Fam Plan. 2010; 23(3):199–210. 10.1111/j.1728-4465.2010.00232.x [ DOI ] [ PubMed ] [ Google Scholar ]
- 45. Todd C, Christian D, Davies H, Rance J, Stratton G, Rapport F, et al. Headteachers’ prior beliefs on child health and their engagement in school based health interventions: a qualitative study. BMC Res Notes. 2015; 8:161. 10.1186/s13104-015-1091-2 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data availability statement.
- View on publisher site
- PDF (606.2 KB)
- Collections
Similar articles
Cited by other articles, links to ncbi databases.
- Download .nbib .nbib
- Format: AMA APA MLA NLM
Add to Collections
An official website of the United States government
Official websites use .gov A .gov website belongs to an official government organization in the United States.
Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites.
- Publications
- Account settings
- Advanced Search
- Journal List
Knowledge and utilization of family planning among rural postpartum women in Southwest Nigeria
Benedicta chinyere anate, mobolanle rasheedat balogun, tope olubodun, adebola afolake adejimi.
- Author information
- Article notes
- Copyright and License information
Address for correspondence: Dr. Tope Olubodun, Department of Community Health and Primary Care, Lagos University Teaching Hospita, Lagos, Nigeria. E-mail: [email protected]
Received 2020 Jul 1; Revised 2020 Sep 5; Accepted 2020 Oct 14; Issue date 2021 Feb.
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Background:
In Nigeria, contraceptive use has remained low, 12% for any modern method, despite the huge resources committed to family planning programs by stakeholders. This study was carried out to assess the knowledge and utilization of family planning and determine predictors of utilization of family planning among postpartum women attending primary health care centers (PHCs) in a selected rural area of Lagos State, southwest Nigeria.
This was a descriptive cross-sectional study conducted among 325 postpartum women attending PHCs in Ibeju-Lekki local government area of Lagos State selected using a multi-stage sampling technique. A pretested, interviewer-administered questionnaire was used to collate data which was analyzed using the IBM SPSS Statistics version 23.
The mean age was 29.94 ± 5.14 years. All the respondents (100%) had heard of contraceptive methods, however only 38 (11.7%) had good knowledge of family planning. About 38.5% of the respondents used modern family planning methods during the postpartum period. The most commonly used methods were male condoms (26.3%) and implants (17.0%). The significant predictors of postpartum family planning (PPFP) were non-intention to have more children [AOR = 1.88 (95% CI: 1.14–3.11)], and good knowledge of family [AOR = 2.31 (95% CI: 1.11–4.81)].
Conclusion:
It is recommended that interventions be designed to educate and advocate for the use of family planning methods not only to stop childbearing but also to space pregnancies. Education about family planning should also be intensified to improve knowledge of family planning, and thus practice.
Keywords: Family planning, knowledge, Nigeria, post-partum, rural
Introduction
All over the world, maternal health issues continue to pose serious concerns. This is considering that pregnancy and child birth are the major causes of morbidity and mortality among women of childbearing ages.[ 1 ] This concern is re-echoed in the third Sustainable Development Goal, which includes targets to reduce the global maternal mortality ratio to less than 70 per 10,000 and to ensure universal access to sexual and reproductive health care services, including family planning information and education and the integration of reproductive health into national strategies and programs by 2030.[ 2 ] Globally, the population growth is on the increase because of increase in medical advancement and control of diseases. However, the developed countries have witnessed a decline in population growth as a result of deliberate policies to have smaller families achieved through birth control measures, unlike most developing and underdeveloped countries which still have high birth rates.[ 3 ]
In Africa, majority of the countries that have the lowest rates of contraceptive use have the highest fertility rates and invariably the highest infant, child, and maternal mortality rates.[ 4 ] Annually in sub-Saharan Africa, about 14 million unintended pregnancies are recorded.[ 5 ] In 2017, a study found that 214 million women in developing countries had an unmet need for modern contraceptive methods.[ 6 ] Nearly 70% of postpartum women who engage in unprotected sexual activities within 2 years after child birth are exposed to the risk of being pregnant in Sub-Saharan Africa.[ 5 ] In Nigeria, some studies show that there is a high level of unmet need for family planning among women in spite of their high level of awareness of common methods of contraception. For instance, a community-based study conducted in rural areas of Imo State, South East Nigeria reported 70% unmet need for family planning,[ 7 ] while another study in a rural area of Osun State, South West Nigeria, found an unmet need of family planning at 86.6%.[ 8 ] This statistic is particularly high among women who are poor, less educated, and especially residents of rural areas.[ 9 , 10 , 11 ]
To tackle population explosion and eliminate high rates of unwanted pregnancies, family planning becomes imminent. Family planning is a valuable tool in helping to space pregnancies, thus reducing the risks of maternal and child deaths.[ 12 , 13 ] Postpartum family planning (PPFP) refers to a woman's use of any modern method of contraception for the prevention of unintended and closely spaced pregnancies during the first 12 months following her most recent childbirth.[ 14 ] The contraceptive prevalence rate (CPR) in the country is low at 17% among currently married women age 15–49 years, with 12% using a modern method, while 5% use a traditional method.[ 15 ] Uptake of postpartum contraceptives will in addition to reducing unplanned pregnancies, improve maternal and child health outcomes,[ 12 ] considering the fact that short birth intervals of less than 15 months are often linked to unfavorable outcomes like preterm births, still births, induced abortions, miscarriages neonatal and child mortalities and maternal deletion syndrome.[ 16 , 17 , 18 ]
Despite high contacts with health care providers during immunization, the unmet need of postpartum women for family planning is still high.[ 19 , 20 ] It is therefore crucial for the survival of child and mother that their needs for family planning be met. This study was carried out to assess the knowledge and utilization of family planning, as well as to determine the predictors of utilization of family planning among post-partum women attending primary health centers (PHCs) in a selected rural area of Lagos State, southwest Nigeria.
Materials and Methods
Description of study area.
Lagos State is a state located in the southwestern geopolitical zone of Nigeria. Lagos is a port city and the most populous city in Nigeria.[ 21 ] The study was carried out in Ibeju- Lekki Local Government Area (LGA), one of the four rural LGA's in Lagos State. According to the National Population Commission (2006) census, Ibeju-Lekki had a population of 117,481 but an estimated population of 162,200 for the year 2016.[ 22 ] The LGA has 7 wards and there are 12 PHCs which offer antenatal and post natal services, deliveries, immunization clinics, and family planning services.
Study design and population
This study was a descriptive cross-sectional study conducted between August and September, 2018. The study population consisted of women within the reproductive age group (15–49 years) who were 6–12 months postpartum and who were accessing child health services (immunization and treatment) from the PHCs in Ibeju-Lekki LGA.
Sample size determination and Sampling technique
The minimum sample size was determined using the Cochran's formula for the determination of sample size for descriptive studies.[ 23 ] A standard normal deviate of 1.96, prevalence of use of modern contraceptives from a similar study in rural Edo state among women of childbearing age (26.4%)[ 24 ] and a margin of error of 5% were imputed into the formula to give a minimum sample size of 295. Assuming the non-response rate of 10%, the minimum sample size of 325 was estimated.
A two stage multi-stage sampling technique was used in the selection of respondents.
The first stage was the selection of PHCs, which involved selection of 5 out of the 12 PHCS in Ibeju-Lekki LGA using a simple random sampling method by balloting. The second stage involved selection of respondents by systematic random sampling method. The sample size was divided equally across the 5 randomly selected PHCs, thereby allocating 65 participants to each PHC. The sampling interval was calculated by dividing the estimated number of patients visiting the PHCs daily, usually between 100 and 140, by 65, which was approximately 2. The first participant was selected by simple random sampling technique, and every 2 nd person presenting to the health centre (or someone allocated an even number) was selected to participate in the study. However, in the event that the person with an even number did not meet the inclusion criteria, the next woman who met the inclusion criteria was recruited for the study.
Data collection
Data was collected using a pretested, interviewer-administered questionnaire, which was developed from literature.[ 24 , 25 , 26 ] The questionnaire had four sections, namely: sociodemographic characteristics of the respondent, reproductive history; knowledge of family planning, and utilization of family planning.
Four females having a minimum qualification of ordinary level diploma (OND) certification were recruited as research assistants for the purpose of data collection. They were trained on questionnaire administration by the principal investigator while emphasizing the importance of confidentiality and sensitivity. The questionnaire was pretested among 25 respondents in Epe LGA, Lagos State, another rural community in Lagos with similar socioeconomic activities. The pre-testing was carried out to check for ambiguities and deficiencies in the questionnaire after which necessary corrections and adjustment were effected.
Data analysis
Data entry and cleaning was done on Microsoft Excel 2010. Data was then imported unto IBM SPSS Statistics version 23 (© Copyright IBM Corporation 2011) and analyzed. Frequency tables and figures were generated for categorical variables. Numerical variables were summarized using mean and standard deviation for normally distributed variables and median and interquartile range for numerical data that were not normally distributed. PPFP was defined as current use of any modern method of contraception among the postpartum women.
Knowledge of family planning was assessed by scoring knowledge questions. The respondents were asked to mention the uses of family planning, and the methods of family planning they knew. Uses of contraceptives (prevent people from getting pregnant, allow for child spacing, prevent STIs) was scored 2 points if mentioned. Common types of contraceptives (male condom, female condom, injectable, intrauterine contraceptive device IUCD, Pills, Implants) were scored as 2 if mentioned. Less common contraceptive methods (diaphragm, vasectomy, bilateral tubal ligation) and natural methods (periodic abstinence, coitus interuptus, and lactational amenorrhea) were scored as 1 if mentioned. Zero was given for every correct option not mentioned and for incorrect responses. The highest possible score was calculated as 24 and the lowest possible score 0. Respondents who scored between 0 and 12 were graded as having “poor knowledge” while respondents who scored between 13 and 24 were graded as having “good knowledge.”
Chi-square test was used to determine associations between sociodemographic characteristics, parity, age of baby, mode of delivery, intention to have more children, knowledge of family planning, and utilization of PPFP. Variables that were significant from the bivariate analysis at P value ≤0.1 were imputed into a multivariate logistic regression model to determine the predictors of utilization of PPFP. Level of significance was set at P value ≤0.05.
Ethical considerations
Ethical approval for this research was obtained from the Human Research and Ethics Committee (HREC) of the College of Medicine, University of Lagos, with assigned number: ADM/DCST/HREC/APP/195. Required approval was also obtained from authorities of the Lagos state primary health care board and consent from authorities of the selected primary health centers. The aim of the study was thoroughly explained to the participants and written informed consent obtained from each of them before administering the questionnaire. The respondents were assured of confidentiality by not using identifiers.
Mean age of respondents was 29.94 ± 5.14 and more than half of the respondents (59.7%) were between the ages of 21 and 30. Most of the respondents (97.2%) were married. A little more than half 167 (51.4%) had only secondary school education with most of them 211 (64.9%) being artisans (self-employed) in trades such as hair dressing, tailoring, petty trading, catering while 47 (14.5%) were house wives. [ Table 1 ].
Socio-demographic characteristics of Respondents
Majority of the respondents 260 (80.0%) had between 1 and 3 children. Respondents with babies between 6 and 9 months were more 257 (79.1%) while those with babies between 10 and 12 months 68 (20.9%). Most respondents had their index birth by spontaneous vaginal delivery 275 (84.6%). A greater percentage of the respondents 210 (64.6%) still intended to have more children, 100 (30.8%) had no intentions of having more children while 15 (4.6%) were undecided [ Table 2 ].
Reproductive history of Respondents
All the respondents (100%) had heard of contraceptive methods. Majority (90.2%) had heard from the hospital/health center [ Figure 1 ]. All the respondents (100%) reported that family planning prevents women from getting pregnant and 51.7% said family planning was to allow for child spacing [ Table 3 ]. For modern methods of contraception, 60.3% knew about male condoms, implants (59.7%), injectables (59.4%), and pills (51.4%). For natural methods, 15.1% knew about coitus interruptus (withdrawal method), 6.8% mentioned Periodic abstinence, and 5.2% mentioned lactational amenorrhea [ Table 3 ].
Respondents' main source of information on family planning
Respondents Knowledge of Family Planning
*Multiple responses. IUCD-Intra-uterine contraceptive device
More than half of the respondents 194 (59.7%) were using a form of contraceptive while 125 (38.5%) were using a modern method. Of those that used contraceptives, the most commonly used modern method was the male condom 51 (26.3%), closely followed by implants (17.0%) and injectables (9.3%). The most commonly used natural method was the coitus interruptus 43 (22.2%) while the most common traditional method was the use of Salt water/strong alcohol/lime juice 9 (4.6%), use of rings, amulets, padlocks 4 (2.1%) [ Table 4 ].
Utilization of Family Planning
There was a statistically significant relationship between intention to have more children ( P = 0.003), knowledge of family planning ( P = 0.023) and use of PPFP. A higher proportion of women with no intention for more children (49.0%) use family planning as compared with women who still want more children (31.9%). A higher proportion of women with good knowledge (55.3%) were using family planning as compared with women with poor knowledge (36.2%). The relationship between age, marital status, level of education, occupation, religion, ethnicity, parity, baby's age, mode of delivery, and utilization of PPFP was not statistically significant [ Table 5 ].
Factors Associated with Utilization of Post-Partum Family Planning
*Fishers exact
Intention to have more children was a significant predictor of utilization of PPFP. Respondents who had no intention to have more children were 1.88 times more likely to utilize PPFP, when compared with respondents who had intention to have more children [AOR = 1.88 (95% CI: 1.14–3.11)]. Also, respondents who had good knowledge were 2.31 times more likely to utilize PPFP, when compared with respondents with poor knowledge [AOR = 2.31 (95% CI: 1.11–4.81)] [ Table 6 ].
Predictors of Post-Partum Family Planning
Ref-reference category
This study was carried out to assess the knowledge and utilization of contraceptives among post- partum women in a rural community in order to identify factors that influence residents of such communities from utilizing PPFP and recommend appropriate interventions that will increase use of contraceptives among postpartum women.
All the respondents had heard of contraceptive methods. The most common methods of contraception known were male condoms, implants, injectables, and pills. Only 125 (38.5%) of the respondents were using a modern method of contraceptive. Intention to have more children and good knowledge of family planning were significant predictor of utilization of postpartum in the multivariate analysis.
Results from this study reveal that awareness of family planning was universal (100%). This is consistent with findings from a community-based study among women of reproductive age in Ogbomosho, Nigeria, in which contraceptive awareness among respondents was also universal (100%).[ 27 ]
Knowledge of family planning methods in this study was equally high (86.8%), with more than three quarters of the respondents having good knowledge of modern contraceptive methods. This is comparable to findings from a study carried out among women attending postnatal clinic in Okitipupa LGA, Ondo State, Nigeria, and among rural women of childbearing age in Rivers State Nigeria.[ 28 , 29 ] Male condoms and implants were the most common forms known to the postpartum women with 90.2% of the respondents citing the health centre/health personnel as their main source of information. This is a testament to the effectiveness of health education given by the health personnel during ante natal, postnatal, or immunization sessions. This finding is similar to those of a mixed study among women of childbearing age from two South-Western States, Nigeria and another study from rural Lagos in which most of the respondents became aware of contraceptive methods from their antenatal clinics.[ 30 , 31 ] However, this result was contradicted by a community-based study among women of reproductive age in Umuahia, Abia State, in which respondents cited electronic media (television/radio) as their main source of information.[ 32 ]
In our study, knowledge of family planning did not translate to practice. Although majority of the respondents had good knowledge of modern contraceptive methods, only 38.5% of the postpartum women were using a modern method of family planning (PPFP). Male condoms, implants were the most commonly used modern methods while coitus interruptus was the most commonly used natural method. Similar findings was reported from a study among women of child bearing age in Rivers State, Nigeria, with 36.8% of the women were using a modern form of family planning and another study in rural Lagos, in which condom was the most commonly used method of contraceptive.[ 29 , 31 ] This study showed low use of contraceptive methods such as female condoms (0.3%), bilateral tubal ligation (0.6%), and IUCD (2.2%), as noticed in a study among women of reproductive age in a semi-urban community of Ekiti State, Southwest Nigeria.[ 25 ]
The results from this study established a statistically significant association between intention to have more children and knowledge of family planning with use of PPFP ( P = 0.003, P = 0.023, respectively) in the bivariate analysis. Multivariate analysis showed respondents who had no intention for more children were 1.88 times more likely to utilize family planning, when compared with respondents who intended to have more children. Women use FP to either limit births or space births. However, in this study, women with no intention for more children use family planning more, probably because they had achieved their ideal family size and needed to stop childbearing. Women who wanted to have more children used family planning less, probably for fear of family planning, causing infertility. Similar result is corroborated in two studies among women of reproductive age in Southwestern and North Central, Nigeria in which respondents who reported non preference for another child used contraceptive more and respondents who were desirous of more children used contraceptive less.[ 33 , 34 ]
Also, respondents who had good knowledge were 2.31 times more likely to utilize PPFP, when compared with respondents with poor knowledge. Women with good knowledge know the various options of family planning available and understand its importance to postpartum women as a tool not just for stopping childbearing but also in spacing child births and preventing STIs. Therefore, will use family planning more. This result is similar to that of a community-based study in rural Ethiopia in which women with good knowledge were more likely to use family planning than those with poor knowledge.[ 35 ]
Most of the women were within the ages 21–30 years, most were married and most had secondary level of education. Majority of the women had babies that were between 6 and 9 months of age and most wanted to have more children. All the women had heard of family planning and male condom, implants, injectable and pills were more commonly known. Over 90% had their information from the hospital/health center. About 60% were currently using any method of family planning while only 38% were using a modern method (PPFP). In the multivariate analysis, women who did not want to have more children were more likely to practice PPFP. Also, women with good knowledge of family planning were more likely to practice PPFP.
Despite the level of awareness being universal and the knowledge of family planning methods being high, use of PPFP was low. The women in this study had only given birth to babies, 6–12 months prior to the study and should have been using contraceptives for child spacing and/or limiting births. However, use of family planning was significantly higher among women who did not want to have any more children and non- intention to have more children was a predictor of use of PPFP. It is therefore recommended that effective programs aimed at promoting the use of family planning in child spacing, and not only in limiting births should be advocated for and implemented. Primary care Physicians and other health workers should intensify health education about family planning to increase knowledge of family planning, and thus practice and also encourage the use of family planning in child spacing.
Financial support and sponsorship
Conflicts of interest.
There are no conflicts of interest.
- 1. World Health Organization Maternal Mortality. 2020. [Last accessed on 2020 Sep 10]. Available from: https://www.who.int/news-room/fact-sheets/detail/maternall-mortality .
- 2. Sustainable Development Goals. Goal 3: Ensure healthy lives and promote well-being for all at all ages. 2020. [Last accessed on 2020 Sep 10]. Available from: https://www.un.org/sustainabledevelopment/health/
- 3. UNFPA. Population dynamics in the least developed countries: Challenges and opportunities for development and poverty reduction. 2011 [ Google Scholar ]
- 4. Akinyemi A, Adedini S, Hounton S, Akinlo A, Adedeji O, Adonri O, et al. Contraceptive use and distribution of high-risk births in Nigeria: A sub-national analysis. Glob Health Action. 2015:8. doi: 10.3402/gha.v8.29745. doi: 10.3402/gha.v8.29745. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 5. Ameyaw EK, Budu E, Sambah F, Baatiema L, Appiah F, Seidu A, et al. Prevalence and determinants of unintended pregnancy in sub-Saharan Africa: A multi-country analysis of demographic and health surveys. PLoS One. 2019;14:e0220970. doi: 10.1371/journal.pone.0220970. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 6. Darroch JE, Singh S, Ashford LS. Guttmacher Inst; 2014. Adding it up: The costs and benefits of investing in Sexual and Reproductive health UNFPA. [ Google Scholar ]
- 7. Nwachukwu I, Obasi OO. Use of modern birth control methods among rural communities in Imo State, Nigeria. Afr J Reprod Health. 2008;12:101–8. [ PubMed ] [ Google Scholar ]
- 8. Ijadunola KT, Orji EO, Ajibade FO. Contraceptive awareness and use among sexually active breast feeding mothers in Ile-Ife, Nigeria. East Afr Med J. 2005;82:250–5. doi: 10.4314/eamj.v82i5.9315. [ DOI ] [ PubMed ] [ Google Scholar ]
- 9. Asif MF, Pervaiz Z. Socio-demographic determinants of unmet need for family planning among married women in Pakistan. BMC Public Health. 2019;19:1226. doi: 10.1186/s12889-019-7487-5. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 10. Prata N. Making family planning accessible in resource-poor settings. Philos Trans R Soc Lond B Biol Sci. 2009;364:3093–9. doi: 10.1098/rstb.2009.0172. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 11. Sensoy N, Korkut Y, Akturan S, Yilmaz M, Tuz C, Tuncel B. Factors affecting the attitudes of women toward family planning. Family Planning. 2018:33–50. [ Google Scholar ]
- 12. DaVanzo J, Hale L, Razzaque A, Rahman M. Effects of inter-pregnancy interval and outcome of the preceding pregnancy on pregnancy outcomes in Matlab, Bangladesh. BJOG. 2007;114:1079–87. doi: 10.1111/j.1471-0528.2007.01338.x. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 13. DaVanzo J, Hale L, Razzaque A, Rahman M. The effects of pregnancy spacing on infant and child mortality in Matlab, Bangladesh: How they vary by the type of pregnancy outcome that began the interval. Popul Stud (Camb) 2008;62:131–54. doi: 10.1080/00324720802022089. [ DOI ] [ PubMed ] [ Google Scholar ]
- 14. Rutaremwa G, Kabagenyi A, Wandera SO, Jhamba T, Akiror E, Nviiri HL. Predictors of modern contraceptive use during the postpartum period among women in Uganda: A population-based cross sectional study. BMC Public Health. 2015;15:262. doi: 10.1186/s12889-015-1611-y. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 15. National Population Commission (NPC) [Nigeria] and ICF. Nigeria Demographic and Health Survey 2018. National Population Commission (NPC) [Nigeria] and ICF. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF; 2019. [Last accessed on 2020 May 19]. p. 130. Available from: https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf . [ Google Scholar ]
- 16. Rodriguez MI, Chang R, Thiel de Bocanegra H. The impact of postpartum contraception on reducing preterm birth: Findings from California. Am J Obstet Gynecol. 2015;213:703–6. doi: 10.1016/j.ajog.2015.07.033. [ DOI ] [ PubMed ] [ Google Scholar ]
- 17. Singh S, Darroch JE. Adding it up: Costs and benefits of contraceptive services. UNFPA: Guttmacher Inst; 2012. [ Google Scholar ]
- 18. Ndugwa RP, Cleland J, Madise NJ, Fotso JC, Zulu EM. Menstrual pattern, sexual behaviours and contraceptive use among post-partum women in Nairobi urban slums. J Urban Health. 2011;88:341–55. doi: 10.1007/s11524-010-9452-6. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 19. RamaRao S, Ishaku S, Liambila W, Mane B. Enhancing contraceptive choice for postpartum women in sub-Saharan Africa with the progesterone vaginal ring: A review of the evidence. Open Access J Contracept. 2015;6:117–23. doi: 10.2147/OAJC.S55033. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 20. Sonalkar S, Gaffield ME. Introducing the World Health Organization post-partum family planning Compendium. Int J Gynecol Obstet. 2017;136:2–5. doi: 10.1002/ijgo.12003. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 21. Wikipedia. Lagos State. 2020. [Last accessed on 2020 Jun 20]. Available from: http://en.wikipedia.org/wiki/Lagos_State .
- 22. The official website of Ibeju Lekki Local Government, Lagos. [Last accessed on 2018 Mar 31]. Available from: www.ibejulekki.lg.gov.ng/
- 23. Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med. 2013;35:121–6. doi: 10.4103/0253-7176.116232. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 24. Ogboghodo EO, Adam VY, Wagbatsoma VA. Prevalence and determinants of contraceptive use among women of child-bearing age in a rural community in Southern Nigeria. J Community Med Prim Health Care. 2017;29:97–107. [ Google Scholar ]
- 25. Durowade KA, Omokanye LO, Elegbede OE, Adetokunbo S, Olomofe CO, Ajiboye AD, et al. Barriers to contraceptive uptake among women of reproductive age in a semi-urban community of Ekiti State, Southwest Nigeria. Ethiop J Health Sci. 2017;27:121–8. doi: 10.4314/ejhs.v27i2.4. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 26. Bwazi C, Maluwa A, Chimwaza A, Pindani M. Utilization of postpartum family planning services between six and twelve months of delivery at Ntchisi District Hospital, Malawi. Health. 2014;6:1724–37. [ Google Scholar ]
- 27. Adeyemi AS, Olugbenga- Bello A, Adeoye OA, Salawu MO, Aderinoye AA, Agbaje MA. Contraceptive prevalence and determinants among women of reproductive age group in Ogbomosho, Oyo State, Nigeria. Open Access J Contracept. 2016;7:33–41. doi: 10.2147/OAJC.S94826. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 28. Obalase SB, Joseph UE. Knowledge, Attitude and Acceptance of Modern Family Planning Method Among Women Attending Post–Natal Clinic in Ayeka Basic Health Centre in Okitipupa Local Government Area, Ondo State, Nigeria. Biomed J Sci & Tech Res. 2017:1. [ Google Scholar ]
- 29. Osaro BO, Tobin-West CI, Mezie-Okoye MM. Knowledge of modern contraceptives and their use among rural women of childbearing age in Rivers State Nigeria. Ann Trop Med Public Health. 2017;10:1043–8. [ Google Scholar ]
- 30. Oladosun M, Akanbi M, Fasina F, Samuel O. Key predictors of modern contraceptive use among women in marital relationship in SouthWest region of Nigeria. Int J Reprod Contracept Obstet Gynecol. 2019;8:2638–46. [ Google Scholar ]
- 31. Afolabi BM, Ezedinachi ENU, Arikpo I, Ogunwale A, Ganiyu DF, Abu RA, et al. Knowledge, non-use, use and source of information on contraceptive methods among women in various stages of reproductive age in rural Lagos, Southwest Nigeria. Open Access J Contracept. 2015;6:65–75. doi: 10.2147/OAJC.S80683. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 32. Ukegbu AU, Onyeonoro UU, Nwokeukwu HI, Okafor GOC. Contraceptive method preferences, use and satisfaction among women of reproductive age (15-49 years) in Umuahia, Abia State, Nigeria. J Contracept. 2018;3:16. [ Google Scholar ]
- 33. Ajayi AI, Adeniyi OV, Akpan W. Use of traditional and modern contraceptives among childbearing women: Findings from a mixed methods study in two southwestern Nigerian states. BMC Public Health. 2018;18:604. doi: 10.1186/s12889-018-5522-6. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- 34. Ujah OI, Ocheke AN, Mutihir JT, Okopi JA, Ujah IAO. Postpartum contraception: Determinants of intention and methods of use among an obstetric cohort in a tertiary hospital in Jos, North Central Nigeria. Int J Reprod Contracept Obstet Gynecol. 2017;6:5213–8. [ Google Scholar ]
- 35. Semachew Kasa A, Tarekegn M, Embiale N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes. 2018;11:577. doi: 10.1186/s13104-018-3689-7. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
- View on publisher site
- PDF (618.1 KB)
- Collections
Similar articles
Cited by other articles, links to ncbi databases.
- Download .nbib .nbib
- Format: AMA APA MLA NLM
IMAGES
VIDEO
COMMENTS
The International Center for Research on Women (ICRW) conducted a review of the literature to identify barriers to adolescents’ access to and use of family planning services, programmatic approaches for increasing access and uptake of those services, gaps in the evidence that require further research, and areas that are ripe for future investment.
Explore the latest full-text research PDFs, articles, conference papers, preprints and more on FAMILY PLANNING. Find methods information, sources, references or conduct a literature review on...
The purpose of this paper is to examine the evidence on the need for family planning. The available evidence on current levels of unmet need for contraceptives, fertility preferences, and the...
We systematically searched for and summarized reports of strategies to scale up demand generation for family planning. Available evidence shows that interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain.
Family planning serves three critical needs: (1) it helps couples avoid unintended pregnancies; (2) it reduces the spread of sexually transmitted diseases (STDs); and (3) by addressing the problem of STDs, it helps reduce rates of infertility.
Family planning (FP) is a key intervention to limit these adverse health outcomes [4–6]. Such interventions can prevent 90% of abortions, 32% of maternal deaths, 20% of pregnancy-related morbidity globally, and reduce 44% of maternal mortality in low-income countries [1, 7].
Therefore, this meta-analysis aimed to estimate the pooled prevalence of immediate postpartum family planning utilization and its associated factors in Ethiopia by considering the WHO Medical eligibility criteria for contraceptives-2015 for postpartum during the immediate postpartum period.
This study was carried out to assess the knowledge and utilization of family planning, as well as to determine the predictors of utilization of family planning among post-partum women attending primary health centers (PHCs) in a selected rural area of Lagos State, southwest Nigeria.
Family planning (FP) refers to the preparation, knowledge, and methods that assist individuals and couples to plan and attain their desired family size and determine the spacing of pregnancy (World Health Organization [WHO], 2018).
The Integration of Family Planning with Other Health Services: A Literature Review CONTEXT: Integrating family planning services with other health services may be an effective way to reduce unmet need. However, greater understanding of the evidence on integration is needed.