essay about contraceptive measures used for family planning

Fertility Transition in the Developing World pp 97–122 Cite as

The Impact of Voluntary Family Planning Programs on Contraceptive Use, Fertility, and Population

• John Bongaarts 9 &
• Dennis Hodgson 10  
• Open Access
• First Online: 02 September 2022

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Part of the book series: SpringerBriefs in Population Studies ((BRIEFSPOPULAT))

This chapter examines the long-standing debate about the effects of family planning programs on contraceptive behavior and fertility. We begin with a brief overview of the main rationale for family planning, namely the removal of obstacles to practicing contraception by women who want to space or limit their births. The central sections of the chapter then discuss the evidence on the effects of family planning programs. Three sources of evidence are examined: (1) controlled experiments; (2) natural experiments; and (3) statistical studies. These sources provide broadly comparable estimates of the effects of a high-quality family planning program: an increase of 25–35% in contraceptive prevalence and a decline of about 1.5 births per woman in the Total Fertility Rate (TFR) compared to a population without family planning support. The statistical analyses examine the roles of family planning programs in changing contraceptive demand and its satisfaction and the pattern of wanted and unwanted fertility. Demand refers to the proportion of women who do not want to get pregnant and its satisfaction refers to the proportion of women with a demand that practice contraception. As expected, family planning programs raise the satisfaction of demand for contraception and reduce unwanted fertility. Contrary to common conclusions made in economic theories of fertility, family planning programs have a substantial impact on demand for contraception and on wanted fertility. We conclude with a discussion of the criticisms of family planning programs and the claims that these programs have at best a small impact and are not cost-effective.

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7.1 Introduction

When concern about the adverse impact of rapid population growth became widespread in the 1950 and 1960s, policy makers searched for interventions to slow growth. Family planning programs were an obvious choice, but there was significant doubt that these would work, because of the widely held belief that fertility would not decline until societies experienced significant, widespread social and economic change. Influential analysts argued that women in poor countries would not use contraception offered by programs because they wanted large families (Davis, 1967 ; Hauser, 1967 ). These doubts were allayed by findings from surveys which interviewed women about their reproductive preferences. Many women in Asia and Latin America (but not in SS Africa) wanted families of modest size (Lightbourne, 1987 ; Mauldin, 1965 ). Successful small experimental studies confirmed women’s willingness to accept contraceptives, thus providing the scientific foundation for the family planning movement in subsequent decades (e.g., Fawcett, 1970 ; Foreit & Frejka, 1998 ; Freedman & Takeshita, 1969 ). From the late 1960s onward substantial funding from international sources became available to governments that were willing to start family planning programs (Donaldson, 1990 ; Piotrow, 1973 ). The availability of new methods (the pill, IUD, and new methods of sterilization) made the mass distribution of contraceptives more affordable and easier to implement. The family planning movement was particularly successful in Asia and North Africa (Robinson & Ross, 2007 ). In Latin America (and in the Philippines) opposition from the Catholic Church made governments reluctant to promote contraception, but large, well-funded NGOs (e.g., Profamilia in Columbia and BEMFAM in Brazil) took on the task of distributing family planning methods. In sub-Saharan Africa governments generally expressed little interest in family planning before the 1990s with notable exceptions of Botswana, Kenya, Ghana, and South Africa (May, 2017 ). In the 1990s the AIDS epidemic in large parts of the African continent put a damper on government investments in family planning. Everywhere the success of programs relied on strong support of government leaders. In the early 2000s several additional African countries implemented successful programs (e.g., Ethiopia, Malawi, Rwanda, and Zambia). Many other countries including Nigeria and the Democratic Republic of the Congo have made little progress in the development of strong programs.

7.2 The Role of Family Planning Programs in Removing Obstacles to the Use of Contraception

As noted in Chap. 3 the existence of large numbers of unplanned births and abortions in countries around the world is incontrovertible evidence that many women lack full control over their reproductive lives. Unplanned outcomes occur when sexually active women who want to avoid pregnancy either use no contraception or experience contraceptive failure. This is, in turn, largely the consequence of a wide range of social, health, and economic factors that pose barriers to women (and men) who wish to practice contraception (Bongaarts & Bruce, 1995 ; Bongaarts et al., 2012 ; Casterline et al., 1997 ; Casterline & Sinding, 2000 ; Casterline et al., 2001 ; Cleland, 2001 ; Cleland et al., 2006 ; El-Zanaty et al., 1999 ; Cleland forthcoming).

The main obstacles identified by researchers include:

Lack of knowledge. To use a modern method, women must be aware of its existence, and they must know how to use the method, and where to obtain supplies. Knowledge of at least one modern method was very limited in the 1950 and 1960s in the developing world, but by the early 1990s became widespread in Asia and Latin America and in a number of countries in SSA (Curtis et al., 1996 ). Availability of family planning methods. A couple must have access to a contraceptive method to adopt it. For traditional methods such as abstinence and withdrawal no source is required (but partner cooperation is needed); and for permanent methods such as sterilization, one-time access suffices. But for widely used modern methods such as injectables, condoms and the pill, a dependable source within a reasonable distance is needed. The density of these access points varies widely among and within countries. Access is most difficult in rural communities in countries where family planning programs are absent or weak and is particularly problematic when traditional customs restrict women’s mobility. Costs. While physical proximity is important, services must be reasonably priced. The direct cost of commodities (e.g., pills, injection, condoms, IUDs), transportation, and provider fees for contraceptives and health care services can be substantial. As a result, poor women are often unable to afford modern methods without the subsidies provided by family planning programs. Quality of services. To satisfy clients, services must be of adequate quality. This includes the provision of a choice of methods, a well-trained staff and the respectful treatment of clients. Most women prefer female providers. Health concerns and side effects. Health concerns and fear of side effects are two of the most commonly expressed reasons for nonuse and for discontinuing the use of contraception. Choosing a method often involves weighing a variety of drawbacks to find the method that is least objectionable. The most serious health effects are cardiovascular complications of the pill; pelvic inflammatory disease, uterine perforation, and anemia for the IUD; and infections associated with sterilization and other methods. These complications are uncommon if users are well informed and service providers are well trained and have access to appropriate equipment and drugs. Physiological effects (e.g., nausea, headache, weight gain, menstrual changes) associated with some contraceptive methods also influence women’s choices. Still other drawbacks play potentially significant roles in the decision to adopt a method. For example, manipulation of genitals or interruption of intercourse is required for the use of the condom, diaphragm, cap, sponge, and spermicides. Many women dislike the physical exams (often performed by male providers) required for IUD insertions and for fitting the diaphragm and caps. Others fear the surgical procedures associated with sterilization and implants. Loss of potency is a concern for some men who might otherwise consider a vasectomy. Many of these health concerns are based on or exaggerated by rumors and misinformation. Objections from husbands or other family members. For many married women, objections to family planning from their husbands or partners is a sufficient reason not to practice contraception, despite their desire to do so. Other family members (e.g., parents or parents-in-law) or neighbors may also discourage the practice of contraception. Reasons for these objections may include the desire for more children than the women herself wants, costs of contraceptive supply and associated health care, concerns about side effects, and moral or religious beliefs. In traditional societies, family limitation and negotiation over sexual matters may not be considered respectable subjects. Concerns about moral and social acceptability. In nearly every society the introduction of the idea of birth control and the methods used to achieve it meet resistance from political, church, and medical leaders. Family planning was viewed as usurping divine will, encouraging promiscuity leading to a breakdown of family life, and threating individual health and national vitality (Cleland, 2001 ). Such forms of resistance were common in Europe in the late nineteenth century, and resistance remains common in many contemporary developing countries. Sometimes the opposition is embodied in formal religious doctrine (e.g., the Roman Catholic ban on artificial methods and the Islamic opposition to sterilization). Up to the 1970s most African leaders had a mercantilist view of population: larger populations were better than smaller populations and rapid growth was better than slow growth. In Latin America the early enthusiasm for family planning revolved around limiting unsafe abortion rather than reducing fertility or population growth. It was not until about 1980 that the benefits of fertility decline, and smaller families became widely accepted by government leaders and the general population.

These obstacles to adoption of contraception are the main cause of unplanned pregnancies. Removing these barriers is, therefore, the goal of voluntary family planning programs. The primary task of family planning programs is to offer women and couples easy access to a wide range of affordable, reliable, and high-quality contraceptive methods and related services. To achieve this objective, many countries have built service delivery networks that may include hospitals, health and family planning centers, work-based clinics, mobile medical and paramedical units, community-based distribution, and commercial outlets. Contraceptives are usually provided at low cost or for free. The most effective programs have minimized access obstacles by training female outreach workers who visit women in their homes.

To be successful in helping women and couples avoid unintended pregnancies, family planning programs must go beyond simply providing physical access to contraceptive supplies and reduce or eliminate the other obstacles to contraceptive use noted above (Cleland et al., 2012; Cleland forthcoming). A number of approaches can address these barriers, including: (1) education campaigns through mass media, called IEC (information, education, and communication) or BCC (behavioral change communication); (2) training service providers to increase their knowledge and to encourage improvements in the quality of services; (3) increasing women’s empowerment and agency; (4) collaboration with community leaders; and (5) ensuring that others with significant influence on women’s contraceptive behavior (e.g., husbands, partners, mothers-in-law) have accurate information about family planning and the costs and benefits of childbearing.

The final ingredient of a successful family planning program is strong support from government leaders at the local and national level. This support can be encouraged by providing regular briefings on program progress and on the social and economic benefits of contraceptive use and lower fertility. It is also crucial to collaborate with policymakers to remove or revise laws, regulations, official guidelines and other structural factors that are barriers to contraceptive adoption and distribution.

By providing access to high-quality contraceptive services, addressing barriers to use, and ensuring political support, family planning programs can maximize adoption of contraception among women who want to space or limit their births. Information and education campaigns about the benefits of smaller families also play an important role in increasing overall demand for contraception, as will be demonstrated below.

7.3 Program Impact on Contraceptive Use

Well-designed family planning programs can help women implement their fertility preferences and reduce unintended births and abortions. A number of evaluations of these programs have found that they can have a significant impact on contraceptive use and fertility (Ahlburg & Diamond, 1996 ; Bongaarts, 1997 , 2020 ; Bongaarts & Hardee, 2019 ; Miller & Babiarz, 2016 ; Tsui, 2001 ). However, other studies (in particular, Pritchett, 1994 ) conclude that family planning programs have a minimal impact on reproductive behavior. We will examine this controversy in more detail, beginning with a summary of the evidence that family planning programs have an impact on fertility.

Three different approaches have been used to obtain estimates of family planning programs’ impact across a wide range of periods and contexts.

7.3.1 Controlled Experiments

Controlled experiments are the gold standard for evaluating interventions, but very few large-scale experiments have been conducted to assess family planning programs, in part because they are expensive and take a long time to complete. The largest and most influential of these experiments is the Family Planning and Health Services Project (FPHSP), started in the late 1970s in Matlab, a rural district in Bangladesh (Cleland et al., 1994 ; Phillips et al., 1982 , 1988 ). At the time FPHSP started, Bangladesh was one of the poorest and most highly agricultural countries in the world, and there was widespread skepticism that family planning would be accepted in such a traditional society. The FPHSP divided the Matlab district (population of 173,000 in 1977) into experimental and control areas of approximately equal size. The control area received the same services as the rest of the country. In the1970s these services were very limited and did not significantly affect contraceptive use. In the experimental area comprehensive high-quality family planning services were provided, aimed at reducing the costs (monetary, social, psychological, and health) of adopting contraception. In the experimental area women were provided with free services and supplies of modern contraceptive methods; home visits by well-trained female family planning workers; regular follow-up to address health concerns; information campaigns; menstrual regulation services; and outreach to husbands, community leaders, and religious leaders to address potential social and familial objections from men.

The impact of the program was large and immediate (Cleland et al., 1994 ; Phillips et al., 1988 ). As shown in Fig.  7.1 , within two years, modern contraceptive use increased from five to 33% among married women in the experimental area while little change occurred in the control area. The experiment left no doubt that a well-designed family planning program could be successful in a very poor, largely illiterate, agricultural society. Its success led the Bangladesh government to implement a nation-wide family planning program that employed many of the innovations from the Matlab, such as house-to-house visits by well-trained young female community health workers (Cleland et al., 1994 ).

Contraceptive use trends in family planning experiment in Matlab, Bangladesh (Phillips et al., 1988 ; Cleland et al., 1994 )

7.3.2 Natural Experiments

Unlike controlled experiments, which are carefully designed and implemented to evaluate a particular intervention, ‘natural experiments’ take advantage of existing diversity and compare two populations with similar social, economic, cultural, and religious characteristics, but with differing approaches to family planning. Differences between such populations in contraceptive use and fertility demonstrate the potential effects of voluntary family planning (Bongaarts et al., 2012 ; Cleland, 1994 ; Lee et al., 1998 ).

One of the best-known examples of a natural experiment is the comparison of Bangladesh and Pakistan, which were one country from independence in 1947 until 1971. Both had similar cultures and levels of social and economic development. However, the countries differed remarkably in their commitment to voluntary family planning. Following the Matlab experiment, Bangladesh, starting around 1980, implemented one of the world’s most comprehensive national family planning programs based on the Matlab model, while Pakistan’s program lacked government funds and commitment and remained weak and relatively ineffective (Cleland & Lush, 1997 ).

Figure  7.2 plots the contraceptive prevalence rate among married women (mCPR) from 1970 to 2015 for the two countries. Both started at very low levels in 1970 and rose over time, but the increase in Bangladesh was substantially larger than in Pakistan. By 2015 the gap had reached almost 30% points (54.3% vs. 25.6%). The most recent Demographic and Health Survey conducted in 2017–2018 suggests that Pakistan’s mCPR leveled off in the mid-2010s (NIPS-Pakistan & ICF, 2019).

Contraceptive prevalence (modern) in Bangladesh and Pakistan, 1970–2015 (United Nations, 2021)

Previous examinations of the Pakistan-Bangladesh difference in reproductive behavior have also attributed it largely to the much higher quality family planning program in Bangladesh (Cleland & Lush, 1997 ).

Other natural experiments lead to broadly similar conclusions (Bongaarts et al. forthcoming). Rwanda and Burundi are poor, densely populated countries in East Africa with comparable socio-economic profiles. Rwanda’s family planning program is much stronger than Burundi’s leading to mCPR gap in 2015 of 24.1% points (47.2% vs. 23.1%). Ethiopia and Nigeria are the two largest countries in SSA. The former has an effective family planning program while the latter does not. As a result, Ethiopia’s mCPR (36.0%) exceeds Nigeria’s (10.8%) by 25.3% points (United Nations Population Division, 2021 ).

The three natural experiments had comparable results with mCPR gaps in 2015 of 28.7% points for Bangladesh-Pakistan, 24.1% points for Rwanda-Burundi and 25.3% points for Ethiopia-Nigeria.

7.3.3 Natural Experiments: Adjusted Results

These comparisons of three country pairs should be regarded as approximations of the impact of strong versus weak family planning programs because the levels of development in the countries in each pair are not exactly the same. In the absence of family planning programs in both countries of each pair their levels of contraceptive use might still be different in 2015 because socio-economic conditions differ. To address this issue, we continue the analysis of natural experiments but control for the level of education when comparing the countries. As noted in Chap. 4 , education is by far the most influential socio-economic determinant of fertility. Taking its potential confounding effect into account should lead to more accurate results from the natural experiments.

Figure  7.3 plots the mCPR of Bangladesh and Pakistan by level of education from 1970 to 2015. The figure looks like Fig.  7.2 , which is not surprising because the values of all plotted points are the same. But there is a crucial difference between the two figures: In Fig.  7.2 each observation for each country is plotted in the corresponding year, which is measured along the horizontal axis. In Fig.  7.3 the horizontal axis measures the level of education in the corresponding year. For example, the last point (A) in the graph for Bangladesh is the 2015 level of mCPR (54.3%) which is plotted at 6.4 years of education. For Pakistan the mCPR in 2015 is estimates at 25.6 (point C) but in that year the level of education was 5.0 years, significantly below the level in Bangladesh. Pakistan’s mCPR is lower than Bangladesh’s not only because of its weaker program but also because of its lower level of education.

Contraceptive prevalence by education, Bangladesh and Pakistan, 1970–2015 (United Nations, 2021; Wittgenstein Center, 2021 )

To assess the family planning program impact without the confounding effect of education we must compare the two countries when they were at the same level of education. In this case we compare the two countries at an education level of 5 years of schooling, which gives a mCPR of 26 for Pakistan in 2015 and 49 for Bangladesh in 2007 (points C and B in Fig.  7.3 ). The education-adjusted gap between the two countries therefore is 23% points (49–26) rather than the unadjusted gap of 29% points obtained from Fig.  7.2 .

Figure  7.4 presents education adjusted results for the natural experiments in three pairs of countries Bangladesh-Pakistan, Ethiopia-Nigeria, Rwanda-Burundi. The results for the adjusted mCPR gap between the country with the strongest and weakest program countries are, respectively 23, 31 and 15% points for married women.

Education adjusted mCPR in 2015 for three pairs of countries with strong/weak family planning programs (Authors’ calculations from United Nations, 2021)

These findings from natural experiments are informative but do not provide accurate estimates of the full family planning program impact. Instead, these comparisons provide an estimate of the difference between the weaker and stronger programs and do not give an estimate of the total program impact of the strong program country, because the weaker programs have some effect that cannot be ignored. To address this issue, we turn to regression analysis.

7.3.4 Regressions: Program Impact on Contraceptive Use, Demand, and Satisfaction

In the absence of experimental evidence for most countries, researchers have relied on regression analysis to estimate the effects of family planning programs on the level and pattern of fertility. As noted earlier, the extensive literature on the determinants of fertility identifies two general factors as the main determinants of fertility declines in the developing world over the past half century: socio-economic development, in particular education, and family planning programs. Regression analyses have been used to estimate the separate impact of development versus family programs on contraceptive use and fertility change (Ahlburg & Diamond, 1996 ; Bongaarts, 1998, 2020 ; Bongaarts & Hardee, 2019 ; Miller & Babiarz, 2016 ; Pritchett, 1994 ; Tsui, 2001 ). In these regressions, contraceptive use or fertility are the dependent variables and the independent variables consist of one or more socio-economic indicators, plus an indicator of family planning program effort.

A key issue in these regressions is measurement of the strength of a program in a country, which is not straightforward. The oldest indicator is the Family Planning Program Effort (FPE) score, which has been used since the early 1970s to gauge the strength of national programs (Kuang & Brodsky, 2016 ; Ross & Smith, 2011 ). To obtain this score, knowledgeable observers in each country answer questions about a variety of program characteristics and policy actions. Their responses are combined to yield an overall FPE score. Over the past three decades, the FPE score for countries has been measured in eight cycles ending in 2014.

The FPE scores suffers from some shortcomings. Differences among countries and across cycles can occur simply because the experts often must make subjective assessments and the experts change over time. In addition, the questions included in the index have been refined and changed over time. As a result, differences between FPE scores of countries and trends for individual countries should be interpreted with caution.

More recently, Bongaarts and Hardee ( 2017 ) have proposed an alternative program indicator called Public-sector family planning program impact score to measure the quality and scope of a government sponsored family planning program. We will refer to this variable as the ‘program score’ (PS). It equals the product of two other variables: (1) the proportion of demand that is satisfied by modern methods; and (2) the proportion of modern methods that is provided by the public sector. PS therefore equals the proportion of all demand that is satisfied with modern methods from the public sector. This score, which can be consistently measured over time in countries with Demographic and Health Surveys (DHS), does not rely on subjective assessments. It ranges from zero in the absence of a government program to a theoretical value of 100 for the strongest public programs where all demand for contraception is met by the public sector. A country can have low demand and a low mCPR but a high PS if the mCPR is close to the demand and all contraception is provided by the public sector. Conversely, a country can have high demand and a high mCPR but a low PS if the public sector is small and contraceptives are mostly provided through the private sector.

To provide a first look at the relationship between education, program score, and contraceptive use, we plot in Fig.  7.5 the prevalence of modern contraception (mCPR) by the mean years of schooling among women aged 20–39. The figure contains 22 markers, one for each of 22 largest countries in SSA, representing observations at the most recent DHS (ca. 2013). The size of the round marker is proportional to the program score of the country which ranges from 5 in Congo DR to 62 in Zimbabwe.

Contraceptive prevalence by mean years of schooling and program score (circle), 22 sub-Saharan Countries 2015 (United Nations Population Division, 2021 ; Wittgenstein Center, 2021 )

If female education were the only determinant of the mCPR, the observations for all countries would fall on a single upward sloping line. This is clearly not the case, indicating an impact of family planning programs and other factors. In general, the higher the level of women’s educational attainment and the higher the program score, the higher the mCPR. A key finding is that at any level of women’s educational attainment, the mCPR varies widely. For example, in the countries with average schooling levels around six years, the mCPR ranges from 9% in Congo DR to 57% in Malawi. As will be shown below, the differences among countries with similar levels of women’s educational attainment are to a large extent the result of program differences. The findings in Fig.  7.5 suggest that education and program score both have a substantial effect on mCPR, but quantifying these effects requires formal regression analysis.

Our regression analysis of mCPR trends in SSA is an updated and expanded version of one carried out by Bongaarts and Hardee ( 2019 ). The regressions focus on sub-Saharan Africa because most countries in this continent are still in their fertility transitions and many governments have made only limited investments in family planning programs. The debate about the impact of family planning programs is clearly especially relevant in this continent. In addition, the program score was designed for use in SSA, and can be biased in other continents where the private sector has become the dominant provider of services, often with the assistance of governments.

Three regression models are presented below, with mCPR, the demand for contraception, and the satisfaction of demand as the three dependent variables. Each regression has two explanatory variables: (1) education as measured by the average years of schooling among women aged 20–39 (‘education’); and (2) program score, PS. In Chap. 4 education was found to be the dominant socio-economic determinant of fertility especially in SSA. (Adding other socio-economic indicators yielded no new significant coefficients.) The regressions rely on data from 33 countries in SSA with at least two Demographic and Health Surveys after 1990 and with a population size above one million. Data from all available DHSs in each country are included (ICF International, 2021 ) for a total 133 surveys. By using countries as their own controls, fixed effects models account for time-stable differences among countries, which may otherwise introduce bias into parameter estimation.

Model 1 in Table 7.1 presents the results for the regression of the determinants of mCPR. The coefficients for women’s education and PS are highly significant, thus confirming their impact on contraceptive prevalence. A year of education raises mCPR by 2.29% and a point increase in the PS raises the mCPR by 0.64%.

Figure  7.6 plots the country specific estimates of the total program impact at the time of the most recent DHS survey. Each estimate is obtained by multiplying the PS regression coefficient of 0.64 by the observed value of the PS in each country. The biggest program impacts, exceeding 30%, were found in South Africa, Zimbabwe, Zambia, Rwanda, Malawi, Namibia, and Ethiopia. In contrast, the program impact was less than 5% in Cote d’Ivoir, Congo and the Democratic Republic of the Congo.

Impact of family planning program on modern contraceptive prevalence

Models 2 and 3 in Table 7.1 present results from the fixed effects regressions for demand and for the satisfaction of demand. The effects of education and the program score are statistically significant in both models. For example, in Model 3 the coefficient for the program effect on percent of demand satisfied equals 0.91. This means that a 50% change in PS on average leads to an increase of 45% in the percent of demand satisfied. The family planning program score also affects demand for contraception, but with a smaller coefficient of 0.30. In other words, PS affects contraceptive prevalence by raising both demand and the level of satisfaction, with the latter being three times more important than the former.

The three different approaches to estimating the mCPR impact of the highest-quality family planning programs yield the following results: (1) 28% for the controlled experiment in Matlab; (2) 15–31% for differences between stronger and weaker programs in ‘natural experiment’ comparisons of countries; and (3) 30–40% for the absolute effects of the strongest programs in SSA in regression analyses. These findings are broadly consistent with one another. However, the first and second approaches underestimate the absolute program effect and just estimate the difference between weak and strong programs, thus ignoring any program effect in the weaker program countries or control area. The regression approach does not have this bias and can therefore be expected to yield somewhat higher program impact estimates on the mCPR.

7.4 Program Impact on Fertility

The three different approaches to estimating the program impact on contraceptive prevalence can also provide estimates of the program impact on fertility.

7.4.1 Controlled Experiments

As shown in the preceding section, contraceptive use in the experimental area of Matlab rose sharply while little change occurred in the control area. One would therefore expect a more rapid fertility decline in the experimental than in the control area. This was exactly what was observed: a difference of 25% (around 1.5 births per woman) was maintained through the 1980s until the services in the control area and in the rest of the country were also improved (see Fig.  7.7 ).

Fertility impact of family planning experiment in Matlab, Bangladesh (ICDDR, 1994 , 2001 ; Phillips et al., 1982 )

A similar but more complex quasi-experimental study was conducted in the Navrongo district of Northern Ghana in the 1990s, where over a third of women wanted to space or limit additional births but few were using contraception. Though direct estimates of changes in contraceptive use from the Navrongo project are not available, an evaluation found that the project led to improved knowledge and use of modern contraception and to a decline in the TFR of one birth per woman in the initial three years of the project, a 15% decline in fertility relative to comparison areas (Debpuur et al., 2002 ).

7.4.2 Natural Experiments

As expected, the differences in mCPR trends between Bangladesh and Pakistan since 1970 have led to differences in fertility transitions. In 1970 the TFR was close to 7 births per women in both countries, a level that had probably not changed significantly for many decades. In the 1980s the TFRs began to diverge (see Fig.  7.8 ) and by 2015 the gap between the two countries reached 1.6 births per woman (3.7 vs. 2.1).

Total fertility rate 1970–2015 Bangladesh and Pakistan (United Nations, 2019 )

Natural experiments in other countries yield broadly similar results. Ethiopia and Nigeria, and Rwanda and Burundi are pairs of countries with comparable socio-economic profiles. The TFRs declined to substantially lower levels in countries with stronger programs (Ethiopia and Rwanda) than in corresponding weaker program countries (Nigeria and Burundi). The 2015 difference between the TFRs of the stronger and weaker program countries ranged from 1.0 birth per woman for Ethiopia-Nigeria pair to 1.5 births per woman for the Rwanda-Burundi pair.

7.4.3 Natural Experiments : Adjusted Results

The TFR results from these natural experiments are confounded by differences in socio-economic development between the countries in each pair. To address this issue, we introduce a control for the level of education in all countries. As discussed in Chap. 4 education of females is the most important determinant of fertility decline.

The adjustment procedure used for the mCPR can also be applied to obtain an estimate of the education adjusted gap for the TFR. Figure  7.9 plots the TFR of Bangladesh and Pakistan by level of education from 1970 to 2015. In 2015 the TFRs of the two countries differed by 1.6 births per woman. But at the education level of five years of schooling, the gap is just 1.1 births per woman. The education adjustment clearly reduces the gap.

Total fertility rate by level of education, 1970–2015, Bangladesh and Pakistan (Authors’ calculations; United Nations, 2019 )

This, however, is not the whole story because there is another bias. As is clear from Fig.  7.9 , Bangladesh started off in 1970 at a higher fertility level than Pakistan. To assess the impact of relative impact of the programs we must take this different starting point into account. We do this by comparing the declines in fertility of the two countries between the first and last points where a comparison is possible (i.e., at education levels of 1.4 and 5.0 years, respectively). At the education level of 1.4 Bangladesh’s fertility is higher than Pakistan’s by 0.4 births per woman and at the education level of 5 the gap is 1.1. The decline is 4.4 births per woman in Bangladesh and 2.8 in Pakistan. The difference in declines is therefore 1.6 births per woman. This gap might be the result of the difference in the strengths of family planning programs in Bangladesh and Pakistan (in the early 2000s the PS score of the two countries equaled 39 and 19 respectively). Differences in other socio-economic conditions that grew over time also had an impact but the adjustment for level of education minimizes their role.

Figure  7.10 presents education adjusted declines for the natural experiments in three pairs of countries: Bangladesh-Pakistan, Ethiopia-Nigeria, Rwanda-Burundi. The adjusted TFR gaps in declines are 1.6, 2.4 and 2.0 births per woman, respectively, which might be attributable to differences in the strength of family planning programs.

Education adjusted declines in TFR: stronger versus weaker program countries (Authors’ calculations; United Nations, 2019 )

7.4.4 Regressions: Program Impact on Fertility

The regression analyses of fertility declines rely on the same methodology as the regression analyses of the mCPR presented above. The determinants of fertility and its wanted and unwanted components in SSA will be assessed by relying on fixed effect regressions using country-level data from all DHS surveys in 33 countries with at least two such surveys. Table 7.2 presents the results of four models:

Model 1: The determinants of the TFR

The two independent variables included in Model 1 are women’s education and the family planning program score. The coefficients for both variables are highly significant. On average, an increase of one year in school reduces the TFR by 0.185 births per woman and one point increase in the family planning score reduces the TFR by 0.025 births per woman.

Model 2: the determinants of wanted TFR

The coefficients for education and program score are both highly significant and negative as expected on theoretical grounds. On average, one year of education reduces wanted fertility by 0.215 births per woman and one point in the PS score reduces the wanted TFR (WTFR) by 0.016 births per woman.

Model 3: the determinants of unwanted TFR

Model 3 repeats Models 1 and 2 except that the dependent variable is unwanted fertility (UWTFR). The results show a significant effect of program score but not for education. The latter finding is surprising because educated women generally have more knowledge about and access to contraception and have higher opportunity costs associated with an unwanted birth. The explanation for this unexpected finding lies in the process discussed in Chap. 3 . Model 3 produces biased effects because it ignores the potential confounding effect of declining wanted fertility on unwanted fertility. As wanted fertility declines the potential number of unwanted births rises. Improvements in education and family planning programs have an uphill battle to overcome this rising level of potential unwanted fertility. The result of these competing factors is a non-significant effect for education and a relatively small but significant effect for family planning.

Model 4: the determinants of unwanted TFR with control for wanted TF

To reveal the unbiased effect of education and family planning score it is necessary to control for the confounding effect of declining wanted fertility. This is the objective of model 4 which is the same as model 3 except that wanted fertility is added as a third explanatory variable. As expected, model 4 results show a highly significant inverse effect of WTFR. In addition, the effects of education and family planning program are larger than in model 3 and are statistically significant (at the 10% level for education). The coefficient for the effect of program score on unwanted fertility (−0.016) is the same as for the effect on wanted fertility.

To provide further insight into these regression results we calculate the absolute effects of women’s schooling and the family planning program on the TFR in each country. This effect can be estimated by multiplying the regression coefficients in model 1 by the observed values of the two explanatory variables. Figure  7.11 plots the resulting fertility effects in countries with a population over 5 million at the time of the most recent DHS survey. The average education effect (1.04 births per woman) exceeds the average program effect (0.84 births per woman). There is considerable variation among countries. For example, the education effect exceeds 1.5 birth per woman in Kenya, South Africa and Zimbabwe, but is less than 0.5 in Mozambique, Burkina Faso, Mali, Niger, and Chad. The countries with the highest program effects (around 1.5 births per woman) are Malawi, Rwanda, South Africa, Zimbabwe, and Zambia. Footnote 1

Education and family planning program effects on TFR decline

The three different approaches to estimating the fertility impact of family planning programs yields comparable results: a reduction of 1.5 births per woman over a reproductive lifetime in the Matlab experiment, 1.6 to 2.4 births per woman in countries involved in the natural experiments, and around 1.5 in the countries in SSA with the highest family planning program scores.

7.5 Program Impact on Population Trends

By addressing the reproductive needs of couples, family planning programs raise contraceptive prevalence. This in turn reduces fertility and population growth, changes the age structure, and increases the demographic dividend.

To illustrate, we compare fertility and population trends in Pakistan and Bangladesh. In 1975–1980, the two countries had nearly the same high fertility near 7 births per woman, but, as seen above, trends diverged in subsequent decades, with more rapid declines in Bangladesh than in Pakistan. By 2015, Bangladesh’s fertility declined to 2.1 births per woman, while in Pakistan fertility stood at 3.7, a difference of 1.6 births per woman.

The different fertility trajectories resulted in increasingly large differences in population size over time (see Fig.  7.12 ). In 1980, the two populations were virtually the same size (about 80 million), but by 2100, Pakistan’s population is projected to be more than double the size of Bangladesh’s (403 vs. 151 million) (United Nations, 2019). This suggests that the Bangladesh family planning program led to a large reduction in the country’s potential 2100 population. Footnote 2 Fertility and population trends are also affected by levels of socio-economic development, but this is unlikely to be the main explanation for the different population trajectories. Development levels, as measured by years of education, were similar in the 1970s in Bangladesh and Pakistan, which were and still are largely poor agricultural majority-Muslim countries. But over time education differences have appeared with education levels in 2015 reaching 6.4 years in Bangladesh and 5.0 years in Pakistan. This would be expected because one of the benefits of more rapid fertility decline is greater investments in education. It might therefore be argued that at least some of the education advantage of Bangladesh is due to earlier investments in its family planning program and the resulting demographic dividend (see Chap. 6 ).

Population Projections Bangladesh and Pakistan (United Nations, 2019)

The different fertility trajectories of Pakistan and Bangladesh also affect trends in the age structure and the demographic dividend. Figure  7.13 plots the proportion of working age people for the two countries from 1970 to 2015. After 1980 (the onset of fertility decline in Bangladesh), the working age proportion of the population grew substantially faster in Bangladesh than in Pakistan. The economy also grew faster in Bangladesh than in Pakistan after 1990 (World Bank, 2021 ). There are, of course, other factors that contributed to the more rapid growth in Bangladesh, but the demographic tailwind was no doubt a key factor.

Percent of population aged 18–64, Bangladesh and Pakistan (United Nations, 2019 )

As noted earlier, the potential for a demographic dividend in SSA lies mostly in the future. To assess the potential demographic impact of a substantial investment in family planning programs in Africa, we compare the high and low variants of the UN population projections for SS Africa (United Nations Population Division, 2019 ). The difference between these two variants is the fertility level assumed in the future: the high variant exceeds the low variant by one birth per woman. Such a one-birth decline is achievable with the implementation of a high-quality family planning program (in fact Sect. 7.4 suggests the effect could be around 1.5 births per woman).

According to the medium variant, the population of SSA will quadruple in size from one billion in 2015 to 3.8 billion in 2100 (see Fig.  7.14 ). This projection assumes a steady decline in fertility and includes the impact of the AIDS epidemic. The high variant (with fertility a half birth higher than in the medium variant) projects 5.2 billion people in 2100. This trajectory could well become reality if no significant further investments are made in family planning, because past fertility declines have been much slower in SSA than in Asia and Latin America. The UN low variant projection (with fertility a half birth below the medium variant) estimates a population of 2.7 billion in 2100. This low variant could well be achieved with substantial new investments in family planning to meet a rising demand for contraception as desired family size declines. In that case, the population of SSA in 2100 would be nearly 2.5 billion lower than projected in the UN high variant and 1.1 billion below the medium variant. Clearly, a small reduction in fertility (1 birth per woman) has a large impact on future population growth (2.5 billion).

Population projection variants, Sub-Saharan Africa (United Nations, 2019 )

The alternative UN population projections also differ in their associated age distributions. Figure  7.15 plots the proportion of working age people for each projection variant in SSA. As expected, the high variant (with the highest fertility) has a much lower pace of increase in this proportion than the low variant. The peak of the dividend period occurs in the next few decades with the dividend about twice as large in the low than in the high variant.

Percent of population aged 18–64, Sub-Saharan Africa (United Nations, 2019 )

The main conclusion from this exercise is that small differences in fertility trends can cause large differences in future demographic trends. Family planning programs can bring about fertility declines of about 1.5 births per woman; thus, they can potentially have a large impact on population size and age structure in future decades.

7.6 Critics of Family Planning Programs

As discussed in Chap. 5 , the literature on the fertility impact of family planning programs has been contentious. The most detailed and influential of these critiques was published in 1993 by Lant Pritchett. In contrast to earlier critiques (Davis, 1967 ; Demeny, 1979 ; Hauser, 1967 ) Pritchett undertook extensive analyses of reproductive statistics that had been gathered in World Fertility Survey and DHS up to about 1990.

To assess the separate roles of socio-economic development and family planning programs Pritchett examined the available empirical evidence on levels of wanted and unwanted fertility in a large number of developing countries. His main findings were that there is a strong—about one to one—correlation between wanted fertility (WTFR) and the TFR, but no significant correlation between unwanted fertility (UWTFR) and TFR. He drew several conclusions:

a)  “Excess” or “unwanted” fertility plays a minor role in explaining fertility (Pritchett, 1994 : 34)

This claim has been found problematic in several subsequent studies (Bongaarts, 1994 , 1997 , 2011 , 2020 ; Casterline, 2009 ; Lam, 2011 ). The central flaw in Pritchett’s analysis was its reliance on cross-sectional data because in the early 1990s relatively few countries had repeated fertility surveys. As the number of surveys has grown in the 1990s and 2000s an increasing number of countries have at least two surveys, thus allowing the estimation of actual changes over time in fertility indicators.

Figure  7.16 presents an updated decomposition of the change in the TFR into wanted and unwanted components. Footnote 3 The trends are derived by comparing fertility estimates from the earliest and latest available DHS surveys (on average from 1996 to 2014) in 54 countries from Bongaarts ( 2021 ).

Average decline in TFR, and its wanted and unwanted components between first and last DHS surveys after 1990 (Bongaarts, 2021 )

Key findings:

The average decline in the TFR (0.84) for all countries substantially exceeds the decline in the wanted TFR (0.51). This finding is contrary to Pritchett expectation of approximately equal changes in the wanted TFR and total TFR. The same is true for the regional estimates.

The average unwanted TFR for all countries declined by 0.34 (from 1.0 to 0.66), while Pritchett predicted constant unwanted fertility. The decline in the unwanted TFR accounts for 40% of the decline in the TFR in all countries. This is consistent with the findings of Casterline (2010), Lam ( 2011 ) and Günther and Harttgen ( 2016 ).

Substantial differences exist between regions: the contribution of decline in the wanted TFR is much larger in Asia/N.Africa/L.America (65%) than in SS Africa (14%).

These findings demonstrate that the declines in unwanted fertility over time play an important role in reducing overall fertility.

b)  If improved family planning programs were driving fertility declines, they should be accompanied by a reduction in excess fertility. This is not the case (Pritchett, 1994 : 34).

This statement ignores the rise in the exposure to the risk of unwanted pregnancies that occurs as desired family size declines. As discussed in the previous section, in the absence of contraception, a decline in desired family size would be accompanied by a roughly equivalent rise in unwanted/excess births because women have three decades of potential reproductive years when they are usually sexually active and biologically capable of getting pregnant. In reality, such huge increases in unwanted fertility are not observed because women practice contraception, but unwanted births nevertheless occur because of the obstacles to contraceptive use and because of contraceptive failure. Family planning programs reduce but do not eliminate these obstacles. As a result, a substantial impact of family planning programs is consistent with a non-declining level of unwanted fertility in the early phases of the fertility transition.

c) In his discussion of the Matlab experiment Pritchett admits its large impact on contraceptive use and fertility, but then claims: “ The fertility changes were large not because fertility was particularly responsive to program intervention but because the effort was massive and expensive. This program expense makes it unlikely that this degree of effort will be replicated at a national scale in Bangladesh, or in any low-income country .” (Pritchett, 1994 : 36)

This statement is incorrect as demonstrated by the experience of Bangladesh and several other poor African countries such as Ethiopia, Malawi and Rwanda. Once the success of the Matlab project became known around 1980, the government of Bangladesh implemented a nationwide program based on the lessons from this experiment. As shown in Fig.  7.2 the country’s modern contraceptive use rose rapidly and reached 27% in 1990 and 54% in 2015, well ahead of the mCPR in Pakistan. Another demonstration of the impact of the introduction of a nationwide family planning program is found in Iran. As documented in Chap. 2 Iran had the most rapid fertility decline in the developing world with the TFR declining from above 6 in 1986 to below 2.5 in 1997. Socio-economic indicators improved during this period, but not at an extraordinary rate. The most plausible main explanation for Iran’s rapid fertility decline is the introduction of a family planning program around 1990 (Roudi-Fahimi, 2002 ).

d)  fertility desires are largely determined by socio-economic forces other than family planning and .. fertility desires determine fertility (Pritchett, 1994 : 19). In the conclusion: “we have focused ..on the importance of desired fertility in explaining fertility variations and on the relatively small independent role of contraceptive access (or family planning programs more generally) . (Prichett, 1994 : 41)

These statements reveal two common but erroneous assumptions made by Pritchett and other critics. First is the suggestion that family planning programs are only about access to contraceptive supplies. Earlier in this chapter we discussed the many other obstacles that face potential users of contraception and the key role family planning programs play in addressing these obstacles. Access is of course part of the reason for unplanned pregnancy, but family planning programs have much broader objectives. The second problem with the above statement is that Pritchett assumes that family planning programs have no effect on wanted fertility. As argued above, fertility preferences are affected by media campaigns implemented by programs and by statements from government officials. The evidence presented in the regression analyses summarized in Tables 7.1 and 7.2 document the important role of family planning programs as a determinant of demand for contraception and on wanted fertility (see also Bongaarts, 2011 ).

In short, Pritchett’s influential analysis is seriously flawed. He correctly concluded that fertility preferences are a key driver of fertility declines. But his claims that unwanted fertility is nearly constant and that family planning programs have trivial effects are incorrect.

7.7 Conclusion

This chapter examined the long-standing debate about the extent to which family planning programs influence contraceptive behavior and fertility. Three sources of evidence were examined: (1) controlled experiments; (2) natural experiments; and (3) statistical analyses. The three sources provided broadly comparable estimates of the impact of a family planning program i.e., a rise of 25–35% in contraceptive prevalence and a decline of 1.5 births per woman in the TFR. The regression analysis was also used to examine the effects of family planning programs on contraceptive demand and its satisfaction, and on wanted and unwanted fertility. As expected, family planning programs increase the satisfaction of the demand for contraception and reduce unwanted fertility. Contrary to common assumptions made in economic theories of fertility, family planning programs also have a substantial impact on the demand for contraception and on wanted fertility. These findings help explain why family planning programs have been effective in several countries in SSA where desired family size has historically been high relative to other regions in the developing world.

These regression results are slightly different from those presented in Bongaarts ( 2020 ). The main reason for this difference is that Bongaarts ( 2020 ) uses the standard DHS calculation for wanted fertility while the present study relies on a different approach proposed by Bongaarts ( 1990 ).

The difference in population projections is partly due to more rapid future life expectancy improvements in Bangladesh than in Pakistan. The UN’s constant mortality projections yield populations sizes of 344 million for Pakistan and 120 million for Bangladesh. This finding indicates that differences in fertility trends are the dominant cause of differences in population projections to 2100.

Wanted and unwanted fertility is estimated with a procedure proposed by Bongaarts ( 1990 ).

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Bongaarts, J., Hodgson, D. (2022). The Impact of Voluntary Family Planning Programs on Contraceptive Use, Fertility, and Population. In: Fertility Transition in the Developing World. SpringerBriefs in Population Studies. Springer, Cham. https://doi.org/10.1007/978-3-031-11840-1_7

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Measuring family planning quality and its link with contraceptive use in public facilities in Burkina Faso, Ethiopia, Kenya and Uganda

Timothee fruhauf.

1 Department of Gynecology & Obstetrics, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Baltimore, USA

Linnea Zimmerman

2 Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E4531, Baltimore, USA

Simon Peter Sebina Kibira

3 Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, New Mulago Hill Road, Kampala, Uganda

Fredrick Makumbi

4 Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, New Mulago Hill Road, Kampala, Uganda

Peter Gichangi

5 University of Nairobi and Ghent University, Nairobi, Kenya

Solomon Shiferaw

6 Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia

Assefa Seme

Georges guiella.

7 Institut Supérieur des Sciences de la Population, Université Ouaga 1 Pr Joseph Ki-Zerbo, Burkina Faso

8 Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E4546, Baltimore, USA

The individual impacts of several components of family planning service quality on contraceptive use have been studied, but the influence of a composite measure synthesizing these components has not been often investigated. We (1) develop a composite score for family planning service quality based on health facility data from Burkina Faso, Ethiopia, Kenya and Uganda and (2) examine the influence of structural quality on contraceptive practice in these four countries. We used nationally representative cross-sectional survey data of health facilities and women of reproductive age. First, we constructed quality scores for facilities using principal component analysis to integrate 18 variables. Second, we linked women to their closest facility using geo-coordinates. Third, we estimated multivariable logistic regression models to calculate women’s odds ratios for modern contraceptive use adjusting for facilities’ quality and other factors. In Burkina Faso, Ethiopia and Uganda, the odds of using a modern method of contraception was greater if the nearest facility provided high- or medium-quality services compared with low quality in the univariable model. After controlling for possible confounders, the adjusted odds ratios were significant for high quality (aOR: 3.12, P value: 0.005) and medium quality (aOR: 2.57, P value: 0.009) in Ethiopia and in the hypothesized direction but not statistically significant in Uganda or Burkina Faso, and in the opposite direction in Kenya. A process quality measure—having been visited by a community health worker—was statistically significantly associated with modern contraceptive use in three of the four countries (Burkina Faso aOR: 2.18, P value: 0.000; Ethiopia aOR: 1.78, P value: 0.000; Uganda aOR: 1.96, P value: 0.012). These results suggest that service quality in public facilities may be less relevant to contraceptive use in environments where the universe and reach of providers changes actively. Programs promoting contraception therefore need to consider quality within facility types and their service environments.

Key Messages

• Differences in how quality is defined and measured have led to disparate conclusions about the link between family planning service quality and contraceptive use.
• This study constructs a composite measure that synthesizes evidence on the components of family planning service quality and links it with individual level data to explain contraceptive behaviour.
• Unadjusted models show the quality of family planning services in public facilities to be positively associated with the use of modern contraceptive methods and short-acting methods in three of four countries, but once adjusted for covariates, including distance and facility type, quality is positively and significantly associated in Ethiopia only and positively but not significantly in Uganda.
• The quality of family planning services can be an important factor affecting contraceptive use, varying by type of facility and meriting consideration when developing strategies to reduce unmet need for contraception, reach new contraceptive users and sustain current use.

Introduction

The public health benefits of family planning are well documented; links between birth limiting and spacing and reductions in maternal, neonatal and under-five mortality are clear ( Cleland et al. 2006 ; Ahmed et al. 2012 ). Recognizing the importance of promoting such an effective intervention in areas with limited resources, the Family Planning 2020 initiative set the goal of increasing use of modern contraceptives by 120 million additional women in the world’s poorest countries by 2020 ( Brown et al. 2014 ).

Although 38.9 million new contraceptive users were added between 2012 and 2016, significant progress remains to be made ( Family Planning 2020 2017 ). Unmet need for contraception is estimated to be as high as 27.7% for married women in sub-Saharan Africa ( Bradley et al. 2012 ). Considering the role quality of family planning services in meeting those needs is warranted. Quality arose noticeably at the International Conference on Population and Development in Cairo in 1994 as an important factor affecting contraceptive use ( United Nations Population Fund 1994 ). Since then this association has been extensively examined.

Early on, modelling showed that an increase in the number of available methods would indirectly increase contraceptive prevalence by improving acceptance and continuation of use ( Jain 1989 ). However, later studies linking data on quality of services and individual behaviour reported mixed results. In Peru, Mensch et al. (1996) found a weak association between a 3D measure of quality and contraceptive use, but not with an 8D measure of quality. In Morocco, aspects of quality were associated with contraceptive intention, but not contraceptive use ( Magnani et al. 1999 ). In Egypt, continuation rates for the pill were related to the number of trained personnel, access to female physicians and the number of methods available ( Ali 2001 ). In contrast, a later study also in Egypt found that a 4D quality index was associated with the use of an intrauterine device ( Hong et al. 2006 ). In Tanzania, information provided to clients and technical competence were associated with contraceptive use ( Arends-Kuenning and Kessy 2007 ). Quality of care at initiation of services was linked to continuation of use in the Philippines ( RamaRao et al. 2003 ). Finally, a panel study in Bangladesh showed that women who perceived the quality of their care to be higher were more likely to subsequently adopt and continue using a method ( Koenig et al. 1997 ). The magnitude of the association between quality of family planning services and contraceptive use is not clear, but many studies indicate that certain elements of quality can influence contraceptive behaviour ( RamaRao and Mohanam 2003 ). Reducing unmet need, reaching new users and maintaining use therefore require some attention to quality.

These differences in findings are largely due to differences in defining and measuring quality. Two frameworks initially laid the foundation for defining quality. In 1966, Donabedian defined quality as resulting from three components: structure (infrastructure and equipment, management, availability of services, counselling), process (interpersonal and technical) and outcome (client satisfaction) ( Donabedian 1966 ). This framework has since been critiqued for excluding some contextual factors tied to healthcare providers and client characteristics ( Coyle and Battles 1999 ). In 1990, Bruce established a new framework specific to family planning. Six factors were identified as critical for patients: choice of method, information given to clients, technical competency of providers, interpersonal relations, follow-up mechanisms and appropriate constellation of services ( Bruce 1990 ). Later in 1993, the International Planned Parenthood Federation added the perspective of providers by establishing the tools needed for providers to provide quality care to their clients ( Huezo and Diaz 1993 ). Since then, suggestions have been made to expand the scope of quality to include other aspects of reproductive health care, the existence of formal standards for quality, the effects of gender relations on care and factors that modify access to services such as distance, provider attitudes and eligibility criteria. While these frameworks have grounded many of the studies on the quality of family planning, their focus differs and no effort has been made to reconcile them. On the contrary, these multiple perspectives have allowed researchers to select individual aspects of quality, often yielding disparate conclusions about the link between quality and contraceptive use ( RamaRao and Mohanam 2003 ; Tumlinson 2016 ).

A recent literature review on the quality of family planning care in sub-Saharan Africa by Tessema et al. (2016 ) synthesizes the different factors that have been linked to quality, as measured through client satisfaction. Their analysis largely tracks the Donabedian framework and serves as the foundation for the conceptual framework for this study ( Figure 1 ). Factors that affect the quality of family planning can be categorized into three pillars according to this literature review: (1) client, provider and facility characteristics, (2) structural factors and (3) process factors. First, socio-demographic characteristics included age and education status of the client. Second, structural factors included staffing, convenience of available services, cleanliness, infrastructure, contraceptive method-mix and stock, equipment and supplies and fees. Third, process factors included provider–client interactions, confidentiality, client waiting time and eligibility requirements. The review finds client characteristics ( Agha and Do 2009 ; Hutchinson et al. 2011 ; Tafese et al. 2013 ), and the provider’s years of experience ( Agha and Do 2009 ) linked to family planning quality. Similarly, structural factors and facility characteristics such as staff levels, private or public ownership and geographic location, and process factors, such as waiting time, counselling and confidentiality, were tied to quality ( Hutchinson et al. 2011 ; Tafese et al. 2013 ; Wang et al. 2014 ).

Conceptual framework

Despite acceptance of these multifactor frameworks, studies about quality of family planning often select certain aspects of quality or use proxy measures rather than measuring quality as a composite concept. Building on the wealth of data about the variables that affect quality, and in particular the latest synthesis by Tessema et al. (2016) , this study uses a dimensionality reduction technique to quantify a composite measure of quality on the basis of this evidence. This approach has been used to measure other notions that are difficult to attribute to a single factor (such as household wealth) and appear better suited to reliably assess quality given the multifactorial nature of family planning quality ( Creel et al. 2002 ; Vyas and Kumaranayake 2006 ; RamaRao and Jain 2016 ; Tumlinson 2016 ).

Accepted tools to measure family planning quality in resource-poor settings have typically included the Service Provider Assessment Survey (SPA) implemented by ORC Macro International and the Quick Investigation of Quality (QIQ) survey ( MEASURE Evaluation 2016 ). Both include provider interviews, client exit-interviews, provider–client observations and facility audits to obtain a complete overview of family planning. However, these data sets are limited in their ability to examine individual behaviour. Some studies have linked facility data from the SPA and individual level data from the Demographic and Health Surveys (DHS) ( Wang et al. 2012 ). However, this is done at the cluster level rather than by individually linking every female respondent to specific facilities due to limited geographic information system (GIS) data; furthermore the SPA and DHS are not typically fielded at the same time additionally limiting inferences. These methodological limitations have previously been identified by researchers and cited as impediments to quantifying the effect of quality on individual contraceptive behaviour ( Mensch et al. 1996 ; Hutchinson et al. 2011 ).

This study uses data from Performance Monitoring and Accountability 2020 (PMA2020), a new multi-country platform that surveys female respondents and facilities about family planning with a similar scope to the SPA and QIQ ( Zimmerman et al. 2017 ). However, PMA2020 facility and individual level data are collected at the same time and can be linked using GIS data at the individual level. This study is therefore able to analyse associations between the service provision environment and female contraceptive behaviour.

The objective of this study is to determine if the quality of family planning service provision influences the contraceptive behaviour of women in four sub-Saharan countries: Burkina Faso, Ethiopia, Kenya and Uganda. More specifically, it was hypothesized that the higher the quality of family planning provided at the nearest facility, the more likely a woman was to use a modern method of contraception. To examine this link, a composite measure of quality was first created for public facilities offering family planning services and each facility was attributed a quality score. The composite score for each public facility was then linked to sampled female respondents for whom the nearest facility was that public one. The relationship between the quality of that nearest facility and the woman’s modern contraceptive use or her use of short acting methods was then examined.

Materials and methods

Data and sampling.

Two data sets from PMA2020 were used for each country: a survey of facilities referred to as service delivery points (SDPs) and a survey of women of reproductive age. PMA2020 is a multi-country project that collects a nationally representative sample of data from women aged 15–49 years among selected households and SDPs every six months to one year. Questionnaires are standardized and data are comparable across countries. The female questionnaire collects information on socio-demographic characteristics, reproductive preferences including birth history and contraceptive knowledge, use, history and intention. The SDP questionnaire focuses on facility characteristics, available services, staffing, infrastructure and the provision of family planning services including the availability of contraceptive methods, integration of services and observation of the exam room for family planning visits.

For each country, PMA2020 interviews a probability sample of females 15–49 years and a probability sample of SDPs. A two-stage cluster sampling design is used with enumeration areas (EAs), selected from a frame based on the last census, as the primary sampling unit and households as the secondary sampling unit. Enumeration areas are randomly selected by the country statistical agency within defined strata and all households are listed and mapped. Thirty-five households are randomly selected from the listing—more if the average number of eligible women per household is low—and their occupants enumerated. All women 15–49 years in the selected households are then consented to be surveyed. The four country samples of females for this study are all nationally representative. SDPs are selected on the basis of the probability sample of EAs thereby representing SDPs accessible to the female population in each EA. In all selected EAs, up to three private SDPs are randomly selected and surveyed. In addition, public SDPs for the three lowest levels of care from tertiary to primary SDPs (typically, the health post, intermediate health centre and district or referral hospital) assigned to each selected EA are interviewed. The SDP sample thus is representative of the service environment accessible to the female sample.

This analysis is based on data from four countries’ PMA2020 surveys between late 2015 and mid 2016: Burkina Faso (March–May 2016); Ethiopia (March–April 2016); Kenya (November–December 2015); and Uganda (April–May 2016). The estimation of the composite quality measure was restricted to public SDPs offering family planning services for which information on a set of theoretically relevant factors was available in all four countries. The quality score could not be calculated for private SDPs for which quality-relevant data was not collected. As a result, the influence of the quality of the service provision environment on contraceptive behaviour was only studied among women for whom the nearest SDP (shortest distance between household and facility) was public. The majority of modern contraceptors in these four countries access public facilities for their methods, however: nearly 60% in Uganda, 72.1% in Kenya, 79.5% in Ethiopia and 85.1% in Burkina Faso. More importantly, among women whose closest facility was public, most contraceptors sourced their method from a public facility: 65.5% in Uganda, 74.8% in Kenya, 96.1% in Ethiopia and 86.5% in Burkina Faso. Furthermore, private facilities are geographically concentrated in urban cities and towns. The nearest facility offering family planning services to women is more likely to belong to the public, rather than private, sector ( Pomeroy et al. 2010 ; Campbell et al. 2015 ). Public facilities also offer contraceptive methods freely, which in these low-income settings and particularly for rural users, is an attractive option ( National Research Council Panel on Reproductive Health 1997 ). Thus, while facilities in the private sector are important, and increasingly so, the public sector remains a main source for contraceptive information and services. The analysis only included women defined as usual household members and who slept in the house the night before. Table 1 provides the sample sizes. Missing data was highest for the availability of handwashing stations in Burkina Faso ( n  = 9, 8.1%), Ethiopia ( n  = 11, 2.8%) and Kenya ( n  = 6, 2.2%). In Uganda, missing data was highest ( n  = 12, 5.3%) for protection of family planning methods from water, sun and pests.

Survey dates and sample sizes in the four study countries

SDP, service delivery point; FP, family planning.

Eighteen variables from the SDP data set were included to build a composite measure of quality for public SDPs offering family planning services. These variables were selected on the basis of the conceptual framework ( Figure 1 ) informed by research literature. As this study focused on building a measure of service quality using data from SDPs, client characteristics were not included. Similarly, facility characteristics (i.e. public or private ownership and geographic location) were not relevant because the analysis was restricted to public SDPs.

Among the structural factors, the variables included the total number of healthcare staff, whether an SDP supports community health volunteers (CHVs), the number of days per week during which family planning services are offered, two variables assessing cleanliness (presence of clutter or dirt in the examination room and storage of contraceptive supplies away from water, sun, pests and off the floor), whether an SDP was visited by a supervisor in the past six months, whether water and electricity were available on the day of the survey, whether staff had access to handwashing stations, whether fees were charged for family planning services, the total number of contraceptive methods provided, whether an SDP offers long-acting reversible contraceptive (LARC) methods, whether any of the methods provided were out of stock in the past three months, and the total number of supplies observed as available in the examination room. The staffing variable was transformed to the log scale to assure normality and included all healthcare personnel, their titles differing by country. Not all countries were asked about the same contraceptive methods. The list of supplies in the exam room was standardized on the basis of the SPA. Variables representative of process factors included whether an SDP provides visual and auditory privacy in the examination room, has a system to collect, review and report on client opinions, prescribes, counsels on and provides family planning services to unmarried adolescents, and provides post-abortion services.

The primary predictor used to assess the influence of quality on contraceptive use was the quality tertile (low, medium or high) of the nearest public SDP offering family planning for each woman. The main outcome of interest was the woman’s use of a modern method of contraception (mCPR). The use of a short acting modern method of contraception (short-acting mCPR), defined as injectable, pills, emergency contraception, female or male condoms, was a secondary outcome. The relationship between quality and use of short-acting contraceptive methods is hypothesized to be especially important because short-acting methods usually require multiple client–facility interactions making quality of services at a facility a more relevant factor in the decision to use these methods. Secondly, exploring this relationship by analysing quality at the closest facility is specifically appropriate for short-term methods because of higher frequency of interaction, making proximity a relevant factor. Long-acting methods, such as implants, IUDs and sterilization, require usually only one visit and quality of the closest facility may be less relevant. Thirdly, this analysis only includes public facilities which often support CHVs who conduct family planning community outreach and are only authorized to distribute short-term methods such as condoms and pills ( Scott et al. 2015 ). This activity is rarely sponsored by private facilities. CHW outreach is captured as a process quality measure as the individual woman’s report of having been visited in the past 12 months and included as a covariate.

Other covariates of interest included distance (kilometres) to the nearest public SDP, which was measured continuously on a logarithmic scale with spline functions. Spline terms were used to approximate linearity because log distance did not appear to have a single linear relationship with mCPR. Breakpoints in the spline functions were selected by examining the LOWESS curve of mCPR by log distance and varied by country. Facility type for the nearest public SDP offering family planning was another covariate and was categorized by level of care (from level 1 to 4, with the first level being akin to a district or referral hospital and the lowest being a health post or clinic) and differed by country. Additional individual-level variables served as controls: age, marital status, highest level of education, urban or rural place of residence and household wealth quintile for each woman.

The composite quality measure was constructed by country using principal component analysis (PCA) including 18 variables selected on the basis of the conceptual framework. These variables were normalized and coded with similar valence (e.g. larger values for continuous variables and higher categories for categorical variables were associated with higher quality). The same variables were included for all countries unless the SD was null. The factor loadings for the principal component that explained the highest proportion of the variance in each SDP sample were used as weights to calculate a normalized SDP quality score. The quality score was categorized by tertile and each public SDP classified as low, medium and high quality by country. Cronbach’s alpha was calculated as a measure of consistency for the variables included in the factor analysis.

To study the influence of quality on contraceptive use, we matched women whose nearest SDP was public to that facility and treated the latter facility’s characteristics as representing the woman’s service environment. The geo-coordinates of the household and SDP were used to calculate the minimum straight-line distance to determine nearest. This approach assumes that the closest service provision environment captures the health system’s strength in contraceptive access and can affect women’s’ contraceptive behaviours. Univariable and multivariable logistic regression models are used to calculate the odds ratios (ORs) and adjusted odds ratio (aORs) of using a modern method of contraception or a short-acting modern method of contraception. Variance inflation factors (VIF) were calculated for all covariates to assess multicollinearity. P values with alpha of 0.05 and 0.01 are reported. Weighted results are reported to account for the stratified two-stage cluster sampling design and the variances of the covariates are adjusted accordingly. Missing values were handled using listwise deletion. Data analyses were performed with Stata 12.1 (College Station, TX: StataCorp LP).

A composite measure of quality

The characteristics of the samples of public SDPs offering family planning services are presented in Table 2 for the four study countries. On an average, 111 SDPs in Burkina Faso offered 7.6 methods (SD: 1.3) on 6.8 days/week (SD: 0.5) and had a total log staff size of 3.6 (SD: 1.4). SDPs varied most with respect to support to CHVs ( n  = 46, 42.2%), exam room cleanliness ( n  = 70, 64.2%), water availability ( n  = 70, 63.1%), absence of stock outs for all methods provided ( n  = 77, 69.4%) and availability of family planning services for unmarried adolescents ( n  = 72, 64.9%). On an average in Ethiopia, 388 SDPs offered 6.5 methods (SD: 1.6) on 5.4 days/week (SD: 1.0) and had a total log staff of 2.9 (SD: 1.6). The most variation was recorded for support to CHVs ( n  = 109, 28.1%), exam room cleanliness ( n  = 53, 13.7%), availability of electricity ( n  = 210, 54.1%), water ( n  = 194, 50.0%) and handwashing stations ( n  = 297 78.8%), absence of stock outs ( n  = 217, 55.9%), service provision to unmarried adolescents ( n  = 175, 45.1%) and post-abortion ( n  = 285, 73.5%). On an average, 267 SDPs in Kenya offered 6.9 methods (SD: 1.5) on 5.2 days/week (SD: 0.6) and had a total log staff size of 2.2 (SD: 1.3). SDPs varied most in their support of CHVs ( n  = 137, 51.3%), water availability ( n  = 186, 69.7%), absence of stock outs ( n  = 146, 54.7%) and provision of services to unmarried adolescents ( n  = 152, 56.9%) and post-abortion ( n  = 176, 65.9%). On an average in Uganda, 228 SDPs offered 5.6 methods (SD: 2.3) on 5.5 days/week (SD: 1.2) and had a total log staff of 2.7 (SD: 1.1). Most variation was recorded for support to CHVs ( n  = 134, 58.8%), electricity ( n  = 140, 61.4%) and water ( n  = 103, 45.2%) availability, provision of LARC methods ( n  = 150, 65.8%), absence of stock outs ( n  = 54, 23.7%) and provision of services post-abortion ( n  = 158, 69.3%) and to unmarried adolescents ( n  = 161, 70.6%).

Sample characteristics of public service delivery points offering family planning in the four study countries

SDP, service delivery point; FP, family planning; SD, standard deviation; CHV, community health volunteer.

Using PCA, we identified the first component explaining the most variance among SDPs for the 18 included variables by country ( Table 3 ). The first component explained 78.9% of the variance in Ethiopia, 63.4% in Uganda, 45.7% in Kenya and 42.1% in Burkina Faso. Cronbach’s alpha values ranged from 0.60 (Burkina Faso) to 0.75 (Ethiopia). Factor loadings differed by country, but there were common trends. Staffing was the highest or second highest loading variable in all countries (0.7546–0.8713). The total number of contraceptive methods (0.4929–0.8535), the availability of water (0.4504–0.6784) or electricity (0.3516–0.6339), and the provision of post-abortion services (0.4594–0.6354) also consistently loaded highly across the four countries. In Ethiopia the provision of family planning services free-of-charge, in Kenya the number of supplies in the exam room and in Uganda the provision of LARCs also had high loadings. For each SDP, a normalized quality score was calculated on the basis of the loadings for the first principal component by country. The distribution and estimates by tertile are presented in Figure 2 .

Principal component analysis for the quality score for public service delivery points offering family planning in the four study countries

PC, principal component; SDP, service delivery point; CHV, community health volunteer; FP, family planning.

– represents no variation in variable (i.e. 100% of SDPs in one category), variable was dropped from the PCA.

Quality scores for public SDPs in four countries

The influence of quality on contraceptive use

The characteristics of women 15–49 years whose nearest SDP was public are reported in Table 4 . In Burkina Faso, 20.8% of women 15 to 49 years reported using a modern method of contraception (the modern contraceptive prevalence rate or mCPR) and 11.6% a short acting method. For almost two-thirds of women ( n  = 1897, 66.8%) their nearest SDP scored low on quality, with 624 (22.0%) women close to a medium-quality SDP, and 317 (11.2%) close to a high-quality SDP. Most women lived nearest to health and social promotion centres ( n  = 2529, 84.6%) followed by medical centres ( n  = 405, 13.6%). In Ethiopia, the mCPR was 26.1% and short-acting CPR was 20.1%. For more than the majority of women ( n  = 3892, 58.6%) the nearest public SDP provided family planning services of low quality; 1863 (28.1%) and 887 (13.4%) women lived nearest to an SDP providing family planning services of medium and low quality, respectively. Approximately half lived closest to a health post ( n  = 3442, 50.5%) and 3082 (45.2%) to a health centre. In Kenya, 44.8% of women reported using a modern method and 30.7% were using a short acting method. The quality of the nearest public SDP was more equitably distributed with 1071 (35.0%), 1173 (38.3%) and 821 (26.8%) women living close to an SDP providing low, medium- and high-quality family planning services, respectively. The closet public SDP was a pharmacy for the majority of women ( n  = 1757, 56.3%), followed by a health centre ( n  = 932, 29.9%) and a hospital ( n  = 391, 12.5%). In Uganda, the mCPR was 24.2% and short-acting CPR was 19.3% among women 15–49 years. Slightly less than half ( n  = 798, 48.3%) of women lived near a low-quality SDP, 670 (40.6%) closest to a medium-quality SDP, and 183 (11.1%) closest to an SDP providing high-quality family planning services. Most women ( n  = 769, 42.5%) lived closest to the lowest level (level two) health centre, followed by 667 (36.8%) for level three health centres and 269 (14.8%) for level four health centres. Only 106 (5.8%) women had their closest SDP being a district hospital. The percent of women reporting being visited by a community health worker in the past year ranged from 10.7 in Kenya to 18.2 in Ethiopia.

Sample characteristics of women 15–49 years whose nearest service delivery point offering family planning is public in the four study countries

mCPR, modern contraceptive prevalence rate; SDP, service delivery point; FP, family planning.

– represents category not defined in this country.

Facility types by country: Burkina Faso: 1) Hospital and polyclinic, 2) Medical centre, 3) Health and social centre, 4) Pharmacy; Ethiopia: 1) Hospital and polyclinic, 2) Health centre, 3) Health post; Kenya: 1) Hospital, 2) Health centre, 3) Health clinic, 4) Pharmacy; Uganda: 1) Hospital, 2) Health centre 4, 3) Health centre 3, 4) Health centre 2.

The quality of family planning services in public SDPs was positively associated with modern contraceptive use in Burkina Faso, Ethiopia and Uganda in the univariable analysis ( Table 5 ). In Burkina Faso the odds for women using modern methods of contraception was significantly higher if they lived closest to a public SDP providing high-quality family planning services than one providing low-quality services (OR = 1.91, P  < 0.000). In Ethiopia, the odds of using modern contraception were significantly greater among women who lived closest to a medium-quality SDP compared with women who lived closest to a low-quality SDP (OR = 1.39, P  = 0.037). After adjustment for control covariates, the relationship strengthened and remained statistically significant in Ethiopia ( Table 5 ). The odds of using modern contraception were 2.57 ( P  = 0.009) times higher among women living closest to an SDP providing medium-quality services compared with women living closest to an SDP providing low-quality services. The odds of using contraception were even higher for women living closest to a high-quality SDP than a low-quality SDP (aOR = 3.12, P  = 0.005).

Unadjusted and adjusted a ,b odds ratio from logistic regression of modern contraceptive use on selected covariates in four study countries

SDP, service delivery point; FP, family planning; OR, odds ratio; aOR, adjusted odds ratio.

The relationship was reversed in Kenya: the adjusted odds of contraceptive use were unexpectedly lower among women who lived closest to a facility providing high-quality family planning services compared with women living closest to a low-quality facility (aOR = 0.53, P  = 0.008).

Being visited by a community health worker in the past year was significantly and positively associated with the odds of using modern contraception in three countries—Burkina Faso (aOR = 1.71, P  = 0.003), Ethiopia (aOR = 1.72, P  = 0.000) and Uganda (aOR = 1.99, P  = 0.018)—suggesting outreach serves as an important predictor of process quality.

Distance to the nearest SDP measured with spline functions and two spline breakpoints captured significant change in the slopes of the SDP’s distance in relation to use in Burkina Faso and Kenya but not Ethiopia and Uganda. The second spline breakpoint in Burkina Faso and Kenya had higher aORs than the first suggesting that women living far from an SDP in these countries may be making greater effort to use contraception.

The main contraceptive methods used in all four countries were implants, injectables, pills and male condoms, with injectables dominating the method mix in all countries except Burkina Faso where implants were the most used method ( PMA2020 2017 ). As visible from Table 4 , short-acting method use comprises the majority of contraceptive prevalence for this sample as well. When restricting the outcome to short-acting modern contraceptives, quality was positively associated with contraceptive use in Burkina Faso, Ethiopia and Uganda and negatively associated in Kenya in the univariable analysis ( Table 6 ). This relationship remained significant in the multivariate analysis in Ethiopia: women who live closest to a medium-quality SDP or a high-quality SDP had 2.48 or 2.94 greater odds of using a short-acting method of contraception, respectively, than women living closest to an SDP providing low-quality family planning services (aOR = 2.48, P  = 0.003; aOR = 2.94, P  = 0.006). In Burkina Faso, women who lived closest to a medium-quality SDP had lower odds of using short-acting contraceptives compared with women living nearest to an SDP providing low-quality services (aOR = 0.52, P  = 0.019). Similarly, in Kenya, the odds of using a short-acting contraceptive were lower among women living closest to a high-quality SDP compared with a low-quality SDP after adjusting for covariates (aOR = 0.63, P  = 0.048). Sensitivity analyses including all nearest SDPs regardless of their managing authority (public vs private) revealed no change in regression modelling for modern contraceptive use or short-acting contraceptive use. Similarly, restricting the models to include only contraceptive users showed no change (results not shown).

Unadjusted and adjusted a ,b odds ratio from logistic regression of short acting modern method use on selected covariates in four study countries

Service quality at the nearest SDP tended to show the same associations for women’s use of modern contraception as with their use of a short-acting method. There was a slightly stronger relationship in Burkina Faso where the aOR associated with medium, compared with low, quality declined in magnitude from 0.69 to 0.52 and became statistically significant ( P  = 0.019). The spline terms for distance had similar aOR values for the short-acting method use model as they did for the overall modern method use model.

As with any modern method of contraception, women who were visited by a CHW in the past 12 months were significantly more likely to use short-acting modern method of contraception in Burkina Faso (aOR = 2.18, P  = 0.000), Ethiopia (aOR = 1.78, P  = 0.000) and Uganda (aOR = 1.96, P  = 0.012) but not in Kenya.

Because of the relatively lower variance explained by the first component of the PCA for Burkina Faso and Kenya, we also constructed a second quality score for these countries based the second component ( Table 3 ). This component explained another 24.8% of the variance in Burkina Faso and 36.7% in Kenya. However, high loadings were limited to two items in Burkina Faso—whether an SDP offers post-abortion services and handwashing stations—and three items in Kenya—the number of contraceptive methods provided, the cleanliness of the exam room, and whether an SDP supports CHVs. Once divided into tertiles and included in the multivariate analysis, quality as measured by the second component was not significantly associated with either outcomes (results not shown).

This study first attempts to quantitatively measure quality of family planning services in four countries by synthesizing multiple factors identified in the literature into a composite index using PCA. The quality score constructed explains a large proportion of the variance across the four SDP samples. Whether with one or two factors, the proportion of variance explained ranged from 63.4% to 82.4% and Cronbach’s alpha values of internal consistency were high. Second, the study examines the relationship between service quality and contraceptive behaviour by linking health facilities and women. Most importantly, this study shows that is possible to create an index of quality with the same underlying variables to facilitate comparisons and assess patterns of associations with individual level contraceptive outcomes across different settings.

The need for a composite measure of quality is evidenced by the multiple elements that are typically listed in accepted frameworks on family planning quality. These frameworks adopt different perspectives that need to be integrated to achieve a complete understanding of quality. Much attention has been paid to the six components of quality detailed by the Bruce framework ( Bruce 1990 ) from the client’s perspective and the three categories characterized by the Donabedian framework ( Donabedian 1966 ) that mix provider and client approaches. However, many researchers have pointed out elements excluded by these frameworks or conduct studies focused on just one element. On the basis of the components identified in the latest systematic review by Tessema et al. (2016) , this study creates a quality score able to integrate across multiple perspectives and approaches.

Notably, many of the variables that were given the highest loading or weight across countries on the basis of the first principal component were structural in nature (staffing, family planning methods and functionality represented by water and electricity availability) and elements tied to process had lower weights with the exception of provision of post-abortion services. Several studies have emphasized the breadth of methods available as one of the most important aspects of quality suggesting that facilities offering more methods may be of higher quality ( Magnani et al. 1999 ; Ali 2001 ; Blanc et al. 2002 ; Mugisha and Reynolds 2008 ; Tafese et al. 2013 ; RamaRao and Jain 2016 ). Indeed, studies often reach conclusions on service quality on the basis of the method mix offered by facilities ( Steele et al. 1999 ; Ali 2001 ; Hancock et al. 2015 ). The number of methods available was found in this study to have a consistently high loading across the four countries, empirically underscoring the importance of offering multiple methods, especially as this relates to supporting continued use of contraception. However, there remains a need to measure quality from multiple angles, particularly from clients, and the findings from this analysis establish a place for a composite index of service quality.

Moreover, this analysis overcomes the empirical constraint of maximum variation in individual behaviour that can be explained when quality is measured at the cluster level by linking every woman individually to her closest public service provision environment. In linking each woman to her nearest facility, this approach also avoids restricting the analysis to the behaviour of contraceptive users, a constraint that affects studies measuring both quality and contraceptive use through client samples. Finally, this analysis also overcomes some of the selection biases that affect studies that rely on interviews of facility users to measure the quality of those same facilities.

This study found a positive association between the quality of the public family planning service provision environment and contraceptive use in Burkina Faso and Ethiopia at the univariable level. However, after adjusting for distance, facility type and other common covariates at the individual- and facility-level, service quality was only significantly and positively associated with a woman’s odds of contraceptive use in Ethiopia while positively but not with statistical significance in Uganda. While prior studies have addressed quality and contraceptive use, direct comparison of their findings to this analysis is difficult due to methodological differences in measuring quality and the multilevel nature of this study’s data. Nevertheless, the regression analysis provides additional evidence regarding the importance of the quality of services for overall contraceptive use and short-acting method use, in the same direction as the most recent studies linking facility and individual data on intrauterine device use in Egypt ( Hong et al. 2006 ), modern contraceptive use in Tanzania ( Arends-Kuenning and Kessy 2007 ), continuation of pills or injectables in Nepal ( Gubhaju 2009 ), and uptake of modern contraception at follow up in the Philippines ( RamaRao et al. 2003 ).

The study found that quality of family planning services in public facilities was inversely related to contraceptive use in Kenya. This unexpected observation most likely reflects the growing importance of LARCs, particularly implants, and the exclusion of private sector SDPs from the analysis. Indeed, in the core PMA2020 survey of women of reproductive age, 35% of them were found to purchase their method of contraception from a private facility and among women living closest to a public facility, 25% obtained their method from a private source. As a result, analysing the public service provision environment in isolation provides a necessary but partial perspective on understanding the contraceptive behaviour of women in Kenya. The growth of the Kenyan private sector and the development of informal provider or social marketing systems that often deliver implants and injectables ( Agha and Do 2009 ) has resulted in an increase in provider density that may require reconsidering the assumption that the service provision environment affecting use is defined by the nearest facility, even if private facilities were considered in the analysis. This shifting provision environment may also modify the expected relationship between its quality and contraceptive use.

The composite score accounts for facility-level structural factors affecting service quality. Including a woman’s visit from a CHW in the model allows for assessing public outreach services and accounts for an aspect of health system process quality measured at the individual level. CHW visits were significantly associated with use of modern and short-acting methods in Burkina Faso, Ethiopia and Uganda, but not in Kenya, and excluding the variable did not alter the quality score’s association with use (results not shown). This further reinforces the association identified between the quality score and contraceptive use, whereby the actual relationship between public service features and individual consumption is more nuanced than commonly perceived.

Several limitations of the analysis are to be noted. First, inferences about selected factors’ influence on the likelihood of contraceptive use are limited by the cross-sectional nature of the survey data. This design does not provide the needed temporality to establish causal effect of the quality of services on contraceptive behaviour. The study does, however, benefit from the absence of temporal ambiguity, present when facility and household surveys happen independently in time, given the identical period in which the facility and individual surveys were conducted by PMA2020. Secondly, generalizability of the findings is restricted to public facilities in Burkina Faso, Ethiopia, Kenya and Uganda and women for whom public facilities were the closest. The share of facilities that the sample of public SDPs represents differs by country and is more appropriate in Burkina Faso, Ethiopia and Uganda than in Kenya where the private sector is more developed. Thirdly, individually linking each woman to her closest facility strengthens the study’s ability to measure the effect of quality on individual contraceptive behaviour, but it requires the assumption that the closest service delivery environment influences contraceptive decisions. The study is limited by its inability to link each woman to the actual facility she is using. Finally, the measure of quality incorporates many structural and process variables available in the facility data set but does not capture provider and client characteristics that may influence the quality of services offered by facilities.

This analysis has focused on assessing the role of the quality of family planning services on contraceptive practice, an aspect of fundamental importance for international initiatives that seek to increase contraceptive use. Specifically, it establishes a quantitative measure of quality by building a composite score for public facilities in Burkina Faso, Ethiopia, Kenya and Uganda. The index was also used to examine the effect of quality on contraceptive behaviour by linking data from the closest public facility to the woman’s data and a mixed relationship between quality and modern contraceptive use was found. Structural quality is positively and significantly associated with modern contraceptive use in Ethiopia and only positively but not significantly in Uganda. In Burkina Faso and Kenya, higher public facility service quality was associated with lower contraceptive use but only significant comparing high- to low-quality facilities in Kenya. However, process quality reflected in home visits by CHW, deployed from public facilities, was positively associated with modern contraceptive use in Burkina Faso, Ethiopia and Uganda. The patterns observed in this study may reflect the growing number of providers, including lower-level and informal providers, affecting the density of the service provision environment and perhaps modifying the relationship between facility-level quality and contraceptive use. Developing a quality score for private facilities through replication of the principal component analysis will be a beneficial next step in environments such as Kenya where the service provision environment cannot be summarized by the public sector. This analysis is illustrative of the first steps in creating a comprehensive methodology for the measurement of quality of family planning services in low-resource settings, such as in sub-Saharan Africa. Understanding the impact of family planning service quality on individual contraceptive behaviour continues to challenge the field while guiding programs to focus on it remains an important strategy to reducing unmet need for contraception.

Ethical approval

As a secondary data analysis, this study was determined not to qualify as human subjects research and exempt from requiring approval by the Institutional Review Board of the Johns Hopkins Bloomberg School of Public Health (FWA #00000287).

This work was supported by the Bill & Melinda Gates Foundation under Grant OPP1079004 to the Bill & Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.

Conflict of interest statement : None declared.

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The Philippines has the largest annual population growth rate in Southeast Asia, with family sizes and birth rates that are among the region’s highest. In 2016, two million pregnancies occurred to Filipino women who wanted to wait to have more children or stop having children altogether. Yet, more than two-thirds of married women use less effective, short-acting contraceptive methods, such as pills or condoms.

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Open Access

Peer-reviewed

Research Article

Family planning uptake and its associated factors among women of reproductive age in Uganda: An insight from the Uganda Demographic and Health Survey 2016

Contributed equally to this work with: Anthony Mark Ochen, Che Chi Primus

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Health Services, Alebtong District Local Government, Lira, Uganda

Roles Methodology, Visualization, Writing – original draft, Writing – review & editing

Affiliation KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya

• Anthony Mark Ochen, 
• Che Chi Primus

• Published: December 6, 2023
• https://doi.org/10.1371/journal.pgph.0001102
• Peer Review
• Reader Comments

Despite the government efforts to reduce the high fertility levels and increase the uptake of family planning services in Uganda, family planning use was still low at 30% in 2020 which was the lowest in the East African region. This study was undertaken to determine the prevalence and factors associated with the uptake of family planning methods among women of reproductive age in Uganda. This community-based cross-sectional study utilized secondary data from the Uganda Demographic and Health Survey (UDHS) of 2016. The survey data was downloaded from the Measure Demographic Health Survey website after data use permission was granted. Data was collected from a representative sample of women of the reproductive age group (15–49 years) from all 15 regions in Uganda. A total of 19,088 eligible women were interviewed but interviews were completed with 18,506 women. Data analysis was performed using SPSS statistical software version 32.0 where univariable, bivariable, and multivariable analyses were conducted. The prevalence of family planning use was found to be 29.3% and that of modern contraceptive use was found to be 26.6%. Multivariable analysis showed higher odds of current family planning use among older women (40–44 years) (aOR = 2.09, 95% CI: 1.40–3.12); women who had attained the secondary level of education (aOR = 1.91, 95% CI: 1.32–2.76); those living in households with the highest wealth index (aOR = 1.87, 95% CI: 1.29–2.72); and awareness of the availability of family planning methods (aOR = 1.41, 95% CI: 1.17–1.72). In conclusion, the study suggests improving women’s education attainment, socio-economic position, and awareness may help increase use in the population.

Citation: Ochen AM, Primus CC (2023) Family planning uptake and its associated factors among women of reproductive age in Uganda: An insight from the Uganda Demographic and Health Survey 2016. PLOS Glob Public Health 3(12): e0001102. https://doi.org/10.1371/journal.pgph.0001102

Editor: Claire E. von Mollendorf, Murdoch Children's Research Institute, AUSTRALIA

Received: August 29, 2022; Accepted: November 9, 2023; Published: December 6, 2023

Copyright: © 2023 Ochen, Primus. 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.

Data Availability: The dataset used is openly available upon permission from the MEASURE DHS website (URL. http://www.dhsprogram.com/data/available.datasets.cmf ).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Reducing the number of unplanned pregnancies can be achieved through better birth spacing, as children born less than two years before or after the birth of their siblings have been found to have a higher rate of mortality during their first five years of life [ 1 ]. In addition, it will lower the number of infants born at extremely high mortality risk because their mothers died during or soon after delivery. Uganda has one of the fastest-growing populations in the sub-Saharan Africa (SSA) region at a rate of 3.2% per annum [ 2 ]. It has a persistently high fertility rate of 5.4 children born per woman which is higher than the total wanted fertility rate of 4.3 [ 3 ]. The use of family planning (FP) among women increased from 23% in 2000 to 39% in 2016, however, the increase was most pronounced for the use of modern methods which rose from 18% in 2001 to 35% in 2016 [ 3 ]. The total population of Uganda was 34.6 million persons in 2014 representing an average annual growth rate of 3.0% between 2002 and 2014 [ 4 ]. Uganda aspires to become a middle-income Country by 2025, however, the country has only managed a decline in poverty levels from 24.3% in 2010 to 19.7% in 2015 [ 5 ]. The 2002 health financing strategy estimated that for the sector to be able to provide the Uganda National Minimum Health Care Package, USD 28 per capita expenditure would be required. However, for the Financial Year 2013/14, only USD 12.0 per capita (which includes donor projects and Global Health Initiatives) was available [ 6 ]. The Total Fertility rate in Uganda declined from 7.1 children per woman in 1991 to 5.8 children per woman in 2014 [ 4 ].

The Uganda Demographic and Health Survey (UDHS) 2016 estimates that the total demand for family planning in Uganda among women increased from 58% in 2000–01 to 67% in 2016, and the proportion of demand satisfied by modern methods increased from 18% to 35% over the same period. The unmet need has decreased slightly since 2000, from 35% to 28% in 2016 [ 3 ]. Despite these slight gains, there were still 336 maternal deaths per 100,000 live births and an infant mortality rate of 43 deaths per 1,000 live births [ 3 ]. This poses a great threat to the development and well-being of the Ugandan population as reflected in the high infant mortality rates and maternal mortality ratios. High birth rates not only affect maternal and child mortality but also frustrate governments’ efforts in the provision of social and health services to communities.

The World Health Organisation (WHO) refers to family planning (FP) as a process that allows people to attain their desired number of children and determine the spacing of pregnancies, which is achieved through the use of family planning methods and treatment of infertility [ 7 ]. Of the 1.9 billion women of reproductive age group (15–49 years) worldwide in 2019, 1.11 billion needed to space/cease future pregnancy; of these, 842 million used modern contraception, and 270 million had an unmet desire to space/cease future pregnancy [ 8 ]. The modern contraceptive prevalence among women of reproductive age increased worldwide between 2000 and 2019 by 2.1% from 55.0% to 57.1% [ 8 ]. Some of the sustained preferences for the large family size are a result of limited choice of methods; limited access to services particularly among young, poorer, and unmarried people; fear or experience of side effects; cultural or religious opposition; poor quality of available services; users and providers bias against some methods; and gender-based barriers to accessing services [ 8 ].

The United Nations (UN) estimates the total fertility rate (TFR) of the sub-Saharan Africa region at 4.7 births per woman in 2015–2020 which is more than twice the level of any other world region [ 9 ]. Consequentially, the population of sub-Saharan Africa is expected to grow from 1 billion in 2015 to about 2 billion in 2050 and nearly 4 billion in 2100 [ 9 ]. Therefore, family planning services are voluntary but access to the wide range of contraceptive methods for women to choose from may enhance their health prospects and have comprehensive benefits for their societies’ social and economic development. There are great benefits to investing in family planning including reduced maternal and neonatal mortality through decline in abortions and pregnancies [ 10 ]. For this reason, numerous scholars have pointed out that promoting voluntary access to a wide variety of contraceptive methods for women is an important component of countries’ strategies to advance social and economic development [ 11 , 12 ]. This is well articulated in the Sustainable Development Goals (SDG) 3, target 3.7 calls on countries “by 2030, to ensure universal access to sexual and reproductive health-care services, including for FP, information and education, and the integration of reproductive health into national strategies and programs”; with specifically 3.7.1 which calls for universal access to FP services to ensure healthy lives and well-being [ 13 ].

Despite the government efforts to reduce high fertility levels and increase uptake of FP services in Uganda, the prevalence rate was only 30% in 2020 among married women which was the lowest in the East African region [ 14 ]. The known factors contributing to the low use of family planning methods are multi-factorial and include; limited accessibility to contraceptives, long distance to the health facility, few qualified health experts, fear of side effects, limited male involvement, religion or cultural beliefs, polygamous marriage, and lack of awareness [ 15 – 20 ]. Monitoring factors influencing the uptake of FP services is important to target scarce public resources to those with more need and enhance the progress towards achieving the global targets. Family Planning is central to gender equality and women’s empowerment and is a key driver of all 17 Sustainable Development Goals. Family planning saves lives, improves maternal and child health outcomes, and lifts families out of poverty by helping women have fewer children and freeing them to participate in the labor force [ 21 ]. Furthermore, family planning remains the low-cost, high-dividend investment option for addressing Uganda’s high Total Fertility Rate (TFR), high school drop-out rates as a result of teenage pregnancy, and high Maternal Mortality Ratio (MMR), as well as improving the health and welfare of women and girls including families [ 21 ]. Similarly, the 2020 Demographic Dividend Report demonstrates that investing in family planning will accelerate fertility decline; coupled with mortality decline, the ratio of working-age adults would significantly increase relative to young dependents, thus propelling Uganda towards a middle-income country [ 22 ] Thus far, a recent study that has been published in Uganda only focussed on factors associated with modern contraceptives among female adolescents [ 23 ]. Therefore, this study was undertaken to examine the prevalence and factors associated with the current family planning uptake among women of reproductive age in Uganda using the 2016 Uganda Demographic and Health Survey data.

Methods and materials

Ethics statement.

The survey was approved by the Uganda National Council for Science and Technology (UNCST). Respondents were informed about the survey and informed consent was obtained from participants. The authors received the survey data from the USAID DHS program database after a request to download the dataset was granted. After data access was authorized, the authors of this study maintained the confidentiality of the dataset [ 24 ].

Study context

This study utilized secondary data from the Uganda Demographic and Health Survey (UDHS) 2016. The UDHS 2016 is a part of the global program implemented by the Uganda Bureau of Statistics (UBOS) in collaboration with the Ministry of Health (MoH). The funding for the UDHS 2016 was provided by the Government of Uganda, the United States Agency for International Development (USAID), the United Nations Children’s Fund (UNICEF), and the United Nations Population Fund (UNFPA). The DHS is undertaken every five years and the 2016 survey is the sixth DHS in Uganda, the first one was conducted in 1988.

To generate statistics that were representative of the country as a whole in the 15 regions, the number of women surveyed in each region contributed to the size of the total sample in proportion to the population size of each region. This is because some regions had small populations and others had large populations. The 15 regions of Uganda where the UDHS 2016 was implemented were; South-Central, North-Central, Kampala, Busoga, Bukedi, Bugisu, Teso, Karamoja, Lango, Acholi, West-Nile, Bunyoro, Tooro, Kigezi, and Ankole Regions "" Fig 1 ,""

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https://doi.org/10.1371/journal.pgph.0001102.g001

Study design

This was a community-based cross-sectional study where data was collected from a representative sample of women of the reproductive age group (15–49 years). The data collection method was household surveys and women were interviewed at home.

Target population

The study participants were all women in the reproductive age group of 15–49 years living in Uganda at the time of the survey.

Sample size

A nationally representative sample of 20,880 households was selected for the study. From these households, a total of 19,088 eligible women in the reproductive age group were interviewed using a structured questionnaire [ 25 ]. However, interviews were completed with 18,506 women, yielding an overall response rate of 97%. Response rates were higher in rural (97.6%) than in urban areas (94.8%).

Sampling procedure

The UDHS 2016 used a multi-stage stratified sampling method (in two stages) to select the study participants. Three regions (South Central, North Central, and Busoga) were stratified into island and non-island sub-regions. Each region/sub-region was stratified into urban and rural areas yielding 34 sampling strata. Samples of EAs were selected independently in each stratum in two stages. Implicit stratification and proportional allocation were achieved at each of the lower administrative levels (sub-counties, parishes, and villages) by sorting the sampling frame within each sampling stratum before sample selection, according to administrative units in different levels, and by using a probability proportional-to-size selection at the first stage of sampling. In the first stage, 697 Enumeration Areas (EA) were selected, 162 EA in urban and 535 in rural areas "" Fig 2 ,"". One cluster was eliminated due to disputed boundaries leaving a total of 696 clusters. The EAs were selected with probability proportional to the EA size and with independent selection in each sampling stratum. The EA size is the number of residential households residing in the EA based on the 2014 Uganda Population and Housing Census. Some of the selected EAs were large, with more than 250 households. To minimize the task of household listing, these large EAs were segmented, and only one segment, with probability proportional to the segment size, was selected for the survey. Household listing was conducted only in the selected segment. So, a 2016 UDHS cluster was either an EA or a segment of an EA. In the second stage of selection, a fixed number of 30 households per cluster were selected with an equal probability of systematic selection from the newly created household listing. To minimize bias, no replacements and no changes of the preselected households were allowed in the implementing stages. In total, a representative sample of 20,880 households was randomly selected for the UDHS 2016. All women aged 15–49 who were either permanent residents of the selected households or visitors who stayed in the household the night before the survey were interviewed.

https://doi.org/10.1371/journal.pgph.0001102.g002

Data collection procedure

A structured and pre-tested questionnaire was used as a tool for data collection. The questionnaire was developed in English and then translated into nine different local languages. The questionnaire was developed based on standard DHS survey questionnaires and programmed into tablet computers to facilitate computer-assisted personal interviewing (CAPI) for data collection purposes, with the capability to choose any of the nine languages for each questionnaire. The UDHS and ICF technical teams trained 45 participants who administered the paper and electronic questionnaires with tablet computers. All trainees had some experience with household surveys. The technical teams conducted debriefing sessions with the pre-test field staff and modifications to the questionnaires were made based on lessons learned from the exercise. A total of 173 fieldworkers (108 women and 65 men) were recruited and trained to serve as supervisors, CAPI managers, interviewers, health technicians, and reserve interviewers for the main fieldwork. The training course included instruction on interviewing techniques and field procedures, a detailed review of questionnaire content, instruction on administering the paper and electronic questionnaires, mock interviews between participants in the classroom, and practice interviews with actual respondents in areas outside the 2016 UDHS sample. A two-day field practice was organized to provide trainees with additional hands-on practice before the actual fieldwork.

A total of 84 participants were selected to serve as interviewers, 21 as health technicians, 21 as field data managers, and 21 as team leaders. The selection of team leaders and field data managers was based on experience in leading survey teams and performance during the pre-test and main training. Supervisory activities included assigning households and receiving completed interviews from interviewers, recognizing and dealing with error messages, receiving system updates and distributing updates to interviewers, resolving duplicated cases, closing clusters, and transferring interviews to the central office via a secure Internet file streaming system (IFSS). Data collection was conducted by 21 field teams, each consisting of one team leader, one field data manager, three female interviewers, one male interviewer, one health technician, and one driver. Electronic data files were transferred from each interviewer’s tablet computer to the team supervisor’s tablet computer every day. The field supervisors transferred data to the central data processing office via IFSS. Senior staff from the Makerere University School of Public Health, the Ministry of Health, and UBOS, and a survey technical specialist. The DHS Program coordinated and supervised fieldwork activities. Data collection took place from 20 June 2016 through 16 December 2016.

Variables and measurements

Dependent variable..

The outcome variable of our study is the use of current family planning methods (traditional, folkloric, and modern methods) among women of reproductive age.

Independent variables.

For this study, we used the women’s questionnaire which collected information from women of reproductive age, 15–49 years. The women’s questionnaire consisted of 12 sections, however, we used variables for four sections; section 1 –respondent’s background, section 3 –contraception, section 9 –fertility preferences, and section 10 –husband’s background and women’s work. The independent variables used were: age (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49), place of residence (urban, rural), level of education (no education, primary, secondary, higher education), literacy level (cannot read at all, read parts of the sentence, read whole sentence, no card required, visually impaired), current marital status (never married, married, living with partner, widowed, divorced, separated), religious affiliation (anglican, catholic, muslim, Pentecostal, other), currently working (no, yes)husband’s education (no education, primary, secondary, higher education, don’t know, not applicable), wealth index (lowest, second, middle, fourth, highest) regions of Uganda (kampala, south Buganda, north Buganda, busoga, bukedi, bugisu, teso, karamoja, lango, acholi, west nile, bunyoro, tooro, ankole, kigezi), decision maker on use of family planning (mainly respondent, mainly husband, joint decision, others, not applicable), last source of FP user (government/pharmacy, community delivery, NGO, private clinic, private pharmacy, shop/church/friend, others, not applicable), current use of FP methods (no, yes), current use of methods (no method, folkloric method, modern method), current method type (not using any method, pill, IUD, male condom, female sterilization, periodic abstinence, withdrawal method, implant/norplant, lactational amenorrhea, injections, others), pattern of FP use (currently using, used since last birth, used before last birth, never used), intention to use contraceptive (using modern methods, using traditional methods, non-user intends to use later, used before last birth, never used), knowledge of ovulatory cycle (during her period, after period ended, middle of the cycle, before period begins, at any time, others, don’t know), pregnancy after birth (yes, no), knowledge of family planning methods (yes, no), heard about FP on the radio last few months (yes, no) heard about FP on the television last few months (yes, no), heard about FP in newspaper last few months (yes, no), heard about FP by phone via text messages (yes, no), visited by field worker last 12 months (yes, no), visited health facility last 12 months (yes, no), told about FP at the health facility (yes, no).

Data management and analysis

The downloaded data was entered into the SPSS software version 32.0 and data was cleaned, transformed to populate cells with few values, and re-coded as well. The collinearity effect was checked during bivariate analysis using a cut-off value of variance inflation factor (VIF) equal to and less than 4. The univariable, bivariable, and multivariable analyses were performed. The Univariable analysis was used to summarise the socio-demographic factors to find the pattern within the dataset meanwhile, the bivariable analysis was used to compare two variables to measure the relationship between them, and also identify variables to include in the regression analysis. On the other hand, multivariable analysis, which is a more complex analysis technique was used to understand the relationship between two or more variables and also control for confounding factors. At the univariable level, frequencies and proportions were determined. At the bivariable level, analysis was done by cross-tabulation using the Pearson Chi-Square (x 2 ) test for categorical variables. Pearson’s Chi-square test was used because it is appropriate to analyze data with a binary outcome and independent categorical variables.

The associations between the outcome and independent variables were measured using the odds ratio (OR) for which a 95% confidence interval (CI) was calculated. All variables that showed a significant association of p<0.05 at the bivariable level were further analyzed at the multivariable level using a binary logistic regression. Binary logistic regression analysis was used because the data set is normally distributed and has a binary outcome. The adjusted odds ratio (aOR) was undertaken using a simultaneous modeling technique to determine the presence of associations between the outcome and independent variables. Model fitness was performed using the Hosmer and Lemeshow Chi-Square test at p>0.05.

Results of the study

Description of socio-demographic characteristics.

A total of 18,506 samples of women of reproductive age (15–49 years) were included in the dataset where 23.1% were adolescents (15–19 years) and 76.3% lived in rural areas ( Table 1 ). More than half (58.9%) attained a primary level of education, 31.4% were married, and 40.8% were affiliated with the Catholic religion. Further analysis revealed that the majority of women (73.9%) were currently working at the time of the interview and most of them (21.8%) lived in households with the highest wealth index. The Baganda tribe represented the highest proportion of ethnic groupings (13.2%) and only a handful of women (15.5%) used government clinics/pharmacies as the main source for family planning methods.

https://doi.org/10.1371/journal.pgph.0001102.t001

Prevalence of family planning uptake

The prevalence of current FP use among women was 29.3%, with 26.6% of them using modern contraceptive methods ( Table 2 ). Most women preferred injections (13.5%), followed by implants (4.8%) and male condoms (2.9%). Analysis of the pattern of FP use showed that less than half (29.3%) were currently using at least one method, 12.1% used since their last birth, 14.1% used before their last birth, and 44.3% never used any FP method.

https://doi.org/10.1371/journal.pgph.0001102.t002

Determinants of family planning uptake

The table of adjusted analyses is indicated in Table 3 . The adjusted analysis revealed significantly higher odds of current FP use among; women who were knowledgeable about their ovulatory cycle (aOR = 2.58, 95% CI: 1.07–6.26); Older women of age group 40–44 years (aOR = 2.09, 95% CI: 1.40–3.12); women who had attained a secondary level of education (aOR = 1.91, 95% CI: 1.32–2.76); those who lived in households with the highest wealth index (aOR = 1.87, 95% CI: 1.29–2.72); women who were aware of the availability of FP methods (aOR = 1.87, 95% CI: 1.04–3.37); and women living in the Lango sub-region of Uganda (aOR = 1.67, 95% CI: 1.05–2.67). The overall model shows a good fit of data with the Pearson Chi-Square test of p = 0.19 and the model is said to fit well when the p-value is more than 0.05.

https://doi.org/10.1371/journal.pgph.0001102.t003

Discussions of key results

Uganda has the lowest FP prevalence rate as compared to the rates in neighboring countries like Kenya (45.5%), Rwanda (51.6%), and Tanzania (34.4%) [ 26 ]. The difference in the FP prevalence rates could be due to the low level of education among women, having three or more children, living in rural areas, husband’s disagreement on contraceptive use, perceived side effects, infant mortality; negative traditional practices, knowledge gaps on contraceptive methods, fears, rumors, and misconceptions about specific methods and unavailability and poor quality of services [ 27 ]. A recent study on contraceptive use further alluded to cultural beliefs, financial constraints to access contraceptives, and limited sources of family planning information like television and newspapers [ 23 ]. The low prevalence of family planning use could negatively affect Uganda’s progress in achieving sustainable development goal (SDG) 3 target 3.7 aimed at ensuring universal access to sexual and reproductive healthcare services, including family planning by 2030 if immediate interventions are not put in place [ 28 ].

Our study found significantly higher odds of FP use among older women in the age group 40–44 years. The previous analysis of the 2011 UDHS and Uganda FP costed implementation plan 2015–2020 revealed disparities in the use of family planning by; age, marital status, education, socio-economic status, and rural-urban geographic location [ 29 ]. Our finding concurs with other studies that found the use of FP increases with older age [ 30 , 31 ]. It is believed that older women are more exposed to information concerning childbearing and the dangers of high parities so they have appreciated the importance of the uptake of family planning methods.

Educational achievements of both women and their husbands were found in some studies to be very significant factors in the use of FP methods [ 31 , 32 ]. However, the present study found the education of women alone as the driver of the FP uptake. Unlike women with no formal education, women with at least secondary education are more likely users of FP methods [ 33 ]. This does not come as much of a surprise as higher education attainment increases female decision-making powers and awareness of the benefits of good family planning practices. This affirms the relevance of education in matters concerning the use of FP in Uganda. Thus, the dispute in Uganda that universal secondary education (USE) works towards enhancing FP use is highly supported.

In our study, women living in households with the highest wealth index had significantly higher odds of FP. This finding concurs with a study conducted in Ethiopia [ 34 ] but, contradicts another study conducted in Uganda which found that wealth was not associated with FP use [ 35 ]. This variation can be explained by current women’s empowerment through education and media awareness. The poor are less likely to be well informed about FP methods which can be attributed to a lack of ownership of television sets, mobile phones, or buying newspapers which limits getting FP information [ 36 – 38 ]. The poor may also have problems accessing healthcare due to long distances to the health facility, lack of money for transportation, and limited access to FP as a result of out-of-pocket expenditures to purchase FP methods [ 39 ].

Our finding found geographical differences to be associated with the FP uptake among women of reproductive age. Specifically, women in the Lango sub-region were more likely users of FP methods as compared to other regions of Uganda. This finding is in line with other studies that have also shown geographical differences to influence FP uptake [ 39 – 41 ]. This is possible considering some of the interventions by the government and other development agencies operating in the region that have yielded a positive impact on enhancing access to and use of FP methods. For example, the use of the voucher-plus system ensured that poor women had access to quality maternal health care and FP services at a reduced cost. Furthermore, some regions systematically fail to benefit from wider improvements in health experienced by the general population as such groupings are geographically or linguistically remote or benefit selectively from national and international investments [ 42 ].

The study showed knowledge as a strong predictor of current family planning use. This was also corroborated by Olugbenga et al (2011) in their study carried out in South-Western Nigeria [ 43 ]. They noted that this pattern should be expected considering much enlightenment that is ongoing on the use of FP in the country. Education exposes women to reproductive health information and empowers them to make appropriate judgments. It is however worth noting that some family planning methods were unpopular among respondents because they were not readily available and relatively more expensive than other methods. These included male sterilization (vasectomy), female sterilization (tubal ligation), lactational amenorrhea, intrauterine device (IUD) levonorgestrel, and vaginal rings.

This study observed that awareness through listening to the local radio was the predominant source of information for FP methods among women. This finding is in tandem with findings elsewhere that have documented the importance of information in influencing FP [ 26 ]. The use of public media sources like listening to the radio, watching television, and reading newspapers increases the awareness of people on FP methods. This present study did not find any significant association between FP uptake and watching television, reading newspapers, and receiving text messages via mobile phones. This may be so because the majority of women are illiterate and live in rural areas where they have access to local radios but not television, newspapers, and mobile phones. However, to improve FP use, media in all its forms play a major role in influencing the usage of FP methods [ 44 ]. Information gives women the freedom of choice and can enable them to make better choices of FP methods in addition to having an opportunity to discuss with their spouses.

Implications of findings

Increased uptake of FP methods brings significant health and other benefits. It further offers a range of potential non-health benefits that encompass expanded education opportunities and empowerment for women, and sustainable population growth and economic development of Uganda.

Strengths and limitations of the study

A major strength of this study is that the data used are nationally representative of women of reproductive age in the entire country, Uganda. A major limitation is that the data are cross-sectional and the authors could not establish temporality between participants’ exposure to some of the independent variables (i.e., program exposure) and the outcome. Since it was a population-based study, health facility factors influencing the use of FP methods were not included in the survey.

Conclusions

Our study shows the prevalence of current FP use in Uganda to be low and a threat to achieving the SDG 3 target of 3.7.1 by 2030. In conclusion, the study suggests that improvement in women’s education attainment, socio-economic position, and awareness may help increase contraceptive use in the population. Policymakers need to amend the existing policies to promote the use of FP methods among young women since they are fewer users of FP methods as compared to older women.

Acknowledgments

We appreciate the USAID DHS Programme for granting us the use of the dataset.

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• Open access
• Published: 01 April 2021

Awareness and use of family planning methods among women in Northern Saudi Arabia

• Ghzl Ghazi Alenezi 1 &
• Hassan Kasim Haridi   ORCID: orcid.org/0000-0002-8425-0204 2  

Middle East Fertility Society Journal volume  26 , Article number:  8 ( 2021 ) Cite this article

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Evaluation of awareness and use of family planning methods is important to improve services and policies. This study aimed to assess awareness and use of family planning methods among women in an urban community in the north of Saudi Arabia.

A cross-sectional study was carried out in a maternity hospital and 12 primary health care (PHC) centers in Hail City between December 1st, 2019, and May 30, 2020.

Four hundred married sexually active women aged 18–49 years were interviewed using a pretested structured questionnaire. The mean age of the participant was 32.0±7.5 years, 73.5% were university educated, and 58% were housewives. More than two-thirds of them (67.6%) had ≥3 living children. Most women (85%) ever used, and 66.5% were currently using any method of contraception; however, only one in five who get counseling for the contraceptive method used, and 40% of the last births were unplanned for. Almost all women reported unavailable family planning clinics in their primary healthcare centers. Most participants (83.0%) desired to have >3 children, which indicates that the main purpose of family planning was child spacing rather than limitation. Relying on natural methods as being safer (36.3%), desire to have more children (19%), being afraid from side effects (15.3%), and possibility of difficulty getting pregnant or might cause infertility (13.0%) were reasons the participants viewed for unsung modern contraceptives.

This study revealed that most women in urban Hail community, northern Saudi Arabia, were aware about and have a positive attitude towards family planning. The majority of the participants ever used, and two-thirds were currently using any contraceptive method/s, which is higher than the national estimate for Saudi Arabia. However, only one in five counseled by healthcare providers for the type of contraceptive method used. Unavailability of family planning services in primary health care centers impedes getting professional counseling. It is imperious to consider family planning clinics to provide quality family planning services.

A woman’s ability to choose whether and when to become pregnant directly affects her health and well-being. Voluntary family planning saves lives and accelerates sustainable human and economic development [ 1 ]. Family planning implies the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births [ 2 ]. Use of contraception prevents pregnancy-related health risks for women and children. When births are separated by less than 2 years, the infant mortality rate is 45% higher than it is when births are 2–3 years and 60% higher than it is when births are four or more years apart [ 3 ]. Family planning offers a range of potential non-health benefits that encompass expanded educational opportunities and empowerment for women and sustainable population growth and economic development for countries [ 4 ]. Family planning is achieved through contraception, defined as any means capable of preventing pregnancy, and through the treatment of involuntary infertility. The contraceptive effect can be obtained through temporary or permanent means. Temporary methods include periodic abstinence during the fertile period, coitus interrupts (withdrawal), using the naturally occurring periods of infertility (e.g., during breastfeeding and postpartum amenorrhea), through the use of reproductive hormones (e.g., oral pills and long-acting injections and implants), placement of a device in the uterus (e.g. ,copper-bearing and hormone-releasing intrauterine devices), and interposing a barrier that prevents the ascension of the sperm into the upper female genital tract (e.g., condoms, diaphragms, and spermicides). Permanent methods of contraception include male and female sterilization [ 2 , 4 ].

Availability of family planning methods and family planning service quality are important dimensions of the global health policies [ 5 ]. Regarding availability, the principles state that health care facilities, providers, and contraceptive methods need to be available “to ensure that individuals can exercise full choice from a full range of methods” and that furthermore, contraceptive methods are to be accessible without informational or other barriers. Regarding service quality issues, the principles state that “client-provider interactions respect informed choice, privacy and confidentiality, client preferences, and needs” [ 5 ].

Even though women in Saudi Arabia have a high total fertility rate compared to developed countries, a major change has occurred in the last decades. The total fertility rate decreased from 7.17 in 1980 to 4.10 in 2000 and to 2.27 in 2020 [ 6 ], a decrease by 45% in the last two decades and by more than two thirds in the last four decades. This substantial change in fertility profile occurred as a consequence of sociodemographic development in the Saudi community, especially in women’s education and work [ 7 , 8 ] as important factors in changing the beliefs of fertility and behaviors towards birth spacing, and the use of the contraceptives.

Monitoring and evaluation of awareness and utilization of family planning methods in communities are important to improve the quality and effectiveness of services, policies, and planning with resulting beneficial impacts on health and quality of life of women, children, families, and communities. An important aspect of research in this respect is to explore views and practices of women in the reproductive age with regard to family planning and fertility preferences, so we aimed in this study to assess awareness, attitude, and use of family planning methods among women in urban community at the north of Saudi Arabia.

Study design and the participants

This cross-sectional study was conducted in Hail City, the main urban area in Hail region, at the north of Saudi Arabia, between December 1st, 2019, and May 30, 2020. A maternity hospital and 12 primary health care (PHC) centers were the setting of this study. PHC centers were selected at random among a total of 24 PHC centers serving all neighborhood of Hail City. The eligible subjects were married women, residing in Hail City for at least 1 year, aged 18–49 years, who were sexually active, not in the menopause with no contraindication from getting pregnant. Participants were selected at random from women in the waiting areas, who visited the selected health care facility for any reason and invited to undergo an interview. Sample size was calculated using Cochran’s Sample Size Formula [ 9 ] to comprise 384 participants, assuming 50% of women are using contraceptive methods (to maximize sample size) and 5% margin error within 95% confidence level. However, a successful 400 eligible participants were interviewed. A prior consent was obtained from the participants before the interview. Efforts were maximally taken during recruiting and interviewing eligible participants in the study to avoid any potential selection or information bias.

Data collection and analysis

A pretested, predesigned questionnaire was used by the investigator to interview the selected study participants. The questionnaire included sociodemographic information regarding age, education, family size, and family income, and questions covered awareness with regard to the concept and methods of family planning and attitude towards and practice of family planning. Data obtained was coded, entered into, and analyzed using Epi Info 7.1.3 program (CDC, Atlanta, GA, USA). Descriptive statistical measures as percentages and proportions were used to express qualitative data. Quantitative data were expressed as mean and standard deviation. Data was presented as tables and graphs as relevant.

A total of 400 women completed the interview among 418 women asked to participate in the study (96.7% response rate). Time factor and wouldn’t like to share personal information were most of the reasons mentioned for non-participation.

The mean age of the participants was 32.0 ± 7.5 years. The age-wise distribution of the participants is shown in Table 1 . Most participants received university education (294, 73.5%). More than half (211, 52.8%) of the participants reported family income <10,000 SR, while those who reported high income ≥15,000 SR were 96 (24.0%). The mean living children per woman was 2.9±2.5 children, with about one-third (130, 32.5%) had more than 3 children (Table 1 ).

Table 2 summarizes awareness about and attitude towards family planning among the study participants. About two-thirds 259 (64.8%) perceived family planning concept as a means for pregnancy spacing, while 88 (22.0%) perceived it as a means of pregnancy limitation, the others 53 (13.3%) were not familiar with the meaning of family planning. Almost all participants (399; 99.8%) were familiar with hormonal contraceptive pills, IUDs (387, 96.8%), and withdrawal (396, 99.0%), and most (364, 91.0%) were familiar with condom and breastfeeding (330, 82.5%) as a means of contraception methods. Still, a good percent was familiar with abstinence (307, 76.8%) and injectable hormonal (252, 63.0%) and hormonal patch (245, 61.3%) contraceptives. Less commonly familiar methods were female sterilization (145, 36.3%), female barrier (92, 23.0%), and male sterilization (68, 17.0%). Figure 1 demonstrates sources of knowledge about family planning among participants. Most sources were non-reliable sources, such as family/friends (67.5%), general internet sites (43.8%), and social media (34/0%); meanwhile, only half (50.3%) of the participants reported consulting healthcare workers.

Sources of knowledge about family planning methods (%)

The vast majority (384, 96.0%) were favoring family planning (agree/strongly agree), with almost the same percent mentioned that family planning have multiple benefits. More than two-thirds (282, 70.5%) of the participating women reported husbands’ support with regard to family planning. A small percent (17.0%) desired a small number (1–3) of children; 55.0% desired more than 3 children, while 28.0% would not like to limit their children number and leave it open. More than two-thirds (67.5%) preferred pregnancy spacing for more than 2 years.

Table 3 summarizes family planning practices as reported by participant women. The majority ( n =341; 85.3%, CI= 81.4–88.6) ever used and 266 (66.5%, CI= 61.6–71.1) were currently using contraceptive method/s. Methods currently mostly used were pills ( n =144, 54.1%), withdrawal ( n =58, 21.8%), IUDs ( n =29, 10.9%), hormonal patches ( n =14, 5.3%), and condom ( n =12, 4.5%) (Fig. 2 ).

Contraceptive method currently used among participants (%)

Less than half ( n =144; 44.0%) of the respondents reported that their husbands practice contraception. The frequently used method was withdrawal ( n =147, 36.8%) and to a lesser extent condom ( n =55, 13.8%) and abstinence during ovulation period ( n =32, 8.0%).

More than 60% (121, 60.5%) bought the contraceptive directly from private pharmacies over the counter as a personal choice, others (52, 26.0%) brought the contraceptive method after medical advice in private dispensary/hospital, and few (27, 13.5%) were prescribed after medical advice in a governmental health care facility.

Table 4 summarizes respondent’s views about the important reasons behind the non-use of modern contraceptive methods among some women. Favoring natural contraceptive methods (36.3%), the desire of more children (19.0%), being afraid of health side effects and complications (15.3%). Other mentioned causes were being afraid of difficulty of getting pregnant (6.5%), the misconception that modern contraceptives may cause infertility (6.5%), and the other miscellaneous causes/non-response (16.4%).

A fundamental change has occurred in Saudi society over the last decades. Socioeconomic development, urbanization, and women’s education and work [ 7 , 8 , 10 ] led to changes in fertility beliefs and behaviors. Results of the present study shed light on an urban community in the north of Saudi Arabia, exploring views, attitudes, and practices of women in the childbearing period regarding family planning, fertility preferences, and health-seeking behavior.

In this study, most of the participating women (85.3%) ever used, and 66.5% were currently using any family planning method/s, which is by far higher than the national estimate for Saudi Arabia (18.6%) stated in the United Nations (UN) “World Fertility and Family Planning 2020” report and also higher than the international prevalence average, where, in 2019, 49% of all women in the reproductive age range 15–49 years were using some form of contraception [ 11 ]. Similarly, the prevalence was also higher than the reported figures in surrounding Gulf Arab countries such as the United Arab Emirates (33.4%), Kuwait (35.5%), Bahrain (32.2%), Oman (19.6%), Qatar (29.1%), and other Arab countries such as Egypt (43.2%), Jordan (31.1%), Iraq (35.1%), Syria (31.6%), Tunisia (34.3%), and Morocco (36.7%) [ 11 ]. However, the estimate is fairly similar to rates in Western countries such as the UK (71.7%), France (63.4%), Italy (55.6%), Spain (56.5%), and the USA (61.4%) [ 11 ].

This reported higher rate of family planning methods used in our study population actually concealing a high proportion of couples using traditional unreliable methods, where one in 4 was using these methods compared to <10% internationally [ 11 ].

Almost all (96.0%) of the participants in our study praised the concept of family planning and agreed about the benefits of family planning for maternal and child health and well-being. Furthermore, the majority of the participants (85.3%) were ever used or currently using (66.5%) family planning methods. This finding indicates the high acceptability of the family planning concept and points to the real desire of families to plan for the timing of pregnancy occurrence and space between children. Translation of this high acceptance and the higher prevalence of using contraceptives was not reflected in lower fertility profile or smaller family size in our sample. About one-third (32.5%) were already having more than 3 living children, and 83.0% reported that they still want more children, and half of them (49.2%) reported that they prefer to have more than 3 children. This indicates that the main purpose of using contraceptive methods among the majority of the participants is birth spacing rather than birth limitation. This finding is consistent with previous study conducted in southwestern Saudi Arabia, where 60.0% of contraceptive users were spacer [ 12 ]. This could be explained on the background of cultural factors, religious traditions and customs of an Islamic society as well as personal views.

An important finding in our study is that, the use of contraceptive methods among participants largely depends upon their personal views (55.0%) or family/friends’ experience (23.2%), while only 21.8% of the participants received medical advice before using their current contraceptive method. This might explain the higher number of couples who relied on unreliable contraceptive methods and the considerable percentage (40%) of the participants who reported that their last pregnancy was unplanned for, which might be attributed to failure of the contraceptive method used. This is not surprising when we find that all participants reported unavailability of a family planning clinic in their PHC centers, with only one in three (33.8%) who reported that their PHC centers may provide family planning counseling and just 2.8% who reported accessibility for prescribing family planning methods. This situation indicates that, in spite of the high social necessity for family planning revealed by the high demand on family planning methods, there is no parallel availability of organized health services coping for this unmet need of women in the region. As a consequence, health-seeking behavior is self-guided based on personal information and beliefs and/or unreliable sources such as experience of relatives and friends. This crucial need for family planning services was also reported in other studies in Saudi Arabia [ 12 ]. The availability of family planning services allows couples to meet their desired birth spacing and family size and contributes to improved health outcomes for children, women, and families [ 13 , 14 , 15 ].

Two important consequences might result from choosing a family planning method without medical advice; first, the likelihood of occurrence of avoidable side effects and complications which might affect the users’ beliefs and behavior; second, due to resorting to traditional methods of family planning, high rates of contraceptive failure occurs. Dissemination of information about options for contraception should become a part of the routine counseling in primary health care centers and other health care institutions as any decision about contraceptive use should be based not only on contraceptive risks/benefits, but also on the efficacy of the method, individual’s life situation, and the level of risk particular to the user characteristics and the life consequences of childbearing for the mother and child [ 16 , 17 ].

Our study has a number of inherent limitations. Firstly, it is a cross-sectional study, so relationships between the predictor variables and the dependent variables can only be described as general associations not a causal relationship. Second, as an interview survey, social desirability bias cannot be eliminated, and recall bias for some events might happen. Third, our study participants were completely from the urban population, so the result cannot be extended to the rural population in the region. However, the current study provides insights to policymakers and health care providers about awareness, attitude, and barriers affecting family planning practice among women in the region to offer need-based health services and to guide health awareness efforts.

This study revealed that most women in the urban Hail community, northern Saudi Arabia, were aware about and have a positive attitude towards family planning. The majority of women ever used, and two-thirds of them were currently using any family planning method/s, which is higher than the national estimate for Saudi Arabia. However, only one in five who received counseling for the type of contraceptive method used from healthcare providers. The unavailability of family planning services in primary health care centers impedes getting professional counseling. It is imperious to consider family planning clinics to provide quality family planning services.

Availability of data and materials

Available from the corresponding author on reasonable request.

Abbreviations

Primary health care

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Acknowledgements

We thank directors and healthcare staff in maternity hospital and participated PHC centers, Hail City, Saudi Arabia, for facilitating the study. We also thank the participant mothers for their agreement, patience, and allowing the time to carry out the interview.

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GA conceived the study idea, participated in development of the data collection tool, carried out all interviews, and participated in interpretation of the study results. HH adapted the study idea, designed the data collection tool, carried out data analysis and interpretation of results, and wrote the manuscript. All authors have read and approved the manuscript

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GA: family medicine senior resident, Family & Community Medicine Joint Program, Hail, Saudi Arabia. HH: Consultant Public Health Medicine; the Designated Institutional Official (DIO) of Academic Affairs & Postgraduate Studies, Health Affairs, Najran; ex Head of the Research Department, Health Affairs, Hail Region, Saudi Arabia.

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The protocol of the study was reviewed and approved by the Regional Bioethics Committee of the General Directorate of Health Affairs, Hail region, with the approval number 2019/22 dated October 6, 2019. Agreed participants signed the study consent form. Participants were guaranteed anonymity, confidentiality of the responses, and voluntary participation, and they can withdraw for any reason and any time, without any implications.

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Alenezi, G.G., Haridi, H.K. Awareness and use of family planning methods among women in Northern Saudi Arabia. Middle East Fertil Soc J 26 , 8 (2021). https://doi.org/10.1186/s43043-021-00053-8

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• Contraceptives
• Family planning
• Saudi Arabia

• Open access
• Published: 24 April 2024

Access to family planning services and associated factors among young people in Lira city northern Uganda

• Eustes Kigongo 1 ,
• Raymond Tumwesigye 1 ,
• Maxson Kenneth Anyolitho 1 ,
• Marvin Musinguzi 1 ,
• Gad Kwizera 3 ,
• Everlyne Achan 1 ,
• Caroline Kambugu Nabasirye 2 ,
• Samson Udho 2 ,
• Amir Kabunga 4 &
• Bernard Omech 1  

BMC Public Health volume  24 , Article number:  1146 ( 2024 ) Cite this article

Metrics details

Access to family planning services among young people is crucial for reproductive health. This study explores the access and associated factors among young people in Lira City, Northern Uganda.

Methods and materials

A mixed-methods study was conducted in March to April 2022. Quantitative data were collected using a structured questionnaire from 553 participants aged 15–24 years. Qualitative data were obtained through in-depth interviews and focus group discussions. Data analysis included univariate, bivariate, and multivariate analyses for quantitative data, while interpretative phenomenological analysis was used for qualitative data.

Overall, 31.7% of the respondents had a good perceived access to family planning services, with 64.6% reporting perceived availability of FP methods. Challenges included lack of privacy (57.7%), fear of mistreatment (77.2%), and decision-making difficulties (66.2%). Among females, good perceived access to FP services was less likely among urban residents (AOR: 0.22, 95% CI: 0.09–0.53), Christian respondents (AOR: 0.51, 95% CI: 0.01–0.36), Muslim respondents (AOR: 0.07, 95% CI: 0.01–0.55) and respondents with poor attitude to FP services (AOR: 0.39, 95% CI: 0.24–0.64), but more likely among respondents with a sexual a partner (AOR: 4.48, 95% CI: 2.60–7.75). Among males, good perceived access to FP services was less likely among respondents living with parents (AOR: 0.19, 95% CI: 0.05–0.67) but more likely among respondents with good knowledge of FP services (AOR: 2.28, 95% CI: 1.02–5.32). Qualitative findings showed that three themes emerged; knowledge of family planning methods, beliefs about youth contraception and, friendliness of family planning services.

The study revealed a substantial gap in perceived access to family planning services among young people in Lira City. Barriers include privacy concerns, fear of mistreatment, and decision-making difficulties. Tailored interventions addressing urban access, religious beliefs for females, and knowledge enhancement for males are essential. Positive aspects like diverse FP methods and physical accessibility provide a foundation for targeted interventions. Youth-friendly services, comprehensive sexual education, and further research are emphasized for a nuanced understanding and effective interventions in Northern Uganda.

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Globally, approximately 16 million girls aged 15–19 give birth each year, with 95% of these births occurring in developing countries [ 1 ]. Additionally, annually, 14 million unsafe abortions take place among adolescents, who face various sexual and reproductive health challenges, including early pregnancy, unsafe abortions, sexually transmitted infections (STIs), and sexual abuse, particularly in Sub-Saharan Africa (SSA) [ 2 ]. Family planning (FP) is a critical aspect of global public health, recognized for its impact on maternal and child health, gender equality, and socioeconomic development [ 3 ]. The international community, as reflected in various global health initiatives and sustainable development goals, acknowledges the importance of ensuring universal access to FP services for all individuals, including young people [ 4 ]. This global perspective emphasizes the interconnectedness of reproductive health and broader efforts to achieve sustainable development [ 4 ]. Access to these services is particularly pertinent among young people, who constitute a significant demographic in many Low-and Middle-income Countries (LMICs).

Uganda, boasting one of the world’s youngest and fastest-growing populations, has nearly half (48%) of its estimated 46 million people under the age of 15, significantly surpassing the averages for SSA (43%) and the world (26%) [ 5 ]. Uganda, as a signatory to global health agendas, has made significant strides in promoting FP services [ 6 ]. The National Population Policy, coupled with the National Reproductive Health Policy, reflects the government’s commitment to ensuring access to FP for all citizens [ 7 ]. However, challenges persist, especially in urban areas. An examination of the national context provides insights into the policy circumstances, healthcare infrastructure, and societal norms that shape family planning services’ availability and utilization among young people in Northern Uganda.

According to the Uganda Demographic and Health Survey (UDHS) 2016, 25% of women aged 15–19 and 1% below 15 had initiated childbearing, with the incidence of unplanned pregnancies significantly rising following the shutdown of schools during the COVID-19 pandemic [ 8 , 9 ]. Reported underlying causes of teenage pregnancy include gender inequality, restricted freedom for girls to voice their concerns, school dropout, and limited access to contraception and knowledge [ 10 ]. Unintended teenage pregnancies can have severe adverse effects on well-being, leading to maternal morbidity and mortality related to childbirth and unsafe abortion [ 11 ]. Moreover, these pregnancies contribute to social consequences such as stigma and discrimination, accounting for 59% of school dropouts in Uganda in 2012, potentially hindering education and future employment opportunities [ 12 , 13 ]. Reports by the World Bank and the World Health Organization (WHO) emphasize the association of adolescents-childbearing with social stigma, lifelong poverty, and health risks, necessitating a comprehensive approach to address these issues [ 14 , 15 ].

Uganda’s current health sector strategy aims to expand youth-friendly health services (YFHS) and promote adolescent sexual and reproductive health and rights information in schools, ensuring access to FP information and services irrespective of age, marital status, or school status [ 16 ]. The country plans to increase access to modern contraceptive use and reduce unmet need for contraception in the coming years [ 17 ]. According to WHO guidelines, addressing the underlying factors, including the timing of first sex and marriage, effective contraceptive use, and the socio-cultural and economic environment, is crucial for delaying childbearing and expanding FP access to adolescents [ 18 ].

Notably, northern Uganda bears one of the highest burdens of adolescent pregnancies, with reports indicating a significant percentage of unintended pregnancies in Lira district in 2019 (33.3%) and a notable number of teenage girls visiting antenatal clinics in Lango sub-region in 2021 [ 19 ]. A recent study in Oyam district reported a high percentage of unintended pregnancies among adolescent girls [ 8 ]. In the context of Lira City in northern Uganda, unintended pregnancies represent a significant challenge affecting various aspects of young people’s lives, including education and economic prospects [ 20 ]. Despite the recognized importance of FP, there is a need for a comprehensive understanding of the factors hindering or facilitating youth access to FP services in Lira City. Existing literature primarily focuses on the prevalence of unintended pregnancies and associated outcomes, emphasizing challenges in accessing reliable information, contraceptives, and quality reproductive health services [ 20 ]. However, there is limited research examining the factors contributing to these challenges, such as cultural norms, stigma, and structural barriers specific to Lira City. Moreover, the evolving circumstances of youth perspectives, preferences, and behaviors related to FP require an updated understanding, considering rapid socio-cultural changes and advancements in technology [ 21 ]. To develop evidence-based intervention strategies, our assessment focused on the knowledge, perceptions, and factors influencing access to contraceptive services among young people in the specific context of northern Uganda.

Study design

This was an explanatory-sequential mixed methods study [ 22 ] conducted in Lira city, northern Uganda between March and April 2023. The mixed-methods approach was adopted so as to generate a more holistic understanding and a stronger inference with two approaches complementing each other [ 23 ].

Study setting

Lira City is among the newly created cities, located approximately 375 km by road north of the capital city of Kampala via Karuma-Kamdini. Lira City is the central business hub for Northern Uganda and comprises the west and east divisions. According to projections by the Uganda Bureau of Statistics (UBOS) in 2014, the population of 2020 for the Lira district was 474,200 people, and it is traditionally inhabited by the Lango tribe, who are farmers and cattle keepers. The urban centers of the district also have people engaged in many small-scale businesses, such as produce businesses and trading.

Study population

The study was among young people aged 15 to 24 years, residing in Lira city. Inclusion into the study was based on being a young person of 15 to 24 years of age who has lived in Lira city for at least six months. Additionally, being present at the selected household during data collection, and those who consented to participate were included in the study. In households where more than one persons were eligible, simple random sampling by lottery method was employed to select one. Exclusion was based on being critically ill to participate, or refusing to participate in the interviews.

Sample size determination

The sample size of the study was estimated using Kish Leslie (1965) as follows:

In the equation above, n is the sample size for the study, Z is the Z score at the 95% confidence interval (1.96), p is the proportion of perceived access to FP services (50%), d is the desired precision of the study (5%), and deff is the design effect due to multistage random sampling. A factor of 1.5 has been used to adjust the sample size based on what previous studies have used [ 24 , 25 ]. A design effect of 1.5 was employed to increase the homogeneity of the participants following the use of a multistage random sampling procedure. Therefore, the final sample size obtained was 577.

Interpretative phenomenological analysis (IPA) was employed for qualitative research to delve into individual experiences, progressing towards an examination of shared and contrasting aspects within a limited sample [ 26 ]. This approach facilitated the identification of thematic connections. Adhering to IPA guidelines advocating for a compact and homogenous sample, purposive sampling was used to recruit 5 participants. This sample size aligns with the recommended number for an IPA study [ 27 ], and was considered sufficient to capture a distinct range of experiences related to the phenomenon under investigation.

Sampling technique

A multistage sampling procedure was employed to select the 577 study participants. The study was conducted in both divisions of Lira City, East and West. From each of the divisions, five wards were selected, making a total of ten wards. This was done by simple random sampling using the lottery method, where the names of wards were written on small papers, folded, mixed in a container, and shaken well, and then five were picked at random without replacement. From each of the wards, two cells were selected using the same procedure, which generated a total of 20 cells. From each of the cells, Village Health Teams (VHTs) were used to obtain lists of households with young people aged 15 to 24 years, and these were used as sampling frames per cell. The number of participants to be selected from each cell was determined by the sample size proportionate to the cell size. In each of the cells, participants were selected through simple random sampling using computer-generated random numbers. Purposive sampling was used to select participants for qualitative interviews [ 28 ]. While purposive sampling guided our selection process, we also sought to include a diverse range of perspectives by engaging with individuals from various backgrounds, including community health workers, educators, and youth leaders. Our rationale for selecting community peer educators stems from their unique position as trusted intermediaries within their communities, often serving as frontline advocates for reproductive health education and services. Similarly, the inclusion of university leaders was motivated by their influence and role in shaping policies and programs related to youth reproductive health within academic settings.

Study variables

Dependent variable.

The dependent variable for the study is perceived access to FP services. Access to healthcare means “the timely use of personal health services to achieve the best health outcomes” [ 29 ]. Many frameworks have been proposed to measure access to family planning services but have all proved not sufficient [ 30 ]. This study adopted one of the common frameworks, Penchansky and Thomas (1981) framework that reflects the fit between characteristics and expectations of the providers and the clients. These characteristics (5As of access) are availability, accessibility, acceptability, accommodation, and affordability [ 31 ]. This conceptualization of access has been adopted because it describes the broad dimensions and determinants that integrate demand and supply-side factors [ 32 ]. According to the model, the five As of access form a chain that is no stronger than its weakest link. For example, improving affordability by providing health insurance will not significantly improve access and utilization if the other four dimensions have not also been addressed. The perception of access to FP services index composed of five questions of yes or no response. For all the questions “yes” was coded 2 and “no” coded 1. The percentage of respondents that perceived access to be good on all five variables had good perceived access to FP services.

Availability: Are the family planning commodities available when you need them, and meet your FP needs?

Accessibility: Is the location of the facilities that provide family planning services convenient for you?

Acceptability: Are the characteristics of the FP service providers (including attitudes and attributes such as age, sex and religion) comfortable for you?

Accommodation: Do health providers organize FP services in ways (including appointment system, hours of operation and facility environment) that suit your needs and preferences?

Affordability: Do you have to pay for family planning services?

All the access questions were asked as yes and no questions and coded 1 and 2, respectively. To measure the index of perceived access, only participants who answered Yes to all the access questions were labeled as having good perceived access to FP services.

Independent variables

The independent variables included sociodemographic characteristics (age, sex, education, religion, marital status, living with parents), sexual-related characteristics (having a child, sexually active, sexual partners), knowledge, and attitudes. The knowledge of the participants was assessed based on a total of nine questions about family planning. Each of the questions was binary coded as 1(Yes) and 0(No). Overall knowledge was therefore measured as a composite score ranging from 0 to 9. The mean score was taken as a cut-off with individuals above the mean score categorized as having good knowledge and those below the mean as having poor knowledge. This measurement was adopted from a recent study [ 33 ]. The overall attitudes of the young people regarding actual use of family planning commodities, which includes the misconceptions, fears, cultural and religious beliefs about family planning commodities such as condoms were assessed based on a total of eight questions with a favorable response coded as Yes (0) and unfavorable response coded as No [ 1 ]. The responses were computed into an overall attitude to FP services score with a total of eight. Similarly, the cut-off was set as the mean with individuals above the mean classified as having a poor perception and those below the mean with a good perception, as from a recent related study [ 33 ]. The knowledge items had a scale reliability coefficient of 0.78 whereas the perception items had 0.70, all these are within the acceptable limits [ 34 ].

Participant recruitment and informed consent processes

After obtaining ethical approval and clearance, five research assistants from the city were recruited and trained on the study protocol and data collection procedures. A pretest of the questionnaire was carried out among 58 youths from Lira district to refine the questions for simplicity and comprehension and to assess validity and reliability using the Statistical Package for Social Sciences (SPSS) software. Lists of households with young people aged 15 to 24 years were obtained by Village Health Teams (VHTs). Sampling was then conducted, and eligible participants were approached for data collection after providing informed consent and, for minors, informed assent. During this process, the study objectives, procedures, benefits, risks, and voluntarism were explained. Interviews took place in a private space within the participants’ homes. In cases where the parent or guardian was absent during data collection, the household was skipped.

Data collection instruments

Quantitative data was collected using a pretested interviewer-administered questionnaire developed by the researcher (Supplementary file 1 ). The questionnaire consisted of four sections: sociodemographic characteristics (age, sex, education, religion, marital status, residence, and parent’s education), sexually related information (ever had a child, engaged in sexual relationships, number of sexual partners, sexual risks encountered), access questions (availability, accessibility, acceptability, accommodation, and affordability), knowledge of family planning services, and attitudes regarding family planning services. This was administered in approximately 15 min. Qualitative data was collected through in-depth interviews and focus group discussions using guides (Supplementary file 2 ). This was done after obtaining insights from quantitative data. Interviews with participants were done at proposed times and places deemed convenient to the participants themselves. During collection, audio recordings were made together with extended field notes to complement the audios. Data collection was done in Lango, verbatim transcribed, and then translated to English for analysis. Data collection was conducted through five in-depth interviews and four focus group discussions all from young people aged 15 to 24 years. A sample of 10 were from the University and 30 were from the community with equal proportions of males and females. These participants were community adolescent peer-educators and University reproductive health leaders. Some were picked after quantitative interviews while others based on their roles regarding reproductive health for the young people.

Statistical analysis

Quantitative data analysis.

The collected data was entered into SPSS software, where it was cleaned and coded, then exported to STATA version 17 software for final analysis. The analysis was conducted at three levels. At the univariate level, data was summarized as frequencies and proportions, means and standard deviations, or median with interquartile range, and presented in frequency tables. In bivariate analysis, perception of access to SRHR services was cross-tabulated with the independent variables one at a time to assess relationships. A crude odd ratio (COR) and a 95% confidence interval were reported. At this level, associations were considered at p  < 0.25 in order to consider all possible predictors [ 35 ], and all those associated factors were taken into multivariate analysis. In multivariate analysis, binary logistic regression was used to estimate the predictors of the primary outcome. The backward elimination method was used to build a predictive model. Results were reported as adjusted odds ratios and 95% confidence intervals. A p -value of < 0.05 was considered statistically significant for variables.

Qualitative data analysis

The data analysis adhered to the seven-stage IPA process outline, derived from Smith and colleagues, as outlined by Brown and colleagues [ 36 ]. Each interview underwent verbatim transcription and was entered into a customized IPA analysis framework. Multiple re-readings of the interviews were conducted, applying in-method triangulation by integrating field notes with observations and commentary from the fieldwork [ 37 ]. This triangulation process enhanced confidence in the outcomes post data analysis. Following the verbatim transcription of the audio data and thorough review of the text, initial notes were made, leading to the development of emerging themes. Connections across these emergent themes were sought to identify subordinate themes. Subsequently, a search for patterns across the cases was conducted to reveal the major themes.

We employed research assistants who are social scientists trained in qualitative study and interview techniques to assure the validity of our study. Data from diverse sources, including field notes and audio recordings, were independently analyzed by two researchers. The newly emerging themes were routinely compared to the original transcribed text, and the writers frequently convened for debriefings to make sure that the subjects were at the center of the data analysis and interpretation. The results of the data analysis were examined and discussed until a consensus was achieved in order to increase the dependability and accuracy of the results. To demonstrate confirmability (the degree to which the findings are shaped by participants and the context rather than the perspectives of the research), the researchers used participants’ narratives and words as noted in the transcripts. Additionally, the researchers dwelled on their previous experiences to reduce their influence on the findings. To ensure that the processes of data collecting and analysis could be traced back to the initial interviews, we have preserved all audit trails from data collection to analysis.

Quantitative findings

Sociodemographic characteristics.

Recruitment into the study was between March and April 2022. Out of a total of 577 participants, 553 were included generating a response rate of 95.8%. Table  1 shows that the majority of the respondents, 65.3% were female, with a mean age of 17 (± 2.1) years and 90.8% aged between 15 and 19 years. Most of the youth, 45.2% were in secondary school, 40.7% were Anglican, and 71.4% were living with their parents. The majority of the youths, 46.8% were sexually active and had had sex in the past 4 months.

Perceived access to family planning services

The mean score for perception of access to family planning services was 1.91 with a standard deviation of ± 0.29. Figure  1 shows that the percentage of respondents that perceived access to be good for all the five variables was 31.7% (95% CI: 28%, 36%). The majority of the young people, 64.6% reported that different FP methods were available at the health facilities. Most of the young people, 79.3%% also reported that the health facilities were within their reach, and 61.3% reported that attitudes and personal characteristics of FP service providers were comfortable for them. The majority of the young people, 66.7% also reported that the manner in which FP services are organized, including facility’s operating and environment, suited their needs and preferences. Additionally, females had overall favorable responses compared to their male counterparts.

Percentage of young people reporting a good response to variables on the perceived access index in Lira district, Northern Uganda

Knowledge and attitudes regarding perceived access to family planning services

Table  2 presents questions used to assess both knowledge and perceptions regarding family planning services. questions 1 to 9 were designed to measure knowledge and 10 to 17 were aimed at capturing perceptions regarding use of family planning commodities. The majority of the young people, 69.4% were aware that FP, 75.6% knew the facility that offers FP services, 89.3% knew how to prevent pregnancy and 75.8% knew about sexual rights. Table  3 also shows that the majority of the young people, 58.1% perceived that FP services were not for young people, 80.5% could access FP whenever they wanted and 90.4% knew that information at the health facility was always kept confidential. However, the majority of the young people, 66.2% cannot decide on using a FP method, 57.7% also reported that there is not enough privacy at the health facilities, and 77.2% fear being mistreated by the staff at the health facilities.

Factors associated with perceived access to family planning services among young people

The bivariate analysis was performed stratified by sex to prevent introduction of bias arising from differencing sample sizes because males were close to a third of the entire sample. Table  3 indicates that among the females, being aged 20–24 years, having a child, being sexually active and having a sexual partner was associated with a higher perceived access to FP services at p  value less than 0.25. On the other hand, having primary and secondary education, urban residence, Christians, Muslims, not in a marital relationship, secondary education of a mother, primary, secondary and tertiary education of father, and good attitude towards FP services were associated with a lower perceived access to FP services at p  value less than 0.25. Table  3 also shows that among males, living with parents, mother’s secondary education level, and good attitude towards FP services had a lower perceived access to FP, where as being sexually active and good overall knowledge of FP services had higher perceived access to FP services with p  value of less than 0.25.

Multivariate analysis was performed to assess the predictors of perceived access to family planning services for males and females, presented as two separate models for females and males. Table  4 show among females, residence, religion, sexual partners and perception regarding use of family planning methods had significant associations. Females respondents who were less likely to consider access to family planning services as good were urban residents (AOR: 0.22, 95% CI: 0.09–0.53, p  = 0.001), those who were Christian (AOR: 0.51, 95% CI: 0.01–0.36, p  = 0.003) and Muslim (AOR: 0.07, 95% CI: 0.01–0.55, p  = 0.012), and those who had a poor attitude towards family planning services (AOR: 0.39, 95% CI: 0.24–0.64, p  < 0.001). Female respondents who had a sexual partner were more likely to consider access to family planning services as good (AOR: 4.48, 95% CI: 2.60–7.75, p  < 0.001). Table  4 also shows that among males, living with parents and overall knowledge about family planning services were significantly associated with perceive access to family planning services. Male respondents that were less likely to consider access to family planning as good were those who lived with their parents (AOR: 0.19, 95% CI: 0.05–0.67, p  = 0.010), and those that were more likely to consider access to family planning as good were those that had good overall knowledge about family planning methods (AOR: 2.28, 95% CI: 1.02–5.32, p  = 0.050).

Qualitative findings

Characteristics of participants.

A total of 5 in-depth interviews and 4 FGDs were conducted with a total of 30 young people; 10 were university students, whereas 20 were from the community. The focus groups were homogeneous in nature, for males and females separated. Two focus groups of 10 participants for males and females were conducted in the community, and two groups of five males and females were conducted from the University youths. The participants were young people aged 15 to 24 years. Themes were obtained through finding similar texts, patterns, and insights. We generated 8 different codes, 7 subthemes, and 3 themes.

Theme 1: knowledge of family planning methods

Majority of the young people did not have adequate knowledge regarding access and use of FP services. This was evidenced as most participants from the community reported that many young people used off label benefits of paracetamol and traditional herbal medicines for contraception. Additionally, many reported their source of information to be friends who seemed not to have adequate knowledge as well. Here are some of the verbatim comments to support the results:

“After having sex today, you can take 4 Panadol tablets immediately after having sex or 6 tablets, though it depends, you can also take it a day after having the sexual intercourse, taking on the third day will be late for it to work well in preventing the pregnancy”. (Female, 22 years, Lira Town, Feb 2023) “When I was in Primary six class. I was living with my sister and she had maids who told me about Panadol use”. (Female, 21 years, Junior quarters, Feb 2023) “Some girls use paw paw leaves, others mixing diclofenac drug with herbs which can also cause abortion. But these procedures can also either lead to incomplete abortion, death or even over bleeding” (Male, 24 years, Barapwo, Feb 2023) . “There is no proper sexual information. In the past, parents called children to prepare for education but today nowhere it’s practiced. Now it is only in schools to ensure that people know that sex is good but has challenges” (Female, 23 years, LU, Feb 2023) .

Theme 2: beliefs about youth contraception

The majority of the participants also reported negative perceptions regarding family planning services. However, this appears to stem from the common narrative that frames sexual health for young people as taboo. To continue, many young people and the community reported distancing themselves from reproductive health programs, citing that their motives are not entirely transparent. Here are some of the quotes that were recorded to emphasize the narrative:

“I see no meaning in engaging in such because they are just avenues for disseminating homosexuality and encouraging the youths to abort. They come in the sense of advocating for rights but instead teach that abortion and homosexuality is okay and a human right” (Female, 24 years, LU, Feb 2023) . “Family planning services are for big people. But there is need for a comprehensive guidance in matters of Sexual health for adolescents and adults about hygiene and opposite sex interaction” (Male, 16 years, Lira town, Feb 2023) .

Theme 3: friendliness of family planning services

Most of the participants reported that reproductive health services for young people are not friendly. The services are provided in environments that do not guarantee privacy and confidentiality, as well as during inflexible hours. To emphasize the narrative, here are a few verbatim comments:

It’s very difficult to go and access family planning services like pills from the teaching hospital…, can you imagine being served by your own lecturer who discourages having sex before marriage……Hmmm it’s funny! (Female, 24 years, LU, Feb 2023) A friend can help buy contraceptives if the user is known to the health worker who is selling. The seller might inform the buyer’s parents when one goes to buy condoms. (Male, 18 years, Amuca, Feb 2023)

The study aimed to assess perceived access to FP services and associated factors among young people in Lira City, Northern Uganda. Though many models have been suggested to measure access, they have all showed deficiencies in measuring actual access to family planning methods [ 30 ]. This study adopted the Penchansky and Thomas (1981) framework that measures perception of access through a 5-item index to explore the level of perceived access in this study. Findings of the current study showed that good perceived access to FP services was among 31.7% of respondents, with 64.6% reporting availability, 76.5% accessibility, 61.3% acceptability, 66.7% accommodative and 87.9% affordability of FP methods at health facilities. Our study indicates a low perceived access to FP services. Among the various components, availability, acceptability and accommodation pose significant obstacles to contraceptive access. A similar study in South Africa also reported the accommodation component as the greatest obstacle for accessing FP services due to integrated care, long waiting hours, and limited operational hours [ 38 ]. Additionally, the study reported that community were less concerned about the availability of trained service providers and a variety of contraceptive methods [ 38 ]. These possibly explain the low perceived access in the current study. In line with the current study, a recent study on utilization of sexual and reproductive services including family planning among young people in Lira city also reported a low level of 42% [ 39 ].

The overall perceived access to FP services at 31.7% suggests a substantial gap in service availability, indicating the need for targeted interventions to enhance accessibility. The presence of different FP methods at health facilities (64.6%) is a positive aspect, but the study unveils underlying challenges that contribute to the overall low perceived access. One of the key positive findings is the proximity of health facilities for 79.3% of participants, emphasizing the importance of physical accessibility. Additionally, positive perceptions towards use of family planning commodities, such as acceptability of FP use by the young people (61.3%) and a conducive environment at health facilities (66.7%), indicate a foundation upon which interventions can build. However, challenges identified, particularly for females, including a lack of privacy (57.7%), fear of mistreatment by staff (77.2%), and difficulties in decision-making regarding FP use (66.2%), highlight the nature of barriers to access. These challenges align with existing literature on the importance of privacy [ 40 ], quality of service [ 41 ], and decision-making autonomy in shaping individuals’ willingness to utilize FP services [ 42 ].

Quantitative findings revealed significant associations between perceived access to FP services and various sociodemographic factors, emphasizing the complexity of the issue. For females, urban residence, religion, having sexual partners, and perception were identified as influencing factors, while for males, living with parents and overall knowledge played a significant role. These associations underline the necessity for tailored interventions that consider the specific challenges faced by each gender. Qualitative findings highlighted insufficient knowledge, negative perceptions, and unfriendly FP services. These findings provide a deeper understanding of the barriers, emphasizing inadequate knowledge of FP methods, negative cultural and societal perceptions about youth contraception, and unfriendly service environments. These findings are consistent with existing literature, highlighting the role of cultural perceptions, knowledge gaps, and service quality in shaping young people’s access to FP services [ 43 ]. In agreement with previous studies, the study underscores the importance of comprehensive sexual education programs and youth-friendly service initiatives [ 44 ]. Our study shows a notable link between Islam and Catholicism and perceived access to FP services, aligning with previous research on religious influences that notes that the use of contraception is not promoted by any of the two religions [ 45 ]. Further exploration and comparative analysis with other studies may help elucidate these discrepancies and provide a more nuanced understanding of the factors influencing access to FP services among young people in Northern Uganda.

Strength and limitations

The study benefits from a mixed-methods approach, which integrates both qualitative and quantitative data to offer a comprehensive understanding of the factors influencing young people’s perceived access to family planning services. However, the cross-sectional design presents a limitation as it hinders the establishment of causality, providing only a snapshot of the situation at a specific moment and limiting exploration of temporal relationships over time. Acknowledging the small sample size and the potential bias introduced by selecting individuals with extensive knowledge on the topic, we recognize the limitation on the generalizability of our findings only to Lira City. The selection of individuals for IDIs may have inadvertently limited the diversity of perspectives represented in our study. Furthermore, participants may exhibit social desirability bias, particularly in studies addressing sensitive topics like sexual and reproductive health. Recall bias among participants, particularly when recalling past experiences related to sensitive topics or events that occurred some time ago, is also a possibility. Lastly, the quantitative sample was skewed towards females and those aged 15–19 years, potentially affecting the representativeness of the findings.

Our study reveals a substantial gap in perceived access to family planning services among young people. Despite high awareness, barriers like privacy concerns and fear of mistreatment contribute to low access. Tailored interventions are needed, focusing on urban service access, religious beliefs for females, and knowledge enhancement for males. Positive aspects, such as diverse FP methods and physical accessibility, form a foundation for interventions. The study emphasizes the importance of youth-friendly services, comprehensive sexual education, and further research for a nuanced understanding and targeted interventions in Northern Uganda.

Data availability

The data for the study is not publicly available due to restrictions from the Research Ethics Committee (REC) for posting of public data. However, can be accessed from the principal investigator on a reasonable request ([email protected]).

Abbreviations

Sexual Reproductive Health and Rights

Sub-Saharan Africa

Village Health Team

World Health Organization

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Acknowledgements

Pre-Publication Support Service (PREPSS) supported the development of this manuscript by providing author training, as well as pre-publication peer-review and copy editing.

The authors want to acknowledge all the young people who took part in the study. In a special way, we also want to thank Dr. Marc Sam Opollo of Faculty of Public Health Lira University for reviewing and guiding our results presentation for the annual sexual and reproductive symposium presentation in 2023.

This research work was supported by a seed grant from the Center for International Reproductive Health Training at the University of Michigan (CIRHT-UM). The content is solely the responsibility of the authors and does not necessarily represent the official views of CIRHT-UM. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.

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All authors made significant contributions to the conceptualization, design, data collection, curation, manuscript writing, and editing. EK, MKA and RT conceptualized and designed the study. EA, MM, GK, CKN, and SU designed the data collection tools and conducted the study. AK and BO gave overall guidance for the study. All the authors gave final approval to the manuscript for journal submission and are responsible for the content of the manuscript.

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Kigongo, E., Tumwesigye, R., Anyolitho, M.K. et al. Access to family planning services and associated factors among young people in Lira city northern Uganda. BMC Public Health 24 , 1146 (2024). https://doi.org/10.1186/s12889-024-18605-8

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Post-abortion family planning use, method preference, and its determinant factors in Eastern Africa: a systematic review and meta-analysis

• Asmamaw Demis Bizuneh   ORCID: orcid.org/0000-0003-4127-8642 1 &
• Getnet Gedefaw Azeze 2  

Systematic Reviews volume  10 , Article number:  172 ( 2021 ) Cite this article

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Utilization of post-abortion family planning is very critical to reduce high levels of unintended pregnancy, which is the root cause of induced abortion. In Eastern Africa, it is estimated that as many as 95% of unintended pregnancies occurred among women who do not practice contraception at all. Therefore, this meta-analysis aimed to assess post-abortion family planning utilization and its determinant factors in Eastern Africa.

Published papers from Scopus, HINARI, PubMed, Google Scholar, and Web of Science electronic databases and grey literature repository were searched from database inception to January 30, 2020, with no restriction by design and date of publishing. We screened records, extracted data, and assessed risk of bias in duplicate. Cochrane I 2 statistics were used to check the heterogeneity of the studies. Publication bias was assessed by Egger and Biggs test with a funnel plot. A random-effects model was calculated to estimate the pooled prevalence of post-abortion family planning utilization.

A total of twenty-nine cross-sectional studies with 70,037 study participants were included. The overall pooled prevalence of post-abortion family planning utilization was 67.86% (95% CI 63.59–72.12). The most widely utilized post-abortion family methods were injectable 33.23% (95% CI 22.12–44.34), followed by implants 24.71% (95% CI 13.53–35.89) and oral contraceptive pills 23.42% (95% CI 19.95–26.89). Married marital status (AOR=3.20; 95% CI 2.02–5.05), multiparity (AOR=3.84; 95% CI 1.43–10.33), having a history of abortion (AOR=2.33; 95% CI 1.44–3.75), getting counselling on post-abortion family planning (AOR=4.63; 95% CI 3.27–6.56), and ever use of contraceptives (AOR=4.63; 95% CI 2.27–5.21) were factors associated with post-abortion family planning utilization in Eastern Africa.

Conclusions

This study revealed that the marital status of the women, multiparity, having a history of abortion, getting counselling on post-abortion family planning, and ever used contraceptives were found to be significantly associated with post-abortion family planning utilization.

Peer Review reports

Post-abortion family planning is the initiation and use of family planning methods immediately after and within 48 h of an induced or spontaneous abortion or treatment of complications before fertility returns [ 1 , 2 ]. The provision of family planning is important for women in the post-abortion period because fertility can return surprisingly quickly after having an abortion. Even if a woman wants to have a child immediately after an abortion, the World Health Organization (WHO) and Federation of International Gynaecology and Obstetrics (FIGO) guidelines recommend she should wait at least 6 months before getting pregnant again [ 2 , 3 ]. The global estimates for the year 2017 indicate that there were 295,000 maternal deaths worldwide, with Sub-Saharan Africa and Southern Asia accounting for approximately 86% (254,000), with Eastern Africa alone accounting for roughly 542/100,000 maternal deaths [ 4 ].

Every year, more than 44 million women have been complicated with induced abortions, and of these, around 20 million women accounted for unsafe abortions. Unsafe abortion contributes to 13% of maternal deaths globally and 37 deaths per 100,000 live births in Sub-Saharan Africa (SSA). The World Health Organization (WHO) estimates that in Eastern Africa unsafe abortion accounts for one in seven maternal deaths [ 1 , 5 ]. In Africa, 99% of all abortions carried out were unsafe, and the risk of maternal death from an unsafe abortion is one in every 150 procedures which is the highest in the world [ 6 , 7 ].

Offering a wide range of post-abortion family planning methods is likely to increase family planning uptake; as a result, in the immediate post-abortion period, WHO recommended that a woman can safely use a full range of contraceptive methods, including condoms, spermicides, oral contraceptives, emergency contraceptive pills, injectable, implants, IUDs, and female sterilization [ 8 ]. Almost every abortion-related death and disability could be prevented through sexuality education; use of effective contraception; provision of safe, legal-induced abortion; and timely care for complications. Post-abortion family planning (PAFP) has been proposed as a key strategy to reduce unintended pregnancy, repeat-induced abortions and lower morbidity and mortality among women, neonates, infants, and children [ 9 , 10 , 11 ]. However, the accessibility and quality of PAFP services remain a challenge in Eastern Africa where a higher number of unintended pregnancies occur each year. In Eastern Africa, a lot of fragmented studies have been conducted to assess post-abortion family planning utilization and its associated factors among post-aborted women. These fragmented studies reported that the magnitude of post-abortion family planning utilization in Eastern Africa ranged from 15.5 to 90.6% [ 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ]. From the reports of these studies, there was a great variation and inconsistency related to the prevalence of post-abortion family planning utilization throughout East African countries.

The reasons for the above variation in the prevalence and associated factors of post-abortion family planning utilization among East African women have not yet been investigated. The provision of safe, legal abortion is essential to fulfilling the global commitment to the Sustainable Development Goal (SDGs) of universal access to sexual and reproductive health (target 3.7). A systematic review and meta-analysis would help policymakers and health managers and planners to make evidence-based decisions that have taken into account all available information, as well as indicating the quality of the results. Therefore, the main aim of this systematic review and meta-analysis was to estimate the pooled prevalence of post-abortion family planning utilization and to identify its associated factors among post-aborted women that could be used in policy formulation and evidence-based decision-making practices in Eastern Africa.

Materials and methods

Study reporting.

In this systematic review and meta-analysis, we used the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)” guideline [ 21 ] (Table S 1 ).

Databases and search strategies

In this systematic review and meta-analysis, we checked databases without the restriction of design and date of publishing. The search included keywords and MeSH terms, combinations, and snowball searching about relevant papers providing data on the prevalence of post-abortion family planning utilization and/or its associated factors in a search focused on eastern Africa. Studies were searched from databases including PubMed/MEDLINE, Web of Science, Embase, Scopus, HINARI, Science Direct, African Journals, and Cochrane Library. Besides, bibliographies of identified articles and grey literature, like Google and Google scholar, Mednar, World Wide Science, and online University repositories have been scientifically searched (Table 1 ). The following websites were hand-searched: Ipas, Jhpiego, Family Health International, Marie Stopes International, Population Council, Post-abortion Care Consortium, Gynuity Health Projects Engender Health, PRIME II, and Eldis. The following search terms were used: (Prevalence OR Epidemiology OR Magnitude) AND (determinants OR associated factors OR predictors) AND (Post-abortion OR postabortion OR postabortal OR post abortal OR post-abortal OR incomplete abortion OR incomplete abortions OR unsafe abortion OR unsafe abortions AND (family planning use OR family planning utilization OR family planning uptake OR family planning services OR contraceptive use OR contraceptive utilization OR contraceptive uptake OR birth control OR fertility control OR population control) AND (east Africa) and related terms. All countries are categorized under Eastern Africa, namely, Kenya, Uganda, Tanzania, Rwanda, Burundi, Ethiopia, South Sudan, Djibouti, Eritrea, Mozambique, Madagascar, Malawi, Zambia, Comoros, Mauritius, Seychelles, and Somalia. The search terms were used independently and in amalgamation using Boolean operators like “OR” or “AND” and related terms. All article searched from databases was exported to EndNote library. Systematic review with narrative synthesis was used to summarize the findings of articles in Eastern Africa.

Inclusion and exclusion criteria

In this systematic review and meta-analysis, both published and unpublished articles in the English language without time limiting that reported prevalence of post-abortion family planning utilization and/or its associated factors among women in Eastern Africa were included. Articles searched from January 1–30, 2020, were included. Additionally, we restricted our search to observational studies such as cross-sectional, comparative cross-sectional, case-control, and retrospective and prospective cohort studies. Interventional studies, case reports, letters, editorials, systematic reviews, narrative reviews, policy statements, news, and inaccessible full text after two contact attempts of the corresponding author by email were excluded from the final analysis.

Data extraction

After removing duplicates from the Endnote version X8 software, all studies were exported to a Microsoft Excel spreadsheet. Two authors (ADB and GGA) independently extracted all important data using a standardized data extraction form which was adapted from the JBI data extraction format. Substantial agreement between reviewers, i.e., Cohen’s kappa coefficient >0.60, was accepted and resolved through discussion and consensus. For the first outcome (prevalence), the data extraction format included (primary author, year of publication, country, study area, sample size, and prevalence with 95% CI). Data were extracted with a 2 by 2 table format, and then, the log odds ratio for each factor was calculated for the second outcome (associated factors).

Measurement of outcomes

This meta-analysis had two outcomes. The first outcome of this study mainly focused on the prevalence of post-abortion family planning utilization in Eastern Africa. The prevalence was calculated by dividing the number of women who used post-abortion family planning by the total number of women who have been included in the study (sample size) multiplied by 100. The second outcome of the study was factors associated with post-abortion family planning utilization, which were measured by using the adjusted odds ratio from primary published studies.

Quality evaluation

Two authors (ADB and GGA) independently assessed the quality of each study using Newcastle-Ottawa scale (NOS) for cross-sectional studies [ 22 ]. All included articles were cross-sectional in design. The methodological quality of the study, comparability of the study, and the outcome and statistical analysis of the study were the three major assessment tools we used to declare the quality of the study. Lastly, studies that scored a scale of ≥ 7 out of 10 were considered as achieving high quality. During quality appraisal of the articles, any discrepancies between the two authors were resolved.

Data synthesis and statistical analysis

We pooled the overall prevalence estimates of post-abortion family planning utilization using the random-effects model [ 23 ]. After extraction of the articles in Microsoft Excel spreadsheet format, the analysis was carried out using the STATA version 14 statistical software. Cochrane Q test and I 2 statistics were computed to assess heterogeneity among studies [ 23 , 24 ]. After computing the statistics, the results showed there was significant heterogeneity among the studies ( I 2 = 99.2%, p <0.001); therefore, considerable heterogeneity was assumed, and Mantel-Haenszel random-effects model meta-analysis was employed to estimate the Dersimonian and Laird’s pooled effect [ 25 ]. Publication bias was also assessed using Egger’s correlation and Begg’s regression intercept tests at a 5% significance level [ 26 , 27 ]. Due to the presence of publication bias in the study, Egger’s test was statistically significant (p=0.006); as a result, trim-fill analysis was executed. Subgroup analysis was done by the study country, sample size, and year of publication to minimize the random variations between the point estimates of the primary study. Forest plot format was used to present the pooled point prevalence with 95% CI. For associations, a log odds ratio was used to decide the association between associated factors and post-abortion family planning utilization.

Of the total retrieved articles from different databases, 1420 articles remained after expunging the duplicates. Out of the remaining articles, 925 and 403 were excluded after reviewing the titles and abstracts, respectively. Therefore, 92 full-text articles were accessed and assessed for eligibility based on the preset criteria, which resulted in the further exclusion of 63 articles primarily due to the outcome of interest not reported ( n =61) and inaccessibility of the full text ( n =2). As a result, 29 studies meeting the eligibility criteria were included in the final meta-analysis (Fig. 1 ).

Flow chart of selection for systematic review and meta-analysis of post-abortion family planning utilization and its associated factors in eastern Africa

Characteristics of original studies

Among the 29 articles which were published in East African countries until January 2020, 70,037 study participants were involved to determine the pooled prevalence of post-abortion family planning utilization. Regarding the study design, all studies were cross-sectional. Fifteen of the studies were from Ethiopia [ 15 , 16 , 17 , 18 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ], five studies were from Kenya [ 20 , 39 , 40 , 41 , 42 ], four studies were from Tanzania [ 43 , 44 , 45 , 46 ], and the rest five studies were from Malawi [ 47 ], Mozambique [ 48 ], Zimbabwe [ 49 ], Somalia [ 50 ], and Rwanda [ 51 ]. Regarding the quality scores, the quality score of each original study ranged from a low of six to a high of eight (Table 2 ).

Post-abortion family planning utilization in eastern Africa

In this systematic review and meta-analysis, the overall pooled prevalence of post-abortion family planning utilization was 67.86% (95% CI 63.59–72.12) (Fig. 2 ).

Forest plot of the pooled prevalence of post-abortion family planning utilization in Eastern Africa

Heterogeneity and publication bias

The existence of heterogeneity within the included studies was declared with the evidence of I 2 = 99.2%. The evidence of asymmetric distribution of the funnel plot and the statistically significant ( p =0.006) value of Egger’s test showed the presence of publication bias (Fig. 3 ).

Funnel plot with 95% confidence limits of the pooled prevalence of post-abortion family planning utilization in Eastern Africa

Trim-fill analysis

In this meta-analysis, due to the presence of publication bias, we executed a trim-fill analysis by using a random-effects model; the filled meta-analysis results showed that three studies were filled, which increases the number of studies from 29 to 32 with the pooled estimate for post-abortion family planning utilization in Eastern Africa was 65.08% (95% CI 59.42–70.73, p <0.0001) (Fig. 4 ).

Trim-fill analysis filled funnel plot with 95% confidence limits of the pooled prevalence of post-abortion family planning utilization in Eastern Africa

Subgroup analysis

Due to the presence of heterogeneity within the included studies, a subgroup analysis based on the country, year of publication, and the sample size was conducted to identify the source of heterogeneity. Accordingly, the highest prevalence was observed in Zimbabwe with 91.97% (95% CI 90.29–93.65), and the lowest prevalence was observed in Mozambique with 37.05% (95% CI 31.86–42.24). Regarding sample size, the highest prevalence was observed in studies with a sample size of ≥1000 with 78.68% (95% CI 73.42–83.93).

Besides, we also executed a subgroup analysis based on publication year. Accordingly, the highest prevalence of post-abortion family planning utilization has occurred in studies published before 2006, which was 69.70% ((95% CI 53.83–85.58), I 2 = 99.3, p < 0.001) (Table 3 ).

Types of post-abortion family planning methods utilized

In this meta-analysis, women in post-abortion time utilized the common post-abortion family planning methods, namely, injectable 33.23% (95% CI 22.12–44.34), implants 24.71% (95% CI 13.53–35.89), oral contraceptive pills 23.42% (95% CI 19.95–26.89), intrauterine devices 9.12% (95% CI 5.36–12.88), and condom 7.43% (95% CI 5.17–9.69) (Table 4 ).

Sensitivity analysis

We executed a leave-one-out sensitivity analysis to further investigate the potential source of heterogeneity observed in the pooled prevalence of post-abortion family planning utilization in Eastern Africa. Our sensitivity analysis suggested that our findings were robust and not dependent on a single study. The pooled estimated prevalence varied between 66.96 (62.59–71.33%) and 69.78% (66.00–73.57%) for post-abortion prevalence after the deletion of a single study (Table 5 ).

Factors associated with post-abortion family planning utilization

Association between marital status and post-abortion family planning utilization.

In this meta-analysis, four studies were included to see the association between marital status and post-abortion family planning utilization. Those women who had married marital status were 3.2 times more likely to use family planning during the post-abortion period compared to their counterparts (AOR=3.20; 95% CI 2.02–5.05) (Fig. 5 ).

The overall pooled odds ratio of the association between marital status and post-abortion family planning utilization in Eastern Africa

Association between parity and post-abortion family planning utilization

Two studies also indicated that multiparity was strongly associated with post-abortion family planning utilization. Multiparous women were 3.84 times more likely to use family planning during the post-abortion period compared to their counterparts (AOR=3.84; 95% CI 1.43–10.33) (Fig. 6 ).

The overall pooled odds ratio of the association between parity and post-abortion family planning utilization in Eastern Africa

Association between having a history of abortion and post-abortion family planning utilization

Two studies also indicated that the history of abortion was strongly associated with post-abortion family planning utilization. Those women who had a history of abortion were 2.33 times more likely to utilize family planning during the post-abortion period compared to their counterparts (AOR=2.33; 95% CI 1.44–3.75) (Fig. 7 ).

The overall pooled odds ratio of the association between history of abortion and post-abortion family planning utilization in Eastern Africa

Association between getting counselling on post-abortion family planning and its utilization

Furthermore, eight study results from the meta-analyses of the study (Fig. 8 ) have also revealed that getting counselling about post-abortion family planning was a significant factor associated with post-abortion family planning utilization of women. Women who had got counselling on post-abortion family planning were 4.63 times more likely to use family planning compared to their counterparts (AOR=4.63; 95% CI 3.27–6.56) (Fig. 8 ).

The overall pooled odds ratio of the association between post-abortion contraceptive counselling and post-abortion family planning utilization in Eastern Africa

Association between ever used contraceptives and post-abortion family planning utilization

In this meta-analysis, three study results revealed that ever used contraceptive method was a significant factor associated with post-abortion family planning utilization. Women who had ever used contraceptive methods were 3.44 times more likely to use family planning compared to those women who had not used contraceptive methods (AOR=4.63; 95% CI 2.27–5.21) (Fig. 9 ).

The overall pooled odds ratio of the association between ever used contraceptives and post-abortion family planning utilization in Eastern Africa

Discussions

Low post-abortion family planning utilization is considered as one of the primary and major causes of induced abortion or spontaneous abortion or stillbirth since most post-abortion women are at risk of pregnancy almost immediately. Therefore, this systematic review and meta-analysis aimed to estimate the pooled prevalence of post-abortion family planning utilization and its associated factors in Eastern Africa. In this meta-analysis, the overall pooled prevalence of post-abortion family planning utilization in Eastern Africa was 67.86% (95% CI 63.59–72.12). This is lower than the study done in Brazil 97.4% [ 52 ], Asia and Sub-Saharan Africa (SSA) 77% [ 53 ], Pakistan 73% [ 54 ], and India 81% [ 55 ]. However, it is higher than a study done in Kenya 60.9% [ 56 ] and Nepal 49.5% [ 57 ]. This might be due to variation in sample size and differences in socioeconomic status, sociocultural values, norms, religious beliefs, and study setting of the study populations. Besides, it might be due to differences in post-abortion counselling practices, availability of family planning methods and services, and more than half of the included studies in the final meta-analysis were from Ethiopia.

Regarding the subgroup analysis, the highest prevalence was observed in Zimbabwe with 91.97% (95% CI 90.29–93.65), and the lowest prevalence was observed in Mozambique with 37.05% (95% CI 31.86–42.24). The possible justification could be due to the difference in the participant’s level of awareness, educational level, religious beliefs, and various misconceptions and large gaps in the availability and distribution of facilities with basic and comprehensive post-abortion care capabilities across countries. Besides, in Zimbabwe, there is a strong family planning program with one of the highest contraceptive prevalence rates in Sub-Saharan Africa (SSA). Zimbabwe also has a restrictive abortion law, with legal abortion limited to circumstances of rape, incest, fetal impairment, or to save the woman’s life [ 17 , 58 ].

In this study, the overall post-abortion family planning utilization was highest in studies published before 2006, which was 69.70% compared to studies published in 2006. The probable reason might be only five studies with a small sample size that were published before 2006 were included in the analysis, which might contribute to the higher utilization of post-abortion family planning methods. Additionally, those published articles before 2006 also include studies done in Zimbabwe which has one of the lowest abortion rates in Sub-Saharan Africa, likely due to high contraceptive use and a robust family planning program [ 59 ].

Regarding the type of post-abortion family planning methods utilized, the most commonly utilized post-abortion family planning was injectable 33.23% (95% CI 22.12–44.34), implants 24.71% (95% CI 13.53–35.89), oral contraceptive pills 23.42% (95% CI 19.95–26.89), intrauterine devices 9.12% (95% CI 5.36–12.88), and condom 7.43% (95% CI 5.17–9.69). This is in line with a study conducted in Brazil, Pakistan, India, and Nepal [ 52 , 54 , 55 , 57 ]. This might be due to most women preferring to use short-acting methods to conceive after a short period due to higher pregnancy desire. Moreover, it might be due to provider bias towards specific methods, general demand for short-term methods (including the barriers women face in accessing longer-term methods like health care coverage, ongoing source of care, quality of care, disparate access to health information, contraception myths, and increased apprehension of side effects), and supply-related concerns might also contribute.

Women who were married were more likely to utilize post-abortion family planning compared to single women. This finding is consistent with the study conducted in Gondar, Ethiopia [ 60 ]. This might be due to married women may be likely to be having sex more regularly than unmarried women, which may explain their high post-abortion family planning utilization. Besides, currently, married women’s decision-making power on family planning has been raised [ 61 , 62 ] and contraceptive prevalence continues to increase [ 63 ]. Similarly, multiparous women were more likely to utilize post-abortion family planning compared to their counterparts. This might be due to multiparous women who were at higher risk of death due to recurrent abortion, anemia, diabetes mellitus, and other chronic diseases; as a result, they decided to use post-abortion family planning for the recommended period before getting pregnant again. Moreover, multiparous women might want to limit their number of children. Additionally, the multiparous mother may feel more confident to decide on post-abortion family planning individually and by discussing with her partner.

The odds of post-abortion family planning utilization were higher among those women who had a history of abortion compared to those women who had not a history of abortion. This might be due to women who had a history of abortion may get counselling on family planning methods, and they became awarded on the use of post-abortion family planning methods. Similarly, the odds of post-abortion family planning utilization were higher among those women who got counselling on family planning methods as compared with their counterparts. This might be explained that women who get counselling about family planning methods may easily understand the risks of frequent pregnancy for women and the growing fetus, which ultimately increases post-abortion family planning utilization.

Post-abortion family planning utilization was higher among women who used contraceptives compared to those women who never used any contraceptives. This finding is supported by a study conducted in Pakistan [54]. This might be due to women who ever used contraceptives had previous exposure to family planning services, which might influence the awareness of women towards post-abortion family planning utilization. Besides, there is limited evidence contributing to each pooled odds ratio (OR) result in the final meta-analysis.

Limitations of the study

The study designs for all primary articles incorporated in this review were cross-sectional; as a result, the confounding variables most of the time might affect the outcome variable. Furthermore, only papers published in English were included in the review. Most of the publications were from a few countries in eastern Africa which may not be representative of the subregion, and there is also a limited sample size from some countries which makes it difficult to conclude for the entire population of the country. Lastly, relevant research published in another language, or not indexed in the selected databases, has been excluded.

This study revealed that the marital status of the women, multiparity, having a history of abortion, getting counselling on post-abortion family planning, and ever used contraceptives were found to be significantly associated with post-abortion family planning utilization. Therefore, based on the study findings, the authors recommended that policies and protocols should be updated to eliminate barriers such as the requirement that women and adolescents have to be married or have parental or spousal consent for contraceptive services. Advocacy is needed from policymakers and governments for ensuring quality post-abortion family planning services and reducing the unmet need for family planning by giving individualized and patient-centred post-abortion family planning counselling and client interaction, upgrading clinical skills on post-abortion contraceptive methods and implementing efforts to reduce stigma. Generally, health systems and providers in Eastern Africa need support to ensure quality PAC in the face of a reportedly high burden of complications arising from unsafe abortion in the subregion. There is a disturbing lack of evidence on PAFP utilization in most countries in the subregion. As a result, little is known about the utilization of PAFP services in the majority of Eastern African countries. Research with longer follow-up with women, a more rigorous study design with more qualitative support to understand women’s reasons for or objections to PAFP, is needed to fill these knowledge gaps.

Availability of data and materials

The dataset supporting the conclusions of this article is available from the authors on request.

Abbreviations

Antenatal care

Confidence interval

Central Statistical Agency

Ethiopian Demographic and Health Survey

Ethiopian Mini Demographic and Health Survey

Post-abortion family planning

World Health Organization

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Table S1 PRISMA 2009 Checklist

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Bizuneh, A.D., Azeze, G.G. Post-abortion family planning use, method preference, and its determinant factors in Eastern Africa: a systematic review and meta-analysis. Syst Rev 10 , 172 (2021). https://doi.org/10.1186/s13643-021-01731-4

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Received : 17 October 2020

Accepted : 01 June 2021

Published : 09 June 2021

DOI : https://doi.org/10.1186/s13643-021-01731-4

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