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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.

figure 1

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 ).

figure 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.

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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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Ghzl Ghazi Alenezi

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Contributions

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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Correspondence to Hassan Kasim Haridi .

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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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Received : 28 October 2020

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DOI : https://doi.org/10.1186/s43043-021-00053-8

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research paper about family planning

Family planning science and practice lessons from the 2018 International Conference on Family Planning

Jean Christophe Rusatira Roles: Conceptualization, Data Curation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Claire Silberg Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Alexandria Mickler Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Carolina Salmeron Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Jean Olivier Twahirwa Rwema Roles: Conceptualization, Data Curation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Maia Johnstone Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Michelle Martinez Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation, Writing – Review & Editing Jose G. Rimon Roles: Conceptualization, Funding Acquisition, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Linnea Zimmerman Roles: Conceptualization, Methodology, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

research paper about family planning

This article is included in the International Conference on Family Planning gateway.

Family planning, return on investment, women empowerment, reproductive rights, reproductive health, gender empowerment, contraceptive technology

Revised Amendments from Version 1

We have amended the paper to address the comments from the reviewers. Abstract section: We have re-written the abstract to improve readability and clarify the thematic grouping process of the 15 tracks into 6 themes and to address other comments made by the reviewers. Introduction section: We have included more context on the theme. Lessons from ICFP 2018 section: We have made edits to address various comments to expand on the demographic dividend framing and human rights-oriented framing.  We have also incorporated more information on the investments and political environment necessary to harness the DD. We have revised the Male Involvement in FP Programming section and provided copyediting to make the section more succinct. We have also made editorial copy editing to remove grammatical errors and improve the flow of the paper. References section: We have updated the reference list.

See the authors' detailed response to the review by Nguyen Toan Tran See the authors' detailed response to the review by Ann Biddlecom See the authors' detailed response to the review by Gillian Mckay

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Introduction

The family planning (FP) community acknowledges that access to safe, high quality, voluntary family planning is a human right. However, the majority of girls and women, particularly in developing countries, continue to have limited and inequitable access to sexual and reproductive health rights, information, and services, including FP 1 . Although more than 500 million couples in developing countries use FP, the United Nations estimates that by 2030, nearly 200 million women seeking to delay or avoid having a birth will have an unmet need for modern contraception 2 . This demand will likely continue to grow as record numbers of young people enter the prime reproductive ages in the decades to come. It is thus essential that the family planning community identifies high impact approaches to address the major barriers and gaps affecting equitable access to quality family planning.

Since its inception in 2009, the International Conference on Family Planning (ICFP) has served as a strategic inflection point for the FP and reproductive health community worldwide. ICFP serves as an international forum for scientific and programmatic exchange that enables the sharing of available findings and the identification of knowledge gaps, in addition to facilitating the use of new knowledge to transform policy. At the London Summit in 2012, the global FP community set an aspirational goal to enable 120 million more women and girls to access voluntary quality FP by 2020, and the FP community broadened that goal to include universal access to reproductive health care and services by 2030 3 , 4 . The ICFP has been an important, collaborative effort in the buildup to establishing that goal, raising visibility, creating momentum around FP, and leading to concrete changes in policy and programs.

The 2018 ICFP, held in Kigali, Rwanda, was centered on the overarching theme, “Investing for a Lifetime of Returns”. This theme was chosen because of the essential role of FP for the realization of all 17 Sustainable Development Goals (SDGs) and spoke to the various returns that investments in FP provides — from better sexual and reproductive health outcomes and improvements in maternal and child health, to education and women’s empowerment, to long-term environmental benefits and socio-economic growth 5 . Over 700 oral presentations were featured at the conference and covered FP advocacy wins, services developments, and research. Oral presentations were grouped into the following conference tracks: 1) Returns on investment in family planning and the demographic dividend; 2) Policy, financing, and accountability; 3) Demand generation and social and behavior change; 4) Fertility intention and family planning; 5) Reproductive rights and gender empowerment; 6) Improving quality of care, 7) Expanding access to family planning; 8) Advances in contraceptive technology and contraceptive commodity security; 9) Integration of family planning into health and development programs; 10) Sexual and reproductive health and rights among youth and adolescents; 11) Men and family planning; 12) Family planning and reproductive health in humanitarian settings; 13) Faith and family planning; 14) Urbanization and reproductive health; 15) Advances in monitoring and evaluation methods. This paper summarizes the highlights of the scientific program and identifies key findings presented during the oral sessions in the fields of research, programming, and advocacy in order to inform future work in these fields.

The findings summarized in this paper are from 64 abstracts from individual and preformed panel submissions accepted for oral presentations at ICFP 2018. Each co-author of this paper reviewed abstracts from up to three conference tracks based on their expertise and provided summaries from these tracks, organized by emerging key themes. The final abstracts were selected for inclusion in this paper based on the novelty of the findings and contribution to the FP field. These summaries were incorporated to develop the final draft of the paper.

Lessons from ICFP 2018

Investing in family planning for a lifetime of returns.

Measuring the returns on investments in FP is crucial for continued funding and support for FP programs. The business cases for FP presented at ICFP demonstrated the ways in which cost-effective FP programming may save money in the short-term and long-term at the individual, community, donor, and national levels. Willcox and colleagues developed a model based on 47 county referral hospitals in Kenya, which demonstrated that for every dollar invested in training and equipment for implant removal services, a future return of USD $1.62 would be accrued from the economic benefits of continued implants uptake 6 . Costing data presented by Tumusiime and colleagues found that in Senegal and Uganda, the total costs—including direct medical costs (i.e. provider time, supplies, drugs), costs of self-injection training (based on a one-page instruction sheet scenario), and direct non-medical costs (i.e. client travel and time costs)—are significantly lower for the self-injection of depot medroxyprogesterone acetate administered subcutaneously (DMPA-SC) as opposed to provider-administered injectables 7 . In Nigeria, Adedeji and colleagues found that for every $1 invested in high-impact intervention-focused FP programs, an estimated $1.40 may be saved on maternal and newborn care, and another $4 could be saved on treating complications from unplanned pregnancies 8 . While self-administered DMPA-SC may provide a cost-effective approach to improving access to long-acting reversible contraceptive (LARC) methods, a study conducted in Rwanda identified LARCs to be more cost-effective than non-LARC methods post-partum, with a savings of $31.42 per pregnancy averted for two years following birth, and additional cost savings expected over longer time frames 9 .

FP may also be a catalyst for the demographic transition and an opportunity to realize the benefits of the demographic dividend. The demographic dividend describes the changes in the population age structure caused by reductions in population-level fertility and mortality rates. These structural population changes result in a large working-age population and a smaller number of youth dependents 10 . With the correct set of political, economic, educational, and employment policies and opportunities, countries characterized by this population age structure have the potential to take advantage of the large working age population to bolster socio-economic development and create generational wealth 11 . Furthermore, this demographic transition may help countries achieve SDG targets. Modeling has shown that FP investments can positively affect SDGs across several sectors including health, governance, economic growth, agriculture, and education 12 , 13 . Despite improvements in FP funding and financing, expanded financial investments in FP are still needed throughout much of sub-Saharan Africa in order to successfully reach the FP targets necessary for countries to reap their demographic dividend potential 14 , 15 .

Strategies to sustain FP advances include long-term financing for FP, particularly the transition from donor-dependent financing to locally owned initiatives. Donor funding to support FP continues to fall short of the amount needed to address the unmet need of family planning globally and the extent of this gap varies significantly across countries and regions 16 . To mitigate the impact of this shortage in donor funding, it is critical for countries to plan for shifts in financing options, including the procurement of finances for subsidized commodities. Locally owned community-based health insurance (CBHI) schemes, characterized by voluntarily pooled funds, may be a promising option in order to sustain FP financing 17 . Research on CBHI schemes from sub-Saharan Africa showed positive effects on healthcare utilization and FP uptake. In Ethiopia, Pathfinder International found that women who were enrolled in a CBHI scheme were 1.3 times more likely to practice modern FP than those who were not enrolled 18 . Since 2014, the Ethiopian government has slowly shifted away from donor-dependence and has launched and expanded the number of CBHI and social health insurance (SHI) programs in more than one-third of districts. Based on current projections, by 2025, the number of modern contraceptive users in Ethiopia will have doubled from 6 million to 12 million, and the private sector will account for 40% of them 19 .

Data gleaned from nationally representative datasets showed a similar global pattern in factors associated with FP utilization. Findings from the Ethiopia (2016), Kenya (2014), Nigeria (2013), and Philippines (2013) Demographic Health Surveys (DHS), as well as Indonesia’s 2015 Susenas survey, revealed trends in the number of insured women and the modern contraceptive prevalence rate (mCPR); specifically, the ratio of mCPR between insured versus uninsured individuals was greatest among women of the lowest socioeconomic status (SES) in the Philippines, Kenya, Indonesia, and Ethiopia 20 – 23 . Insurance coverage was shown to be directly associated with FP utilization. These findings signify the importance of comprehensive health insurance for FP access, particularly amongst marginalized groups 24 . Another important finding related to FP access and insurance showed how national health priorities supersede FP access. While FP is often included under universal health coverage (UHC) schemes, the inclusion of FP is often not operationalized or realized 25 . Data from 22 priority FP2020 countries showed that the challenges to comprehensive UHC include government prioritization of less cost-effective yet urgent curative services, instead of preventive care or primary services 26 .

Additionally, research on health financing highlighted opportunities for new financing models and insurance schemes. In Tanzania, the United Nations Fund for Population Activities (UNFPA) and DKT International implemented an innovative micro-insurance scheme for urban youth and adolescents, which demonstrated high uptake in just one year of initiation. This program, “iPlan”, required a nominal annual fee of $10, after which an individual received comprehensive sexual and reproductive health (SRH) services including contraceptive counseling and commodities for one year 27 . Similarly, researchers found that the Public-Private Partnership Health Posts model in Rwanda was a cost-effective and viable solution for individuals living more than 60 minutes away from health facilities 28 . The social franchising model created by the Family Health Guidance Association of Ethiopia (FGAE) was also shown to be a cost-effective model as compared to static clinics. When compared to the FGAE-owned static clinics, the cost per Couple Years of Protection (CYP), (an indicator used to estimate protection from pregnancy by family planning/contraceptive methods during a one-year period) 29 was significantly less expensive. CYP provided through the FGAE social franchise model was estimated to be between USD $0.73-$1.77, compared to USD $25.61-37.35 per CYP provided at the FGAE-owned static clinics 30 .

Addressing inequities in family planning for adolescents, youth, and key populations

Inequities in access to FP exist across women from different socio-economic groups, age cohorts, health statuses, and physical abilities. Compared to women of other reproductive ages, adolescent girls and young women (AGYW) have specific FP and sexual and reproductive health needs, including low contraceptive uptake, high risk of unintended pregnancies and unsafe abortions, high risk of sexually transmitted infections, and a greater risk of acquiring HIV 31 , 32 .

Involving youth in advocacy and programming efforts was shown to be critical in order to ensure that their unique FP needs are met. Reproductive Health Uganda developed an innovative program to support young people in realizing their right to hold state-actors accountable for improving access to youth-friendly health services. The initiative led to the successful allocation of county-level funds for youth-friendly services in all sectors and created a network of youth advocates for FP programming 33 . In Kenya, the Network for Adolescents and Youth of Africa developed a holistic advocacy network in Kisii County that led to the allocation of KES 7,000,000 (USD 68,000) to contraceptive procurement and FP services in the financial year 2016/2017, the first time a line item for FP was included in the county budget 34 .

FP programs for youth with hearing and speech impairments included a sexual health education program for adolescents in Vietnam and a social media literacy program integrating SRH and FP information exchange in Burkina Faso 35 , 36 . In Egypt, Love Matters Arabic Project was launched to engage young people on SRH issues, dispel myths and taboos, and improve access to accurate and reliable SRH and FP information 37 . Some researchers maintain that to attract youth and gain their trust, programming must include a pleasure component and tie this information to healthy sexual behaviors and practices 29 , 38 . This hypothesis needs further exploration in future research and programming.

Other key populations highlighted during the conference included youth living in conflict zones, people living with HIV, women with disabilities, female sex workers, people who use drugs, individuals with a low socioeconomic status, and individuals who do not identify as heterosexual 39 , 40 . A nationally-representative survey from Ethiopia found that more than 95% of women living with a mental, physical, or visual disability face obstacles in physically accessing health facilities and are less likely to have access to FP information 38 . Furthermore, this sub-population may be more likely to face discrimination by healthcare providers. These barriers to FP services and knowledge may have direct consequences on health outcomes. For example, among women with disabilities who have ever had a pregnancy, more than 85% reported that the pregnancies were unintended 41 .

Studies from conflict zones in Afghanistan, Cameroon, Liberia, Sierra Leone, and Yemen showed that girls who marry before the age of 18 have lower rates of FP use, less intention to use in the future, and a significantly higher risk of unintended pregnancy, compared to married women 18 years of age and older 42 . Among Somali refugee girls aged 10–19 and living in Ethiopia, nearly 75% of girls were aware of how to become pregnant, but fewer were aware of the risks associated with inadequate birth spacing. Despite nearly one in five girls having already given birth, 40% of participants remained unaware of methods to avoid pregnancy 43 .

People living with HIV may also have trouble accessing comprehensive FP services. A study from Uganda found that unmarried women with an HIV-positive status and women of high parity were significantly less likely to use FP post-partum 44 . Women who take antiretroviral therapy have desires to bear children, learn about contraception, and receive information on methods to prevent mother-to-child transmission of HIV 45 . To this end, it is important that programs recognize this population’s unique desires and needs. A program in London demonstrated the promise of service integration to improve access to FP for women living with HIV; Mabonga and colleagues found a 50% increase in LARC use after the integration of FP and HIV services in a postnatal contraception clinic in London 46 . Integrating HIV and FP services into one convenient location helps promote healthy SRH and child health outcomes, while also easing client burden associated with traveling between different clinics.

Reproductive justice: Abortion care, family planning, and women’s wellbeing

Unsafe abortions have emerged as one of the key neglected public health problems, accounting for more than 1 in 10 maternal-related deaths worldwide 47 . Accordingly, abstracts discussing safe abortion access and FP were cross-cutting through the conference’s tracks. Research on unsafe abortions underscored the determinants of abortion practices as well as inequities in the accessibility of safe abortion services. For example, in both Nigeria and Rwanda, younger, uneducated women in rural areas are more likely to seek out and use abortion services. However, due to restrictive abortion laws, these abortions are often unsafe, which poses not only health challenges but legal challenges as well 48 . In 2012, 24% of all incarcerated women in Rwanda were imprisoned for participating in clandestine, illegal abortions 49 . Access to safe abortion services is a critical component of comprehensive SRH yet continues to be heavily restricted in many parts of the world. Several authors called for targeted advocacy for legal provisions to ensure the availability of safe abortion services 50 , 51 . Amendments to national laws, increased and expanded training of providers, and improved access to medical abortions were highlighted as priorities for policymakers 24 , 52 . Furthermore, emphasis was placed on the recognition of social disparities and inequities in abortion prevalence and access 45 .

Analyses of post-abortion care (PAC) programs for women in humanitarian settings in DRC and Yemen found that providers may effectively shift from unsafe practices of dilation and curettage (D&C) to manual vacuum aspiration and medical treatment with misoprostol. Over a period of 5 years, the percentage of PAC clients requiring evacuation who received D&C as treatment was reduced from of 18.6% to 2.0% in DRC and from 25% to 2.8% in Yemen 53 .

Expanding access to safe abortion services can also directly increase women’s access to FP. Research from Kenya found that, regardless of pregnancy intentions, over 70% of women who attended PAC initiated contraceptives during their PAC visit 54 . Analyses of post-abortion family planning (PAFP) service delivery across two states in India also revealed that 28% of women adopted a contraceptive method within two months after their abortion 55 . Another study from Kenya found that women’s PAFP method varied based on the type of abortion the woman experienced. While women who had undergone surgical abortions were more likely to choose intrauterine devices or other LARC methods, women who had medical abortions were more likely to choose implants. While this may be due to the fact that IUDs can be inserted following a surgical abortion but not following a medical abortion, further research is necessary to ensure women receive the FP method that best suits their needs, preferences, and fertility desires 56 . Insights into context-specific ideals of family size as well as abortion care-seeking behaviors are important in understanding how to improve future PAFP service delivery and increase contraceptive use 51 .

Couple dynamics and family planning decision-making

Research on women’s covert use of FP underscored the ethical tensions between supporting and validating women’s ability to exercise reproductive autonomy without disclosure to a partner while also striving to engage male partners in reproductive health decisions 57 . Research revealed that a woman’s decision to covertly use FP may be linked to discordant partner views on childbearing and fertility desires 58 . One study found that when men expressed beliefs that contraception is “women’s business”, women were more likely to engage in covert use and not disclose their FP decisions to their partners 53 . However, women who use FP covertly often struggle with the cost of contraceptives and worry about concealing FP from their partners 53 . Power dynamics continue to influence FP use, even when women choose to use FP methods covertly.

Couple power dynamics and household decision-making also influences FP utilization. Easterlina and colleagues found that 75% of women in West Pokot, Kenya, identified their husband or partner as the biggest barrier to voluntary FP use 59 . In the Afar region of Ethiopia, 58.8% of women reported not having the freedom to make independent fertility decisions 60 . Conversely, researchers have found that the odds of using modern contraception increases significantly when couples make decisions together 61 . Couples who reported shared decision-making on everyday life choices (e.g. financial decisions) in Ibadan, Nigeria, were more likely to report using FP than couples in which decisions were made solely by the husband 62 . Other factors which have been found to influence FP uptake include the educational status of couple dyads, couple’s knowledge of reproductive health and rights, women’s economic security and involvement in microcredit schemes, and gender equitable household dynamics 63 , 64 .

Male involvement in family planning programming

Considering men’s influence on FP decisions, involving male partners in FP programming is essential to meeting FP goals globally. Males have a desire to learn about FP and contraception but often have limited or inaccurate information which fuels false beliefs and myths. In Uganda, when men were asked why they do not allow their wives to use modern FP methods, participants expressed fears that their wives were likely to become promiscuous if they began using contraception. The researchers also found that male participants’ beliefs about FP were often inaccurate, inconsistent, or grounded in gendered stereotypes, fueling fears about wives’ promiscuity 65 . Similarly, research from Kenya showed that 50% of men in Western Kenya lack accurate knowledge on the possible benefits of healthy timing and spacing of pregnancies 55 . In Nepal, men’s limited understanding of contraceptives were shown also to impact their partner’s uptake of IUDs 66 .

Research revealed the potential of male champions and advocacy networks in changing social norms, educating male peers, and creating a culture receptive and open to family planning discussions. In Uttar Pradesh, India, a community-based information diffusion strategy was used to dispel FP myths and misconceptions and provide comprehensive information on non-scalpel vasectomy. To accommodate the diverse lives of men living in informal settlements, men were engaged by their peers at traditional male gathering points at convenient times, such as evening meetings for rickshaw pullers 67 . In Zamboanga City, Philippines, a packaged community-based learning program, EL HOMBRE, used a peer-to-peer information dissemination technique to share information related to FP, family matters, and family planning 68 . Similarly, a male champions program was rolled out successfully in Western Kenya, where 50 male champions held sensitization forums once a month to encourage discussions on healthy timing and spacing of pregnancies 55 . In Benin, USAID/ANCRE implemented a “men as advocates” intervention that included counseling male spouses on FP when their partners left the maternity ward and creating groups of “committed men” to sensitize male peers. Over the course of a year, post-partum FP counseling for males increased by more than 100% across 47 health facilities 69 .

Couple-based approaches to behavioral change and FP uptake also show promise. Project Concern International implemented a social and behavioral change program that used couples as community change agents to address restrictive social norms and SRH myths, improve couple communication strategies, and aid couples in the development of their FP and fertility goals 70 . The Emanzi program in Uganda also showed a positive changes in equitable gender norms, a rise in shared decision-making in the household, and a significant increase in FP uptake 71 .

Gender-transformative programming is grounded in the notion that changes in gendered norms, beliefs, and behaviors lead to positive health outcomes. Landmark gender-transformative programs included the Bandebereho intervention in Rwanda, which consisted of 15-week group education meetings for more than 4,000 young adult men and women and 1,700 expectant and new fathers and couples. When compared to the control group, findings showed an increase in the proportion of young people who had sought SRH services, as well as changes in positive gender norms and increases in shared decision-making 72 . The GroupUp Smart education curriculum in Rwanda targeted prepubescent male and female adolescents and their parents. The program found that adolescent boys’ awareness of preventing pregnancy increased from 65% to 81% and their knowledge of reproductive health significantly increased. Compared to pre-intervention, adolescent boys experienced significant increases in gender equity scores, pointing to the notion that SRH education which includes a gender component may be more beneficial than SRH education alone, particularly when introduced earlier in life 73 .

Breakthroughs in novel contraceptives and systems improvement in family planning

Research advances in contraceptive technology highlighted the importance of beginning with the end-user in mind. In Nigeria and India, initial acceptability research of a microneedle contraceptive patch (MNP) explored client perceptions of the method and quantified desired MNP attributes. Across both contexts, prospective users liked the potential for self-application and both providers and clients found the method to be easily used. Researchers also wanted to identify user preferences for other attributes, including the method’s effect on menstruation, duration of effectiveness, placement location, pain, and the potential for skin reactions at the application site 74 . These findings underscored high overall acceptability of microneedles as a novel delivery method, yet also emphasized the importance of reducing side effects associated with existing contraceptive methods.

Use of the levonorgestrel intrauterine system (LNG-IUS) has risen rapidly in high-income countries and is one of the most effective forms of contraception available. However, the cost of the method is typically a barrier to clients in low-income countries. Research by Marie Stopes International Nigeria and FHI360 piloted the introduction of an affordable version of the LNG-IUS at multiple service delivery points and found that users, providers, and key opinion leaders were receptive and enthusiastic about the method. Many clients also reported reduced menstrual bleeding as a key non-contraceptive benefit of the method. This research also suggested that a multi-stakeholder approach, including coordinated demand-generation activities, may be important in order to advance the scale-up of LNG-IUS in Nigeria and in other similar contexts 75 .

Improved access to subdermal implants and other long-acting methods like IUDs have raised concerns on whether women can access timely removal services on-demand. Data from pilot studies examining the subdermal implant removal tool, RemovAid, suggested that this novel device is safe to proceed to larger studies, and with it, physicians can safely remove one-rod implants and minimize the removal time to just under seven minutes 76 . Furthermore, initial acceptability research revealed that a novel postpartum IUD inserter would be attractive in India due to high unmet need and a lack of trained providers 77 . These products would not require additional supplies, aside from what it’s packaged with, and demonstrated high client and provider satisfaction.

Novel approaches to service delivery and contraceptive commodity procurement included the development of an “informed push” model, which would change the public health sector’s reporting system to allow for consolidated transport routes and combined supply delivery. Rather than following a typical model where an individual health facility is responsible for FP commodity reporting, product requisition, and pick-up, this model relied on health “zone staff” to optimize transport routes and report on stockouts and product consumption. By consolidating FP commodities alongside other health products and optimizing transit routes, the study demonstrated a substantial reduction in the incidence of stockouts and a decline in transit costs 78 . In India, an application developed by the Ministry of Health and Family Welfare also seeks to collect consumption data, forecast demand, and track commodity distribution. While still in the formative stage, individual states have demonstrated an interest in customization of the app per state to allow the government to improve commodity distribution and transfers by tracking “live” data 79 .

Lastly, algorithm-based fertility apps, such as the Dynamic Optimal Timing application, demonstrated a typical-use failure rate that was comparable to or better than other user-initiated methods, including fertility-awareness based methods. This method delivered consistently correct information to women about their daily fertility status, which suggests that the app could allow women to self-manage fertile days to avoid pregnancy 80 .

The 2018 ICFP scientific program underscored new advances in family planning research, programs, and advocacy work, that have important practical and policy implications. Short- and long-term benefits of FP investments were highlighted, from increased empowerment at both the individual and couple levels to reduced maternal mortality and improved population health. Nevertheless, achieving these dividends as a result of FP investments continues to be thwarted by insufficient funding, limited contraceptive choices, and persistent inequality in accessing FP programs and services.

The growing reproductive-age population, particularly in developing countries, and the increasing demand for FP requires innovative financing initiatives to meet the demand and ensure resilient health systems. Community-based health insurance schemes and public-private partnerships between the Ministries of Health and local businesses are promising solutions to ensure that all girls and women with unmet need can access and utilize FP. Future research should focus on scaling cost-effective, self-administered technologies.

While progress is being made globally on improving access to contraceptive services, urgent actions are required to address the FP needs of specific subpopulations that lag behind. These populations include AGYW, female sex workers, women and girls with disabilities, women living with HIV, and populations living in conflict-afflicted regions as well as other humanitarian settings. Research focusing on such populations is becoming increasingly highlighted at ICFP but remains very limited compared to research and program efforts focused on other populations. Future research should explore the needs of such unique sub-populations and evaluate interventions and programs that may successfully be scaled to address the FP needs of these marginalized groups. Gender and social norms continue to play a key barrier in FP demand generation. Further research is needed to evaluate the effectiveness of gender transformative programs that aim to address gender norms that perpetuate social and health inequalities. Empowerment efforts need to continue to engage men as partners while considering women’s autonomy in FP decisions, and ensure that context-specific couple dynamics and social norms are integrated into programming.

Despite achievements and advances in FP access and utilization, the abortion space still lags behind. Unsafe abortions and abortion-related fatalities remain a neglected and preventable public health problem. Current and future advocacy efforts should focus on the legal provision of abortion care to ensure the availability of safe, decriminalized abortion services. Such efforts should be undertaken in parallel with expanded training for providers, while utilizing the opportunities to integrate FP methods in post-abortion care. To further understand PAC, future research is needed to determine what influences a woman’s decision to use contraceptives post-abortion and the specific method choice selected, and why.

Continued improvements in information systems have allowed for the rapid reporting of inventories, consolidated transport routes, and combined supply delivery. Such systems present an opportunity to address supply chain challenges and prevent stock-outs from the sub-national to the national levels. Artificial intelligence and algorithm-based applications present opportunities for FP information access through mobile user technologies. Allowing such systems to communicate with the supply chain may allow women to better access their contraceptive method of choice and allow couples to achieve their desired family size.

Implementation science research should also focus on understanding the key drivers that affect the uptake of research findings. This research can be used to inform evidence dissemination and utilization by policymakers and other decisionmakers at the local and national levels. FP is not only a social justice issue, but a smart investment for individuals and communities. Ensuring that local leaders and policymakers properly understand these two rationales for FP could be key to success for the global community and may lead to more prosperous and resilient communities. Over the last few years, the concept of the demographic dividend has provided a broader ground for advocates to support FP efforts. The economic theory of the demographic dividend tends to resonate well with policymakers and peoples from various religious backgrounds, including religious leaders. Nevertheless, challenges remain for the human-rights rationale to be as widely accepted as the economic theory.

ICFP 2018 generated rich evidence on successes achieved in recent years and highlighted continued gaps in research, implementation and advocacy. Science and practice lessons demonstrated the need for a multi-sectoral, interdisciplinary approach among FP stakeholders in order to inform new actions to attain the 2030 universal access goal. The universal access goal presents an opportunity for the world to close the gap in FP inequities between individuals of different socioeconomic backgrounds and attain shared prosperity across communities. Investing in FP paves the path for generational wealth and a range of health returns. Addressing FP advocacy, services, and research challenges and continuously sharing lessons learned and best practices through platforms such as ICFP will be essential for countries to accelerate progress towards the universal access goal and ultimately, meet the needs of all women and girls.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.

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Comments on this article Comments (0)

Open peer review.

  • It was not clear to me how many panels there were at the conference. Were the 65 individual and preformed abstracts the sum total of the 700+ oral presentations made? If this was a sub-section, how were these abstracts chosen for inclusion?
  • How did the process of thematic grouping of the 15 tracks into 6 themes take place?   
  • Include a line in the abstract around the methods.
  • Quite technical language is used from time to time, which may be inaccessible to those outside of the FP space. e.g. Community Based Health Insurance & Couple Years of Protection: these terms could be better explained in the text or in a footnote.
  • There are too many acronyms, many of which are only used once, therefore could likely be removed to make the paper easier to read.
  • Some light copy-editing is needed for grammatical errors.

Is the rationale for the Open Letter provided in sufficient detail?

Does the article adequately reference differing views and opinions?

Are all factual statements correct, and are statements and arguments made adequately supported by citations?

Is the Open Letter written in accessible language?

Where applicable, are recommendations and next steps explained clearly for others to follow?

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Reproductive health in humanitarian crises, with a focus on outbreaks of infectious disease.

  • At ICFP 2018, there were 700+ oral presentations presented, submitted as both individual and performed abstracts. Each abstract is counted as one oral presentation. All abstracts were reviewed for the novelty of their findings and 64 abstracts were selected for the final paper. We clarified this in the Introduction and Abstract.
  • The thematic groupings were based on key findings from the selected abstracts and major thematic areas highlighted in these findings. The 15 tracks were from the abstract submissions and guided the review process, but for the purposes of this paper, new thematic areas were defined based on the main findings from the abstracts.
  • The abstract has been revised and this comment has been addressed.
  • Thank you for your comment. We have addressed this by explaining CYP and CBHI directly in the text of the paper.
  • We agree with this comment and have removed all acronyms that only occur once in the paper. We have kept acronyms that are used more than once.
  • We have made editorial copy editing to remove grammatical errors.
  • Respond or Comment
  • COMMENT ON THIS REPORT
  • With regard to the abstract, a line on
  • With regard to the abstract, a line on the open letter objective and methods would help transition between the introduction paragraph and the second one.
  • It would be helpful to learn more about why the theme of “Investing for a lifetime of returns” was chosen, taking into account the tensions between the macro level (e.g. economic and environmental) and individual level (e.g. empowerment, rights, and justice, which are just touched upon).
  • The second para under “Investing in family planning” feels incomplete without acknowledging that access to quality education and employment opportunities is critical to realize the benefits of the demographic dividend.
  • Consider stressing how the conference has embraced and contributed to highlighting the development and humanitarian nexus - as well as safe abortion!  
  • The frequent use of abbreviations might impede the text flow.  
  • Slight text editing required (grammar).  
  • Check references: 2 and 4: UN DESA vs "DESA/Desa, UN". 2: more recent source available? Duplicates 44 & 45?

Reviewer Expertise: Global health with a focus on sexual and reproductive health and rights, including contraception and postpartum family planning, in development and humanitarian settings

  • The abstract has been revised and multiple section breaks have been added to make reading the abstract easier.
  • We have made changes in the paper to address this comment: this theme was chosen because of the essential role of FP to achieving the 17 Sustainable Development Goals and spoke to the various returns that investments in FP provide — from reproductive health outcomes, to maternal and child health improvements, to empowerment, increases in education, and population-level socioeconomic growth.
  • This was addressed in the new iteration of the paper.
  •  This was addressed in the new iteration of the paper.
  • We have removed all acronyms that only occur once in the paper. We have kept acronyms that are used more than one time.  
  • Editorial copy editing was provided to remove grammatical errors and improve the flow of the paper.  
  • This has been addressed in the new iteration of the paper.
  • It would be useful to take a further step back from the analysis of content to raise the larger debates on framing family planning that can often be in conflict among stakeholders with different objectives and agendas for action (government, donor, advocates): e.g., Demographic Dividend framing with fertility reduction a focus and macro-level benefits emphasized versus a human rights-oriented framing, where individual well-being and attention to inequities and reproductive justice are a central focus. On page 8 this situation is raised but not discussed (“FP is not only a social justice issue, but a smart investment for individuals  and communities.”)   
  • On a related note, could the authors speak to what motivated the thematic framing of the 2018 conference to be “Investing for a Lifetime of Returns”?   
  • At least a nod to job growth and productivity-related policy supports is needed around the demographic dividend explanation (“The demographic transition leads to numerous, subsequent population-level and societal benefits…”). The fertility reductions and age structure shifts are necessary but not sufficient. Education and health investments are required as well as the ability of the economy to productively employ workers.   
  • Abstract: State the evidence and method in one sentence on which the theme-based key points are based (i.e., content analysis of conference abstracts). Also, the general phrase “locally owned models provide alternative financing solutions” is not clear for a general reader, perhaps add an example (such as….)   
  • The abstract has a heavy focus on research alone (“ICFP 2018 highlighted research advances, implementation science wins, and critical knowledge gaps in global FP access and use.”) and yet a substantial part of the program was devoted to utilization (advocacy, policy and program shifts).   
  • (page 6) Clarify if the contrast group is individual decision-making? (“…have been found to be significantly associated with couple’s FP decision-making 60,61 ”)   
  • Explicit attention by the authors (and the conference) to safe abortion is merited as it is a topic and essential intervention often ignored or sidelined in the scientific literature. A helpful contribution of the conference. 
  • Where possible, minimize the use of acronyms for readability (e.g., AGYW).   
  • Reference 2 is not correct. The statement is about the number of couples in 2030 with unmet need for modern methods (and the 2020 revision is available now for all women, not just married women -- https://www.un.org/en/development/desa/population/theme/family-planning/cp_model.asp ), but the reference is a much older publication on population estimates (DESA, UN. United Nations Department of Economic and Social Affairs/Population Division: World Population Prospects: The 2008 Revision. 2009b.)   
  • (page 6) Given the restricted space of an open letter and the number of studies covered, suggest not highlighting the same local study twice (Easterlina and colleagues).   
  • Reference 4 is an official UN publication - the SDGs - and not from the Dept of Social and Economics Affairs (DESA).   
  • References 44 and 45 are duplicates.   
  • Light copy-editing needed (e.g., in abstract “Promising evidence show that…”, “couple discordance…directly influence…”; elsewhere “95% of women living with a mental…faces…).

Reviewer Expertise: Demographic research focused on contraceptive use, abortion, reproductive decisionmaking and adolescent sexual and reproductive health.

  • This was addressed in the new version of the paper.
  • Thank you for this comment. We have made changes in the paper to address this comment: this theme was chosen because of the essential role of FP to achieving the 17 Sustainable Development Goals and spoke to the various returns that investments in FP provide — from reproductive health outcomes to maternal and child health improvements, to empowerment, increases in education, and population-level socioeconomic growth .
  • We have revised this section and incorporated information on the investments and political environment necessary to harness the DD.  
  • We have provided more details to clarify in the Abstract the process of selecting the final themes for the paper.  
  • The abstract has been revised considerably and we have attempted to address this comment.  
  •             We checked this abstract and changed the wording to provide clarifications.         
  • This has been addressed in the new iteration of the paper. Correct citation: United Nations, Department of Economic and Social Affairs, Population Division (2017). World Family Planning 2017 - Highlights (ST/ESA/SER.A/414).
  • The Easterlina et al. paper was used to augment data on male partners’ lack of education and misinformation related to FP. We have kept the citation but revised the Male Involvement in FP Programming section and provided copyediting to make the section more succinct.  
  • This has been addressed in the new iteration of the paper. Correct citation 4. UN (United Nations). 2015. Transforming our world: The 2030 Agenda for Sustainable Development. https://sustainabledevelopment.un.org/post2015/transformingourworld. Accessed 19 August 2020.
  • This has been addressed in the new iteration of the paper.  
  • Editorial copy editing was provided to remove grammatical errors and improve the flow of the paper.

Reviewer Status

Alongside their report, reviewers assign a status to the article:

Reviewer Reports

  • Ann Biddlecom , Guttmacher Institute, New York City, USA
  • Nguyen Toan Tran , University of Technology Sydney, Sydney, Australia; University of Geneva, Geneva, Switzerland
  • Gillian Mckay , London School of Hygiene and Tropical Medicine, London, UK

Comments on this article

All Comments (0)

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Perceptions of family planning services and its key barriers among adolescents and young people in Eastern Nepal: A qualitative study

Navin bhatt.

1 B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Bandana Bhatt

2 Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal

Bandana Neupane

3 Nepal Health Sector Support Programme (NHSSP)/DFID/Ministry of Health and Population, Kathmandu, Nepal

Ashmita Karki

4 Central Department of Public Health, Institute of Medicine, Kathmandu, Nepal

Tribhuwan Bhatta

5 Department of Electronics and Computer Engineering, Institute of Engineering, Tribhuvan University, Lalitpur, Nepal

Jeevan Thapa

6 Department of Community Health Sciences, School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal

Lila Bahadur Basnet

7 School of Public Health and Community Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Shyam Sundar Budhathoki

8 Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom

Associated Data

All relevant data are within the manuscript and its Supporting Information files.

Introduction

Family planning methods are used to promote safer sexual practices, reduce unintended pregnancies and unsafe abortion, and control population. Young people aged 15–24 years belong to a key reproductive age group. However, little is known about their engagement with the family planning services in Nepal. Our study aimed to identify the perceptions of and barriers to the use of family planning among youth in Nepal.

A qualitative explorative study was done among adolescents and young people aged 15–24 years from the Hattimuda village in eastern Nepal. Six focus group discussions and 25 in-depth interviews were conducted with both male and female participants in the community using a maximum variation sampling method. Data were analyzed using a thematic framework approach.

Many individuals were aware that family planning measures postpone pregnancy. However, some young participants were not fully aware of the available family planning services. Some married couples who preferred ’birth spacing’ received negative judgments from their family members for not starting a family. The perceived barriers to the use of family planning included lack of knowledge about family planning use, fear of side effects of modern family planning methods, lack of access/affordability due to familial and religious beliefs/myths/misconceptions. On an individual level, some couples’ timid nature also negatively influenced the uptake of family planning measures.

Women predominantly take the responsibility for using family planning measures in male-dominated decision-making societies. Moreover, young men feel that the current family planning programs have very little space for men to engage even if they were willing to participate. Communication in the community and in between the couples seem to be influenced by the presence of strong societal and cultural norms and practices. These practices seem to affect family planning related teaching at schools as well. This research shows that both young men and women are keen on getting involved with initiatives and campaigns for supporting local governments in strengthening the family planning programs in Nepal.

An unmet need for family planning results in unintended pregnancies and illegal abortions. This has major health and social implications and is often the leading cause of maternal and child mortality in low-income countries [ 1 , 2 ]. An estimated 214 million women of reproductive age lack access to contraception resulting in an estimated 67 million unintended pregnancies, 36 million induced abortions, and 76,000 maternal deaths each year [ 3 ]. Family planning (FP) is a key intervention to limit these adverse health outcomes [ 4 – 6 ]. Such interventions can prevent 90% of abortions, 32% of maternal deaths, 20% of pregnancy-related morbidity globally, and reduce 44% of maternal mortality in low-income countries [ 1 , 7 ]. FP reduces adolescent pregnancies, prevents pregnancy-related health risks, and helps to prevent HIV/AIDS [ 8 ]. Access to contraception promotes education, raises the economic status of women, and gradually empowers them resulting in improved health outcomes and better quality of life [ 3 , 5 , 9 , 10 ].

Global data show that only 32% of married women from low-income countries currently use modern contraceptives [ 9 ]. According to the Nepal Demographic Health Survey 2016, the total fertility rate was 2.3 births per woman, which is declining and approaching replacement fertility. This is an important achievement. However, the modern contraceptive prevalence rate (mCPR), which is 43%, is still below the target in Nepal [ 11 ]. Nepal has consistently failed to reach the target of mCPR for the past 20 years. The future projection of mCPR for 2030 is 60% [ 5 ], which may be a distant dream if the barriers and enablers are not identified on time to strengthen the current efforts.

Expanding the coverage and access to effective contraceptive methods are essential to meet the Sustainable Development Goals and to achieve universal access to reproductive healthcare services by 2030 [ 11 , 12 ]. For this, the government of Nepal has started a FP program with a focus on increasing the use of FP services and reducing the unmet need [ 5 , 11 ]. However, various factors negatively influence the delivery of FP services including lack of information, limited awareness of dissemination activities, lack of trained staff, and various cultural and religious factors [ 13 ].

Family planning is a choice for many youth, but they often experience barriers such as negative provider attitudes, long distances to healthcare facilities, and inadequate stock of preferred contraceptives [ 13 , 14 ]. Nepali youth are reluctant to use modern contraceptives due to misconceptions about long-term fertility risks, fear of side effects and overall lack of deeper knowledge [ 15 , 16 ]. Besides, FP decisions are mostly dependent on male household members, including husbands and other elder members [ 17 , 18 ]. Married women whose husbands are away as migrant workers face unique contraceptive challenges. When their husbands return home for a few weeks in a year, these women are not prepared with their contraceptives, which can result in unwanted pregnancies [ 18 ].

The extrapolation of the available literature on FP use among adults from Nepal and elsewhere suggests that youth is an under-researched population when it comes to FP There is also a dearth of evidence on perception and key barriers to the use of FP measures in this population. Hence, this study aims to identify the perceptions of the FP services and barriers to the use of FP among the youth in Nepal to assist policymakers in designing appropriate interventions to strengthen the family planning programs in Nepal.

Material and methods

Ethical considerations.

The study received ethical approval from the Institutional Review Committee of B.P. Koirala Institute of Health Sciences, Dharan, Nepal as per the Undergraduate Research Proposal review process (URPRB/01/015). We obtained informed written consent from all participants aged 18 and above. For minors, we obtained assent from the parents of the participants with the participants’ permission. For those who could not read, the information sheet was read aloud by a volunteer, verbal consent was given, and a thumbprint, in the presence of a witness, was used in place of a signature. To maintain the confidentiality of the information and the privacy of the participants, only selected participants and the moderators attended the sessions. Personal identifiers and locator information were not collected, and any identifying information accidentally mentioned was removed from the text before the analysis.

Study setting

The study was conducted among the participants from Hattimuda village of Morang district in Province One of Nepal. Hattimuda village is a community service area of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. BPKIHS is a public-funded health sciences university, which follows a teaching district concept adopted as a part of its community-based medical education curriculum. BPKIHS also runs a tertiary hospital service for the population of eastern Nepal [ 19 ]. There is a public health facility in Hattimuda village that provides primary health care services including FP services such as the distribution of contraceptives. The nearest secondary and tertiary levels of healthcare services are available 18 kilometers away in Biratnagar, which is the provincial capital and the headquarters of Morang district. According to the 2017/18 annual report of the Department of Health Services, the contraceptive prevalence rate of Morang district is 54.6% [ 5 ] whereas the unmet need for FP in Province One as per the Nepal Demographic Health Survey 2016 is 25% [ 11 ].

Study design

This was a qualitative study with an exploratory design to gather a deeper understanding of the perception of FP and its barriers. Focus group discussions (FGD) and in-depth interview (IDI) methods were used. The overall study lasted from November 2017 to October 2018.

Study population and sampling technique

Adolescents and young people between 15 and 24 years of age from Hattimuda were included in the study. We used the maximum variation sampling method to enroll participants. Pretesting, including one FGD and four IDIs, was conducted among residents in another village of the same district. The pretesting guided the selection of participants for FGDs and IDIs. Accordingly, FGDs were conducted among adolescents and young people, separately for male and female participants to allow for free expression of views during the discussion of potentially sensitive issues. Moreover, the respondents recommended that people at the forefront of the community such as the village leaders, schoolteachers, community health volunteers, religious leaders, youth leaders, and students be selected for the interviews to gather more information. Along with the recommendations from the pretesting, brainstorming was done with community volunteers to generate a list of people who understood the issues of adolescents and young people. More volunteers were added to the list upon the recommendation of the initial respondents. Thus, participants representing diverse backgrounds in terms of gender, profession, education, and social status, were selected. The IDIs were done among 25 prominent people in the community, which included leaders, school teachers, female community health volunteers, healthcare professionals working at the health post and FP service centers, and youth leaders from youth clubs. Health care providers were included in the interviews as their views would be invaluable due to their experience as FP service providers and as witnessing the health issues faced by youth. The teachers are regarded highly for their knowledge and opinions in Nepali communities. So, they were selected for the IDI to provide more insight into the educational barriers to FP and to help in youth mobilization for FP activities. Considering the vital role of local leaders in influencing the implementation and regulation of population-level activities in the village, they were selected for IDI. Six focus groups were conducted with a total of 48 respondents ( Fig 1 ).

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Data collection

The Focus Group Discussions (FGD) and In-depth interviews (IDI) were conducted by the researchers within the team with prior experience in qualitative research methods. The interview team included an undergraduate medical student, two postgraduate resident doctors, a public health graduate, and a public health academic researcher. Before data collection, an orientation session was conducted for the interviewers using the interview schedule and the topic guide. The IDI guidelines and interview schedules were developed from the literature review and were modified after pretesting. Validation of the tools was ensured by using the Item Objective Congruence (IOC) index and consultation with academics with experience in FP research. Using a semi-structured open-ended questionnaire, the participants were assessed on their knowledge and perceptions regarding sexual and reproductive health (SRH) and FP, SRH problems faced by youth, challenges and barriers to use of FP services, the role of youth in combating the perceived challenges, and suggestions for enhancing the use of services. Data were considered to have reached saturation when the responses from participants became repetitive and/or no new responses were received.

Focus group discussions

A representative group of youth from diverse backgrounds who could provide credible information about practices and factors affecting the use of FP in the community was selected. Separate FGDs were held for girls and boys to allow for free expression. A moderator was responsible for guiding the discussion and a note-taker for taking the notes, including recording non-verbal responses and ensuring the audio recording. A total of 6 FGDs, each containing 8 homogenous participants, were conducted. Each individual participated once in the FGD. Every member of the group could make their contribution to any question posed before proceeding to another question. Each FGD lasted for 60–90 minutes on average. The discussion was done in the Nepali language as preferred by participants and later translated into English during transcription.

In-depth interviews

In-depth interviews with the key stakeholders were conducted using the Interview Schedule after obtaining the informed consent and audio-recorded with participant permission. A total of 25 IDIs were conducted for the average duration of 30–45 minutes, at a location convenient to the participant, which included their homes and offices.

Data management and analysis

A framework method of thematic analysis was used. The analysis included stages of transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting the data into the framework matrix, and interpretation of the data. The data collected from the focus groups and interviews were transcribed verbatim. The notes taken were used as a guide to segregate the responses by different respondents during the discussion. An independent researcher conversant in the Nepali and English languages cross-checked the transcripts for accuracy and preservation of original meaning during translation. Preliminary codes were assigned to the available data and then organized into thematic units that were continually revisited and revised as necessary. To ensure consistency of data and findings, two authors were involved in data analysis and reporting. The recordings were stored and accessed by the research team only and were destroyed after the analysis and final report preparation.

Operational definition

According to UNFPA, all persons within the age of 15–24 years are considered youth [ 20 ].

The baseline characteristics of the participants can be seen in Table 1 .

The responses from the IDIs and FGDs revealed four broad themes. Within each broad theme were several substantive sub-themes that emerged from the data. The themes and subthemes are summarized in Table 2 below.

Theme 1: Knowledge and perceptions of FP

A) knowledge and sources of information on fp.

Participants demonstrated awareness of some form of FP. However, some knew nothing about it. Health workers were commonly referred to as the sources of information, while some also mentioned peers, radio, television, and books. Male participants openly disclosed their sources of information on FP while some female participants were reluctant to share their sources.

b) Perceptions of FP

Perceptions of FP varied among participants. Some male participants inferred FP measures as women’s business and did not show any interest in talking more about it. Some referred to FP as using condoms during intercourse, while others referred to oral pills and injectable hormones as FP. Some female participants looked at FP as a way of avoiding unwanted pregnancies.

“My sister used to say that she has been using injection (Depo-Provera) to control unwanted pregnancy . I think FP is about the same . ”- 19 years Female , FGD participant

Theme 2: Preference for FP methods and decision-making

Some female participants reported preference for traditional methods of contraception such as coitus interruptus and calendar method over modern methods. These people used modern methods of FP to start with, which they discontinued later due to the side effects. Participants also stated that the health facilities that provide FP services were far, and hence they had no alternative other than natural methods. Male participants hardly mentioned visiting any health facilities for FP purposes.

“Most of our clients who come for it (FP) are women. Even condoms are collected by women. Men rarely come alone or as couples for FP services.” - 35 years old Female, FP service provider, IDI participant

Yet husbands were responsible for the decision-making about FP and choices of methods for most couples. Some participants (both male and females) mentioned that women rather than men should use permanent FP measures. They believed that men being the breadwinner of the family, should not undergo sterilization, for example, as it would make them physically weak.

“Though I love my wife and I am concerned about her. But I have no options. I must work in a factory. I need to lift heavy weights there. All the major house chores are also done by me. These things (sterilization) would make me weak. How can I earn my livelihood then?”- 22 years Male, FGD participant

Some female participants expressed their concerns regarding the use of permanent FP methods. They mentioned that they had already been through various phases of pain, be it during menstruation, pregnancy, or delivery which has made them weak. Thus, they prefer their husbands to undertake any measures.

In contrast, unmarried participants stated that they would rather discuss and decide together with their partners regarding which method to choose in the future. Despite this interest, women were not sure how to engage their husbands in discussion. Some female participants said that they could not persuade their future husbands to use contraceptives as it would be disrespectful, whereas a few male participants believed it was a woman’s responsibility to use FP methods.

“It (FP) is stuff to be done by the women . So , there is no doubt about who would be doing it . Moreover , people would laugh at me if I do it -20 years Male , FGD participant “ Women have already gone through much pain in bringing up and taking care of the children and again keeping this stuff (FP) in their head is unjustifiable . As such, in comparison to the female operative procedure, I have heard that the male one is simple, less time consuming, and does not bring many complications . So, why not we men take the lead on this? ” -25 years Male, Youth leader, IDI participant

Theme 3: Barriers and challenges in the use of FP

A) supply-side barriers and challenges.

Participants indicated that contraceptive services are not always accessible nor affordable in rural areas. Health facilities are far, and many people feel reluctant to travel in a hot climate. Participants who were reluctant to travel said they were doubtful that the health facilities would have the methods in stock even if they managed to walk the distance. Others who were reluctant said they would be unable to afford the contraceptives from a private medical store regularly. A few participants raised the issue of privacy and unavailability of all services at the health centers. Similarly, young males from the community complained that the services at the health post were focused only on mothers and married couples, while the boys and the unmarried people were not given much attention. For this, they suggested changing the term to something other than FP because they believed that FP should include not only those who had families.

Participants expressed their frustration that FP and SRH services in their village had not been running well for more than a year. They felt that the government was not doing anything about it either. Some students expressed the need for an integrated curriculum at school covering every aspect of SRH and FP that would ensure adequate and proper knowledge of such crucial subjects. Despite the students’ desire to learn and understand FP, their teachers are often reluctant to talk about FP in detail. The participants also indicated that family members, in general, forbid girls and women from getting involved in FP awareness activities.

“Though we are eager to learn about those lessons (reproductive organs and health), our teacher skips them. They tell us to read it by ourselves.” -18 years Female, FGD participant

b) Demand-side barriers and challenges

A few participants were confused about which method to choose, how to use it properly and did not even know where to seek FP services locally.

“My husband works abroad. Last year, when he came home during Dashain (festival), we had (intercourse). Later, he returned to his workplace. Meanwhile, I came to know that I was pregnant, after 3 months. I was shocked to hear that. We already had 3 children; 2 of them were unplanned. I did not have enough information about contraceptive measures in this situation. Had I known about them; I would have used them. I had serious trouble travelling to get it aborted.” - 24 years Female, FGD participant

Some female participants expressed their reluctance to use FP methods due to their own or other people’s past experiences and the fear of side effects, including vaginal bleeding, spotting, abdominal pain, nausea, vomiting, headache, acne, and infertility. These female participants expressed the need for a single-use FP method with fewer side effects for women which could be used without their husbands’ consent. The male participants were worried about the risk of unwanted pregnancy due to the breaking of condoms and a few participants also expressed concern that they experienced allergic reactions after the use of condoms. Moreover, they were concerned about not having any alternative methods of contraception other than condoms.

“I have a much bitter experience. I was using Depo injection before. But I started having over bleeding for which I was admitted to the hospital for a few days. Later, I was switched to implants but they also did not suit me. In between I also used pills, but they aggravated my acne and I was feeling nauseated every day. Uff…. I am fed up now. I swear, I won’t ever use any methods.” - 19 years Female, FGD participant “I have heard that keeping these things (Copper-T) in the uterus can cause cancer. Better to avoid it.” - 20 years Female, FGD participant “There aren’t many choices for men. I think using a condom during sex is like tying plastic around the tongue and eating food.” - 21 years Male, IDI participant

Religious and ethnic variation affected use of FP. Participants reported that people belonging to upper caste groups used FP measures more than lower caste groups. Likewise, people who had migrated from the hilly areas used FP services, whereas people from the local ethnic community did not use as they were less aware of it. FP decisions among young people seem to be influenced largely by religious beliefs, stigma, and the perceived role of men and women based on existing social norms. Some participants regarded children as a gift from God and denied using any FP methods. Some believed using FP was going against the law of nature, religion, and culture; thus, they would not avoid childbirth, but rather celebrate every birth. Some indicated that if couples did not have children within 1–2 years of marriage, then people would question the woman’s fertility. Most couples preferred sons to daughters as they believed sons would look after them and their property, while the daughters would be married and sent away, resulting in avoidance of FP measures until they have a son. Some couples even wished to have two sons because if anything unfortunate happened to one, the other son would still be with them to carry the generation forward.

“My aunt gave birth to a son after 5 successive daughters. She is pregnant again this time in the hope to have a son. She says that she cannot trust to have only one son because if anything happens to their only son, then she will have no one to pay tribute after her death.”- 22 years Female, FGD participant

Participants also said that people felt shy talking about FP openly. Female participants also felt uncomfortable asking for contraceptives with male health personnel at the health post. Similarly, teachers felt uncomfortable teaching about reproductive health and FP as their children and relatives could be present as students in the classroom. Participants indicated that some students would laugh and smile, making it difficult for the teachers to run the classroom sessions smoothly.

It was reported by a FP service provider that some men opposed their wives using any FP measures as they perceived that the use of FP measures allowed their wives to become promiscuous when they go abroad for work.

“Some husbands working abroad forbid their wives from using any FP measures because they fear the use of FP measures may provoke a sexual relationship with someone else in their absence”- 30 years Female, Health professional providing medical abortion services, IDI participant

Theme 4: Role of youth and suggestions to improve FP

The youth were interested in getting involved in a “peer to peer education” approach to increase awareness among the community about FP use. This approach would include peer training programs, role-plays/dramas, and counseling sessions to break the key barriers linked with such services. Activities ranging from redesigning the school’s curriculum to strengthening FP services in primary care centers, and from launching mobile outreach clinics to facilitating “spousal communication” were intended to change attitudes and support gender equality in sexual and reproductive health. Participants emphasized forming youth centers and collaborating with other youth clubs in the village. Furthermore, they suggested bringing religious leaders, teachers, doctors, and politicians as advisors of the youth centers would be beneficial as they are influential members of the community.

“I feel bad for my sister who is not given much importance from my parents. She got married against her choice due to her parents’ pressure. Now, they are forcing her to have kids. She is just 15 and if she gets pregnant, what will happen to her health and her child, how can she take care of a baby? I had a long debate with my father yesterday. I have now decided to start a youth club to promote awareness regarding FP and preventing early marriage and teenage pregnancies.” - 23 years Male, FGD participant

Male participants indicated that family planning programs are effective only when men prioritize women’s autonomy. Moreover, they expressed disappointment with the local government for not encouraging the involvement of men in FP programs in their village. To help address this issue, they expressed their interest in supporting the local government in bringing inclusive FP programs to their village.

“For a long time, women have been using those (Contraceptives) by hiding. We are always in fear about what others would say if they came to know about us using it. This can be addressed through male involvement and support.” -24 years Female, FGD participant

This qualitative study provides in-depth information on the understanding and perceptions of youth in Eastern Nepal regarding FP. This study generated findings regarding knowledge and perceptions of rural residents regarding FP and its methods; decision-making and preference among participants; supply-side and demand-side barriers and challenges regarding the use of FP measures; steps that can be taken to improve their use; and the role of youth in increasing FP coverage. Although most participants knew something about FP, a few female participants were completely unaware of it. And while some participants agreed that all married couples should be using FP measures, some unmarried male participants believed that those measures should be exclusively for women. These men said that they would let their wives use them after getting married. Current FP methods for men are either coitus-dependent, such as condoms or withdrawal, or permanent, such as vasectomy. Limited choices for men may have resulted in misconceptions that contraceptives are mostly for women.

Men often claimed to be the sole decision-maker of the family on important matters, including those related to family health and contraception. In most circumstances, men solely decide the FP measure to be used without having a discussion with their partner. This might be one of the reasons why women are bound to adopt a FP method that is not necessarily their choice. Besides, this problem is further reinforced by the limited options of FP methods available for men other than condoms and permanent sterilization. These findings are supported by other studies in South Asia, where family planning measures are mostly considered women’s responsibility [ 21 – 24 ]. Health workers, peers, and mass media were the most common sources of information regarding FP similar to prior studies in India [ 21 , 24 ] and Nepal [ 22 ]. Participants in this study seemed to assign FP responsibility to the other gender in terms of using FP. This could mean that there is a gap in communication within the couples when deciding about FP. There is a need for further research to identify ways to improve communication among couples.

Religious and ethnic variation influence FP use. People belonging to privileged ethnic groups used FP measures more than underprivileged groups. This is despite family planning services being free for all citizens in Nepal. In this study, people who had migrated from hilly regions knew about and used FP services more than those belonging to the ethnic community in the local region. This is an area for further research to understand differences in knowledge and perceptions regarding FP between the population groups. This can be argued as a limitation of the current FP promotion programs, which may not have considered the different needs of people from different religious and ethnic backgrounds [ 25 ]. A few participants reported that their holy scriptures forbade them from using FP methods as they viewed children as a gift from God; any artificial process interrupting pregnancy or preventing the possibility of life is a religious offense for them [ 26 ]. Previous studies from Nepal have shown that this belief has long been rooted in some communities [ 27 – 29 ].

Apart from religious beliefs, fear of side effects, having experienced adverse health consequences after using hormonal contraceptives, and fear of potential infertility in the future are reasons for reluctance using FP methods among women [ 30 ]. Besides, we can speculate that language and cultural barriers, and fear of discrimination especially by male counterparts negatively influence the use of FP measures among some women despite their strong interest in using them. The use of IEC materials in raising awareness and empowering married couples for shared decision-making could help generate demand [ 28 , 29 ]. Local cultural taboos restrict open communication about safer sex measures and sexual health in Nepal, prohibiting young girls and boys from receiving adequate information and guidance regarding sexual and reproductive health and FP [ 31 ].

Most of the married women and men stated that the decision-makers of the family are men. The husband decides whether or not to use contraception, or more specifically, whether or not to let their wives use it. However, unmarried participants expressed their willingness to decide mutually with their spouse regarding FP use in the future [ 21 , 32 ]. Most women in this study seemed comfortable letting their male partners decide on contraceptives. This attitude could be explained by the patriarchal dominance in decision-making [ 19 , 33 , 34 ].

Some men mentioned that condoms inhibit their sexual pleasure, which is why they prefer women to use other methods instead. A study conducted in Far West Nepal and another nationwide study reported similar concerns among men [ 31 , 35 ]. Adolescent girls stated that they were not comfortable talking to a male health worker about FP or to a female worker in the presence of a male health worker, which has also been reported elsewhere [ 36 ]. Some women said that their husbands forbade the use of contraceptives because they thought that contraceptives would allow their wives to become promiscuous and that using FP was a sign of infidelity. This issue, however, was not raised by any men in the study. Some women reported violence as a consequence of using contraceptives without their husband’s consent. Prior qualitative studies also reported that women may suffer domestic violence for opposing their husbands. Studies suggest that a multi-sectoral action involving stakeholders from health, women’s rights, and education sectors is imperative to further research and address this issue [ 29 , 36 , 37 ].

Supply constraints (distance to a provider for getting contraceptives, out of stock, limited choices of contraceptives, unaffordable methods, etc.) could aggravate the unmet need for contraception. These constraints are similar to all regular supplies faced by the health system in Nepal. However, supply-side interventions such as increasing the number of health facilities distributing FP services, policy focusing on consistent operating hours, and full stock of a wide variety of FP methods could largely improve uptake and increase contraceptive coverage [ 18 , 38 ].

Most female participants did not speak up when asked about their perception of the role of men in FP. On the other hand, male participants explained that the role of the youth could be disseminating FP information, conducting awareness campaigns, organizing dramas and role-plays to educate people about the religious and cultural barriers of FP use, etc. With appropriate training, the young men said they would be willing to work for FP advocacy in the community.

Reproductive health leaders and planners should identify men who are willing to share decision-making authority with their wives and devise behavioral change interventions [ 39 ]. Male participation could support the FP programs and also help empower women [ 40 ]. The participants in the study expressed the need for the current FP programs to consider the community members as key stakeholders in planning FP programs. There is a need to further explore possible ways of working with the rural, marginalized communities and hard-to-reach or specific ethnic groups to improve their update of FP services [ 41 ]. There is evidence that mass media messages increase the likelihood of FP use, which could be considered by advocacy and dissemination programs [ 42 ]. Evidence from maternal and newborn health care research shows that interventions that engage men result in more equitable couple communication and shared decision-making. This may be a relatable concept to be considered for FP programs as well [ 43 ].

We urge those in charge of the health and sexual education curriculum to find ways to encourage teachers to give equal attention to these topics, including FP education, as they would to any other. It was reported that teachers were reluctant to teach about FP as they perceived the young students felt discomfort around this topic. Further research to identify innovative youth-friendly methods to teach sexual and reproductive health topics to students may be helpful. Youth groups should be regarded as important stakeholders in the redesign of school health curricula, particularly for their insight into culturally sensitive and otherwise effective ways for delivery. Health professionals, members of local organizations, and community leaders pointed to the necessity of addressing unmet FP needs and the stigma associated with FP use through community education approaches that take into account cultural norms and beliefs [ 44 ]. Interventions focusing on reproductive health education curricula involving school teachers could be considered [ 45 ]. Strengthening health systems, bridging service gaps, improving the integration of contraceptive services and counseling with routine health care are important strategies for increasing contraceptive uptake in eastern Nepal [ 22 ].

Among the study’s limitations was the fact that it was conducted in a single village in eastern Nepal. Our findings might differ if the sample had been drawn from other parts of the country. Although participants spoke fluent Nepali, some phrases used in local dialects could not be perfectly translated into Nepali or English. These responses could have been affected by social desirability as the participants may have felt constrained from speaking freely with people from health institutions. To help reduce these obstacles we held open meetings and drop-in sessions with the support of community youth to disseminate the purpose of the study and build rapport with the young people in the village before we approached them for the study. Moreover, participants were assured anonymity and confidentiality, which may have increased their willingness to participate in the research.

Conclusions

There appear to be information and communication gaps between women and men regarding FP services and programs. The information gap could be addressed by exploring ways to increase information uptake in schools through redesigning the curriculum delivery. Mass media may be used to disseminate appropriate health education regarding FP. Health institutions could consider approaches to create FP information and service centers that are male-friendly. The communication gap may be more deeply rooted in the culture and traditions of Nepalese society. In a mostly patriarchal society, further identification of motivations for men to participate in FP related activities could be challenging. However, it is promising that men may be willing to support their partners for FP decision-making and engage in strengthening FP programs through the “peer to peer” approach via youth-led centers and community clubs. Program managers and policy makers need to take into account the fact that youth are willing to contribute to ongoing FP programs. Doing so would help bridge the information and communication gaps between school education and practice. Innovative research to further explore perceived benefits by youth on the uptake of family planning, sexual and reproductive health services is needed.

Supporting information

Acknowledgments.

We extend our sincere thanks and regards to Dr. Agata Parfieniuk, Kirsty Lunney, and Anu Regmi for their invaluable contributions to the manuscript. We acknowledge the support received from Dr. Meika Bhattachan, Dr. Avinash Kumar Sunny, and Dr. Pawan Upadhyaya during data collection. The authors acknowledge the support received from the BPKIHS and participants for their participation in the study. Special thanks to Dr. Bibisha Baaniya, Dr. Garima Pudasaini, Dr. Soniya Gurung, Dr. Shristi Nepal, Bisha Baaniya, and Arshpreet Kaur for their generous support throughout the study.

Abbreviations

Funding statement.

The author(s) received no specific funding for this work.

Data Availability

  • Research article
  • Open access
  • Published: 17 January 2019

Family planning among undergraduate university students: a CASE study of a public university in Ghana

  • Fred Yao Gbagbo   ORCID: orcid.org/0000-0001-8441-6633 1 &
  • Jacqueline Nkrumah 1  

BMC Women's Health volume  19 , Article number:  12 ( 2019 ) Cite this article

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Globally, the rate of unplanned pregnancies among students at institutions of higher education, continue to increase annually despite the universal awareness and availability of contraceptives to the general population. This study examined family planning among undergraduate university students focusing on their knowledge, use and attitudes towards contraception in the University of Education Winneba.

The study was a descriptive cross-sectional survey using a structured self-administered questionnaire. One hundred undergraduate students from the University of Education Winneba were selected using a multistage simple random sampling technique. A Likert scale was used to assess the attitude of the respondents towards family planning methods.

Findings show that the respondents had a positive attitude towards family planning with an average mean score of about 4.0 using a contraceptive attitude Likert scale. Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility and preference influence usage. Emergency Contraception (Lydia) was reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years who appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma.

The observation that levels of Family Planning awareness levels do not commensurate knowledge and usage levels calls for more innovative strategies for contraceptive promotion, and Education on the various university campus. The study recommends that public Universities in Ghana should consider a possible curriculum restructuring to incorporate family planning updates. In this regard, a nationwide mixed method study targeting other tertiary institutions including colleges of education in Ghana is required to explore the topic further to inform policy and programme decisions.

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The global incidence of unplanned pregnancies amongst students at higher educational institutions every year continues to increase despite the high awareness and knowledge on regular modern contraceptives and emergency contraceptives among students in higher educational institutions [ 1 , 2 ]. Despite the immense contraceptive benefits for students in higher educational institutions [ 3 ], there is no direct positive correlation between the universal awareness, knowledge and use of contraceptives which challenges global health efforts. The poor utilisation of contraceptives in tertiary institutions is associated with many interrelated factors ranging from personal to institutional setbacks [ 4 ]. This eventually contributes to high unplanned pregnancy rates which is estimated to have contributed to about 8 to 30 million annual pregnancies worldwide [ 5 ]. Global estimates have also shown that about 210 million pregnancies occur annually across the world. 75 million (or about 36%) of the 210 are unplanned or unwanted pregnancies [ 6 ]. Students between 18 and 24 years report the highest rates of unplanned pregnancies in the world’s tertiary institutions [ 7 , 8 ]. A situation associated with multiple challenges across the world for countries, academic institutions and the individuals involved [ 9 ].

Studies in Africa, have generally documented low knowledge and awareness levels of effective contraceptive use amongst higher educational students [ 10 ]. Several factors including age, culture, ethnicity, religion, poor access to contraceptive services, peer pressure and lack of partner support were identified as contributing to the non-utilisation of contraceptives in tertiary institutions [ 11 ]. In a study amongst 15 to 24 year old South African women, it was estimated that only 52.2% of sexually experienced women are using contraceptives [ 12 ]. Because 80% of undergraduate students at higher educational institutions are sexually active, it is important that they have access to safe, accessible and adequate contraceptive services [ 13 ].

Although national surveys on family planning [ 14 ] have extensively looked at contraceptive uptake in Ghana, little is known about contraceptive up take among students in Ghanaian Universities. This study therefore examines family planning acceptance among students of the University of Education, Winneba in Ghana to compliment national data on family planning.

A descriptive cross-sectional study design using a quantitative approach of data collection was adopted. This design was chosen because it fits studies in natural setting, explains phenomena from the view point of persons being studied and produces descriptive data from the respondent own written or spoken words [ 15 ].

The study was conducted in the main campus of the University of Education, Winneba. The university was established in 1992 to train middle and top-level manpower for the educational sector of Ghana. It has four main satellite campuses, (Winneba and Ajumako in the Central Region of Ghana, Kumasi, and Mampong campuses in Ashanti Region of Ghana). The Winneba campus has three smaller campuses with five faculties (Faculty of social science education, Faculty of languages, Faculty of science education, Faculty of educational studies and School of creative Arts).

The study population comprised134 ‘non-resident’ undergraduate students of the University of Education Winneba, between ages 17–36 years in 2017 who were registered with an accommodation agent in Winneba that looks for accommodation for students who are unable to obtain university accommodation on campus. This population and age group was selected because anecdotal evidence shows that being a ‘non-resident’ student has the likelihood of making one vulnerable to sexual exploitations whilst seeking accommodation off campus. This age group was considered to be the reproductive age group of the undergraduate students. Because the University only guarantees on campus residential accommodation for only selected first year students, those who do not get the university’s residential accommodation are likely to be victims of sexual exploitations in the Effutu Municipality where the university is situated. This challenge is due to the scarcity of accommodation coupled with the high rent charges for rented accommodation. As per the estimated sample size calculated, a total of one hundred respondents comprising twenty from each of the five faculties were sampled at random to include both male and female students from the various course levels. This was done to ensure a true representation of the student population for the study.

A multistage sampling technique was used to select these respondents for the study. The first stage involved half day orientation of 2 field assistants (male and female) the estimation of the undergraduate students’ population who falls in this category during the period of the study. The second stage involved sample size calculation using an online Raosoft sample size calculator at 95% confidence interval, 5% margin of error and 50% response distribution [ 16 ]. In terms of the figures, the sample size n and margin of error E are given by:

Where N is the population size (134), R is the fraction of responses that the study is interested in, and Z(c/100) is the critical value for the confidence level c. The estimated number of respondents were then randomly sampled and contacted for participating in the in the third stage of the study. The fourth stage of the study involved distributing the developed questionnaires to consented students.

A Structured Questionnaire (See Additional file  1 ), designed by the authors was used to solicit responses from respondents. The questionnaire was exploratory in nature with both opened and closed ended questions to help respondents easily share their views. The questionnaire was pre-tested among 20 potential respondents from a different university. The Contraceptive Attitude Likert scales was used to measure attitudes by asking people to respond to series of statements about the topic, in terms of the extent to which they agree or disagree with them. Thus, tapping into the cognitive and affective components of attitudes [ 17 ]. The Contraceptive Attitude Scale presented positive and negative statements to elicit for responses that portray participants’ attitudes relating to contraception.

One hundred questionnaires were administered, and all the answers to a particular question were arranged, numbered and responses were coded. The responses were again listed and grouped, putting those with the same code together. Data analysis was done after data had been collected and checked for completeness and accuracy. The Statistical Package for Social Sciences (SPSS) software version 23 was used for data analysis. Frequencies, percentages and bar charts were used to describe the data in multivariable tables.

Ethics approval and consent to participate

An approval was obtained from the University prior to data collection. Written consent for participation and publication of findings were also obtained from respondents after the purpose, objectives and potential risk and benefits inherent in the study had been explained to them. Prior to the commencement of the study, the research protocol was presented at the bi-weekly academic research seminars of the Faculty of Science Education, University of Education, Winneba. The seminar brought together lectures of the Faculty (equivalent to an ethical review meeting) who critiqued and reviewed the study protocol for ethical suitability and sound methodology. All participants in the study were given the opportunity to ask questions about the study at any stage, and to withdraw from the study at any time. All data collected were kept confidential and data was analysed anonymously to ensure that results were not traceable to individual respondent.

The overall response rate for the study was 100%. Table 1 presents the background characteristics of respondents. A large number of the respondents were within the age categories of 21 to 24 years and 25 to 28 years. Most of the respondents were single (86.0%) and have no children (86.0%).

Table 2 present results of students’ knowledge, information sources and reasons for accepting or not accepting family planning. Family planning awareness and knowledge among students was a key consideration in the study.

About 94% of respondents answered yes to whether they have ever heard about family planning. Although majority (61%) of the respondents believed FP is helpful, about (67.0%) knew that one could get pregnant by relying on the withdrawal method. It appears most students would be committed to family planning uptake if services are made available. This is evident by 69% of them responding in the affirmative when asked whether they will encourage their family or friends to use family planning services in the University.

Having knowledge of family planning does not necessarily translate into utilization since the respondents had varied reasons for and against using family planning. Respondents who were of the view that FP was not helpful (25.0%) had either not used any family planning method before (28.0%) or had ever suffered unpleasant negative side effects (20.0%) following family planning usage or believed the bible is against family planning (2.0%).

Figure 1 presents respondents’ attitudes towards family planning as estimated using the Contraceptive Attitude Scale. The overall population surveyed had a positive attitude towards family planning (average mean attitude score was about 4.0 out of 5.0).

figure 1

Attitude towards Family Planning

There were however some divergent responses to the questions relating to contraceptive use. Some of these include:

‘I will not have sexual intercourse if no contraceptive method was available’

‘I will use contraceptives even if my partner does not want me to use it’

‘I will not use contraceptives because they encourage promiscuity’

When the respondents were asked if they have ever used any FP method before, the majority of the respondents (67.0%) mentioned that they had never used any FP method. Regarding availability of family planning service when needed, about 64.0% of the respondents indicated that family planning services are always available in chemical shops and from colleges on campus when needed. About 58% will use FP methods in the future. Regarding information on source of family planning services if required, most of the respondents (85%) knew where to get family planning services in their communities (Table  3 ). Young Female students aged 21-24 years were the most vulnerable in accessing and using contraceptives due to perceived social stigma relating to a female student buying a contraceptive.

Table  4 documents the various family planning choices and reasons for the choices. About 65.0% of respondents reported that they primarily use contraceptives to prevent pregnancy and usually use a contraceptive before sexual intercourse (34.0%). When asked to select the primary methods of contraception frequently used, Emergency Contraception was the most reported frequently used (51%) contraceptive followed by male condoms (34.0%). Various side effects associated with some FP methods were also reported. Some respondents were of the view that there should be education for students on the risk and benefits of FP methods for effective use. Others believed FP should not be tolerated among students because it can be abused leading to major health problems that could affect studies. Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility, preference and cost of contraceptives hinders use.

This study examined family planning among undergraduate university students focusing on their knowledge, use and attitudes towards family planning in the University of Education Winneba. The study was a descriptive cross-sectional survey using a structured self-administered questionnaire for data collection. Various findings obtained from the study had reproductive health programme and policy implications. Informal sources of family planning information such as friends, peers and relatives were common information sources for young people [ 18 ] but yet prone to misconceptions, distortions and half-truths. Other studies ranked the family (parents, brothers and sisters) as the lowest source of information on sexuality [ 19 , 20 , 21 ]. These findings are similar to those reported in the current study that high level of awareness (94.0%) of contraceptives is noted among university students.

An observation that a large number of the respondents were within the age categories of 21 to 24 years and 25 to 28 years of which most (86.0%) were single and have no children (86.0%), is an indication that current university students are relatively young and unmarried. A situation that predisposes them to sexual exploitations and requires knowledge on family planning methods to enable them make informed decision and choices regarding their reproductive intentions. Family planning awareness and knowledge among students was a key consideration in the study. The majority (94%) of respondents indicating that they have ever heard about family planning shows a near universal awareness of family planning methods. This is in line with national reports on family planning awareness in Ghana and a significant departure from many other studies which tended to focus on awareness alone or translate awareness to knowledge [ 22 , 23 ]. Understanding the methods and benefits of contraception are critical to having motivated users. It has also been noted that motivation is one of the important factors in minimizing failure rates in the utilization of contraception [ 24 ]. From previous research findings [ 25 , 26 , 27 ] it was established that the most commonly used Family Planning methods among students were short term methods predominantly, condoms, oral contraceptives and withdrawal methods. This confirms finding of other studies that students had little knowledge about effective contraceptive methods [ 28 ]. In the current study, a remarkable percentage (25%) did not know that pregnancy could occur when one relying solely on withdrawal method. Also about 21.0% of respondents did not know what oral contraceptive pills do, and some 3% also said oral contraceptive pill prevents Sexually Transmitted Infections (STIs). It was surprising to note in this era of increasing STIs that about 2% of respondents’ from a tertiary institution belief a single condom can be reused many times if washed and dried.

At the tertiary level, one would have expected that all respondents would have known the implications of unprotected sexual intercourse. However the study finding that about (61%) of the respondents believed family planning is helpful implies that there are some other students who don’t belief in family planning hence having unprotected sexual intercourse. Although accessibility to family planning methods on campus in this study was very high (66.0%), results from other similar studies were to the contrary [ 29 , 30 ]. This therefore suggests that if students know the benefits and how to use contraceptives, they will not experience unwanted pregnancies and its associated consequences of unsafe abortion complications, disruption in academic work and possible death. Contraceptive education is a component of sex education and is one of the proven approaches to prevent risky sexual behaviour and must be introduced on university campuses to guide students’ family planning choices.

Additionally, findings also shows that there are some students about (67.0%) at the university who knew that one could get pregnant by relying on the withdrawal method yet that is their preferred family planning methods. Various studies [ 31 , 32 ] have explained this observation further by indicating that some adolescents girls feel that a partner’s use of condom suggest that they (the girls) might be classified as unclean, likened to commercial sex workers or seen as engaging in extra-relationship sexual activities if they negotiate for condom use during sexual intercourse. The perception of ‘ I trust my partner so no need for condom use’ further explains the frequency of withdrawal methods being a regular family planning method on campus.

Generally, it appears most students were committed to family planning uptake if services are made available as evident by about 69% of them responding in affirmative when asked whether they will encourage their family or friends to use family planning services in the University. This observation is positive for enhanced family planning service delivery on university campuses to meet the needs of students. Contrary to this observation are those of similar studies which reported that Student frown on invasive family planning methods [ 33 , 34 ]. The distinction between invasive and non-invasive methods bothers on factors such as availability of method, ease of use and adherence to instructions of a health professional to use the method.

Respondents outlined various sources of family planning information of which television adverts constituted the most reported (31%) source of information. This observation is quite worrying since anecdotal evidence from university campuses shows that majority of student rarely have and watch televisions whist on the various campuses. It will therefore be very important and useful to devise innovative ways of educating students on family planning methods whilst on campus.

A finding that having knowledge of family planning does not necessarily translate into usage is very revealing and of public health importance. As it would have been expected, using a method is the surest way of explaining its relevance. However in this study, respondents who were of the view that family planning was not helpful had never used any family planning method before (28.0%). It is there important to use of family planning satisfied client for contraceptive education and promotion on University campuses to ensure the desired positive results. These are students who are likely to positively influence their sexually active peers on contraceptive use since they are likely to say: ‘ I will not have sexual intercourse if no contraceptive method was available’ or ‘I will use contraceptives even if my partner does not want me to use it’ as reported in the study.

Regarding information on source of family planning services if required, most of the respondents (85%) knew where to get family planning services in their communities. For availability of family planning services when needed, about 64.0% of the respondents indicated that family planning services are always available in chemical shops and from colleges on campus when needed. The obvious indicated sources of contraceptives on campus (i.e., chemical shops and peers) do not provide varying choice of services there by limiting students to short term and less effective family planning methods. It is encouraging noting that about 58% of respondents will use FP methods in future. This is an indication of them understanding the importance of family planning to studies as about 65.0% of respondents reported primarily using contraceptives to prevent pregnancy and usually use a method before sexual intercourse (34.0%) despite the various side effects associated with some FP methods reported.

Knowledge of contraception, awareness and benefits however do not commensurate contraceptive use among undergraduate students since availability, accessibility and preference influence usage. Emergency Contraception (Lydia) was reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years who appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma. This observation shows that Students always have a unique view on issues especially those in youthful ages. It is therefore important to incorporate their views in family planning programming. The observation that some respondents were of the view that there should be education for students on the risk and benefits of family planning methods for effective use is in the right direction and worth exploring. There are also concerns of values clarification as observed by the findings that some respondents believed family planning should not be tolerated among students because it can be abused leading students to becoming promiscuous or suffering major health problems that will affect their studies.

The following recommendations are therefore being suggested to chart a way forward:

Public Universities in Ghana should consider a possible curriculum restructuring to incorporate family planning lessons in the academic programme for students to acquire current knowledge in this area. The reproductive health education programs should include the importance of using dual contraceptive methods as a means to prevent HIV transmission and pregnancy, as well as information on how to make an informed decision relating to contraceptive choices.

The Winneba Municipal Health Directorate should incorporate family planning education on campuses into their public health programs.

The university health service should also create friendly environment for student to access family planning services and also collaborate with the student body to organise programmes to educate the students on family planning methods.

The student representative council (SRC) should also make family planning education a part of their programs and in collaboration with the university health services organise free STI testing and family planning counselling at least once yearly.

A nationwide mixed method study targeting other tertiary institutions particularly colleges of education in Ghana is required to explore the topic further for a national decision on contraceptive security in tertiary institutions in Ghana.

Conclusions

Findings of this study showed that the awareness of family planning among the students was high. However, levels of contraceptive usage were low and restricted to the short term, Emergency Contraceptives and redrawal methods. The perception by a cross-section of respondents (although by a small group) that condoms can be reused more than once confirms the gross ignorance of contraception practices and the potential risk to STIs and Pregnancy. Additionally, Emergency Contraception (Lydia) being reported as easy to get contraceptive, hence the most frequently used contraceptive (31%) among young female students aged 21-24 years, is an indication that this student population appeared as the most vulnerable in accessing and using contraceptives due to perceived social stigma and must therefore be the prime focus of contraception education and services on the University. The University of Education being a tertiary institution mandated to train teachers, is expected to ensure that its students have accurate and current information on family planning methods relevant to educate others. This is an obvious gap that requires policy decisions at all levels and FP education interventions at the tertiary level of education in Ghana.

Abbreviations

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Statistical Package for Social Sciences

Sexually Transmitted Infections

University of Education Winneba

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Acknowledgements

The authors are grateful to the University of Education Winneba, Faculty of Science Education for the valuable inputs in shaping the manuscript. Many thanks also to the respondents for their corporation during data collection.

The entire study was jointly funded by the authors.

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The raw data and any material related to the study is available upon reasonable request from the corresponding author.

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FYG conceptualized and designed the study. JN supervised the data collection, analysis and drafted the initial report. Both authors discussed the report, edited it together and approved the manuscript for final submission.

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Correspondence to Fred Yao Gbagbo .

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The research protocol was first presented at the Faculty of Science Education, University of Education, Winneba periodic academic seminars for review and approval for methodology and ethical suitability. This seminar, brings together senior members and research fellows of the University to review research protocols and papers meant for publication and conferences. Approval for data collection and publication were subsequently granted following the full incorporation of comments received from the seminar presentation.

Prior to data collection, verbal and written permissions were sought from the respondents to participate in the study. The permission was granted after the objectives and nature of the study were satisfactorily explained to the respondents.

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Additional file 1:.

Appendix I-Questionaire. The appendix I contains the structured question developed by the authors and used for data collection in the study. (DOCX 23 kb)

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Gbagbo, F.Y., Nkrumah, J. Family planning among undergraduate university students: a CASE study of a public university in Ghana. BMC Women's Health 19 , 12 (2019). https://doi.org/10.1186/s12905-019-0708-3

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Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia

  • Ayele Semachew Kasa   ORCID: orcid.org/0000-0003-3320-8329 1 ,
  • Mulu Tarekegn 1 &
  • Nebyat Embiale 2  

BMC Research Notes volume  11 , Article number:  577 ( 2018 ) Cite this article

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To assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia, 2017.

The study showed that the overall proper knowledge, attitude and practice of women towards family planning (FP) was 42.3%, 58.8%, and 50.4% respectively. Factors associated with the practice of FP were: residence, marital status, educational status, age, occupation, and knowledge, and attitude, number of children and monthly average household income of participants. In this study, the level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies. Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced. Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Introduction

Family planning (FP) is defined as a way of thinking and living that is adopted voluntary upon the bases of knowledge, attitude, and responsible decisions by individuals and couples [ 1 ]. Family planning refers to a conscious effort by a couple to limit or space the number of children they have through the use of contraceptive methods [ 2 ].

Family planning deals with reproductive health of the mother, having adequate birth spacing, avoiding undesired pregnancies and abortions, preventing sexually transmitted diseases and improving the quality of life of mother, fetus and family as a whole [ 3 , 4 ].

The Federal Ministry of Health (FMOH) has undertaken many initiatives to reduce maternal mortality. Among these initiatives, the most important is the provision of family planning at all levels of the healthcare system [ 5 , 6 ]. Currently, short-term modern family planning methods are available at all levels of governmental and private health facilities, while long-term method is being provided in health centers, hospitals and private clinics [ 6 ].

The study done in Jimma Zone, Ethiopia showed that good knowledge on contraceptives did not match with the high contraceptive practice [ 7 ]. Different researchers showed that the highest awareness but low utilization of contraceptives making the situation a serious challenge [ 8 , 9 ].

Most of reproductive age women know little or incorrect information about family planning methods. Even when they know some names of contraceptives, they don’t know where to get them or how to use it. These women have negative attitude about family planning, while some have heard false and misleading information [ 10 , 11 ] and the current study aimed in assessing the knowledge, attitude and practice (KAP) of FP among women of reproductive age group in South Achefer District, Northwest Ethiopia.

Methods and materials

Study design and setup.

A community-based cross-sectional study was conducted in South Achefer District, Amhara Region, Northwest Ethiopia from March 01–April 01, 2017. Systematic sampling technique was used to recruit the sampled reproductive age women (15–49 years old). Based on the number of households obtained from the Kebele’s (Smallest administrative division) health post, the sample size (389) was distributed to the households. The sampling interval was determined based on the total number of 4431 households in the kebele. The first household was taken by lottery method and if there were more than one eligible individual in the same household one was selected by lottery method.

The data collection questionnaire was developed after reviewing different relevant literatures. The questionnaire, first developed in English language and then translated to Amharic (local language). Pretest was done on 5% of the total sample size at Ashuda kebele. After the pretest, necessary modifications and correction took place to ensure validity.

Those reproductive age women who answered ≥ 77% from knowledge assessing questions were considered as having good knowledge, those women who scored ≥ 90% from attitude assessing questions were considered as having favorable attitude and those women who scored ≥ 64% from practice assessing questions were considered as having good over all practice towards FP [ 7 ].

Data processing and analysis

The collected data was cleaned, entered and analyzed using SPSS version 21 software. Descriptive statistics were employed to describe socio-demographic, knowledge, attitude and practice variables. Chi squared (χ 2 ) test was used to determine association between variables. Associations were considered statistically significant when P-value was, < 0.05.

Socio-demographic characteristics of participants

The response rate in this study was 97.9%. Among 381 participants included, 185 (49%) were from rural villages. About 47% of the participants were illiterate and 52% were completed primary education. The monthly household income of the majority (42.5%) of the participants was between 1000 and 3000 Ethiopian birr. Regarding the family size of the participant’s, majority (48.3%) of them had ≥ 3 children.

The mean age of participants was 29.7 ± 6.4. Two hundred forty six (64.6%) and 133 (34.9%) were house wife’s and farmers respectively by their occupation. Almost two-third (65.4%) of participants were married, 24.9% were divorced by their marital status (Table  1 ).

Knowledge status of participants

All of participants ever heard about family planning methods. The major sources of information were from health workers (57.5%) and radio (41.5%). Regarding perceived side effects of using family planning, 13.1%, 24.9%, 9.7% and 52.2% of participants were responded heavy bleeding, irregular bleeding, an absence of menstrual cycle and abdominal cramp respectively were mentioned as a side effect. Among those who have children; 24.6% gave their last birth at home and 75.5% gave their last birth at the health institution. Regarding the overall knowledge of study participants, 161 (42.3%) had good knowledge towards family planning and the rest 220 (57.7%) had poor knowledge.

Attitude status of participants

The majority (88.5%) of the respondents ever discussed on family planning issues with their partners and wants to use it in the future. About 24.5% of the participants reported that they believe family planning exposes to infertility. Almost 23 (22.8%) of study participants reported that using family planning contradicts with their religion and culture. Regarding the overall attitude, 224 (58.8%) of the participants had favorable attitude and 157 (41.2%) had unfavorable attitude towards family planning.

Practice on family planning

Three fourth (75.3%) of study participants ever used contraceptive methods. The main types were pills (7.4%) and injectable (77.2%). The most common current reasons for not using were a desire to have a child (53.2%) and preferred method not available (46.8%). Almost half (50.4%) of study participants had good practice and the rest 49.6% had poor practice.

Factors associated with family planning practice

Study participants’ religion was not included in the analysis due to lack of variance, since almost all (99.2%) of participants were Orthodox Christians by their religion.

Women who had good knowledge were more likely to practice FP than those who have low knowledge (χ 2  = 117.995, d.f. = 1, P  < 0.001) and women who had favorable attitude towards FP were more likely to practice FP (χ 2  = 106.696, d.f. = 1, P  < 0.001). It was also seen that residence, age, educational status, occupation, marital status, number of children and monthly income of the were significantly associated with the practice of FP [(χ 2  = 69.723, d.f. = 1, P  < 0.001), (χ 2  = 104.252, d.f. = 2, P  < 0.002), (χ 2  = 119.264, d.f. = 1, P  < 0.001), (χ 2  = 41.519, d.f. = 1, P  < 0.001), (χ 2  = 39.050, d.f. = 1, P  < 0.001), (χ 2  = 144,400, d.f = 3, P  < 0.001) and (χ 2  = 179.366, d.f. = 1, P  < 0.002)] respectively (Table  2 ).

Increasing program coverage and access of family planning will not be enough unless all eligible women have adequate awareness for favorable attitude and correctly and consistently practicing as per their need. Increasing awareness/knowledge and favorable attitude for practicing FP activities at all levels of eligible women are strongly recommended [ 6 ].

The results of the present study showed that 42.3% of study participants had good knowledge, 58.8% had favorable attitude, and 50.4% had good practice towards family planning. This finding was lower than a study conducted in Jimma zone, Southwest Ethiopia [ 7 ], Sudan [ 9 ], Tanzania [ 12 ] and another study done in Rohtak district, India [ 13 ]. The difference may be due to; studies done in Jimma zone, Sudan, Tanzania and Rohtak district involve only those coupled/married women. Married women might have good knowledge and attitude for practicing family planning. But in the current study, all women of reproductive age group regardless of their marital status were studied and this may lower their knowledge and attitude.

The current study showed that, 50.4% of reproductive age women were practicing family planning which was almost in line with a study done in Cambodia [ 14 ] and higher than a study done in rural part of Jordan [ 15 ] and India [ 16 ]. But it was lower than studies conducted in Jimma zone, Ethiopia [ 7 ], Rohtak district, India [ 13 ], urban slum community of Mumbai [ 17 ] and in Sikkim [ 18 ] in which 64%, 62%, 65.6% and 62% of participants respectively used family planning. The difference might be due to that study participants in Jimma zone, Rohtak and Mumbi were relatively residing in large city/town and this may help them to have a better access for family planning compared to the study done in South Achefer District.

In the current study, urban residents were more likely to use family planning methods (71.4%) than their rural counterparts (28.1%). This finding was in line with the findings from Ethiopian Demographic Health Survey (EDHS) [ 2 ]. This might be due to the reason that urban residents are more aware of family planning and hence practicing better.

It has also found that women who completed primary & secondary education were practicing family planning than those who were uneducated (77.1% and 20.6%) respectively. This finding was in line with a study done in Jimma, Ethiopia [ 19 ]. This might be due to the fact that women who were able to read and write would think in which FP activities are useful to be economically, self-sufficient and more likely to acquire greater confidence and personal control in marital relationships including the discussion of family size and contraceptive use.

This study showed that, age of the study participants had an association with practicing FP. Those reproductive age women’s whose age > 30 years were practicing family planning better than those whose age < 18 years. This finding was in line with a study done in India [ 20 ]. This might be due to the reason that, when age increases mothers awareness, attitude and practice towards family planning may increase. In addition, as age increases the chance of practicing sexual intercourse increases and as a result they would be interested to utilize family planning in one or another way.

It has also revealed that women’s average monthly household income has an association with their FP practicing habit. Those study participants whose average monthly income < 1000 ETB were using FP better than whose average monthly income > 3000 ETB. This is might be because those relatively who had better income may need more children and those with low income may not want to have more children beyond their income.

The current study also showed that knowledge and attitude of reproductive age women were related to FP utilization. Those reproductive age women who had good knowledge were utilized FP better than from those who were less knowledgeable. Those participants with favorable attitude were practicing better than those who had unfavorable attitude. This is might be due to the fact that knowledge and attitude for specific activities are the key factors to start behaving and maintaining it continuously.

Conclusion and recommendation

The level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies.

Study participant’s residence, marital status, educational level, occupation, age, knowledge, attitude, their family size and their monthly average income were associated with FP utilization habit of reproductive age women.

Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced.

Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary.

Limitation of the study

As the data were collected using interviewer administered questionnaire, mothers might not felt free and the reported KAP might be overestimated or underestimated.

We do not used qualitative method of data collection to gather study participant’s internal feeling about family planning, so that triangulation was possible. In addition, barriers for utilizing contraception not addressed.

Abbreviations

Ethiopian Demographic Health Survey

Ethiopian birr

Federal Ministry of Health

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AS: approved the proposal with some revisions, participated in data analysis. MT: wrote the proposal, participated in data collection analyzed the data and drafted the paper. NE: approved the proposal with some revisions, participated in data analysis. All authors read and approved the final manuscript.

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We are very grateful to all study participants for their commitment in responding to our questionnaires.

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Semachew Kasa, A., Tarekegn, M. & Embiale, N. Knowledge, attitude and practice towards family planning among reproductive age women in a resource limited settings of Northwest Ethiopia. BMC Res Notes 11 , 577 (2018). https://doi.org/10.1186/s13104-018-3689-7

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Perceptions of family planning services and its key barriers among adolescents and young people in Eastern Nepal: A qualitative study

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation B.P. Koirala Institute of Health Sciences, Dharan, Nepal

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

Affiliation Department of Health Services, Ministry of Health and Population, Kathmandu, Nepal

Roles Data curation, Formal analysis, Writing – original draft, Writing – review & editing

Affiliation Nepal Health Sector Support Programme (NHSSP)/DFID/Ministry of Health and Population, Kathmandu, Nepal

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

Affiliation Central Department of Public Health, Institute of Medicine, Kathmandu, Nepal

Roles Data curation, Formal analysis, Writing – review & editing

Affiliation Department of Electronics and Computer Engineering, Institute of Engineering, Tribhuvan University, Lalitpur, Nepal

Affiliation Department of Community Health Sciences, School of Public Health, Patan Academy of Health Sciences, Lalitpur, Nepal

Affiliation School of Public Health and Community Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliation Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom

  • Navin Bhatt, 
  • Bandana Bhatt, 
  • Bandana Neupane, 
  • Ashmita Karki, 
  • Tribhuwan Bhatta, 
  • Jeevan Thapa, 
  • Lila Bahadur Basnet, 
  • Shyam Sundar Budhathoki

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  • Published: May 26, 2021
  • https://doi.org/10.1371/journal.pone.0252184
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Fig 1

Introduction

Family planning methods are used to promote safer sexual practices, reduce unintended pregnancies and unsafe abortion, and control population. Young people aged 15–24 years belong to a key reproductive age group. However, little is known about their engagement with the family planning services in Nepal. Our study aimed to identify the perceptions of and barriers to the use of family planning among youth in Nepal.

A qualitative explorative study was done among adolescents and young people aged 15–24 years from the Hattimuda village in eastern Nepal. Six focus group discussions and 25 in-depth interviews were conducted with both male and female participants in the community using a maximum variation sampling method. Data were analyzed using a thematic framework approach.

Many individuals were aware that family planning measures postpone pregnancy. However, some young participants were not fully aware of the available family planning services. Some married couples who preferred ’birth spacing’ received negative judgments from their family members for not starting a family. The perceived barriers to the use of family planning included lack of knowledge about family planning use, fear of side effects of modern family planning methods, lack of access/affordability due to familial and religious beliefs/myths/misconceptions. On an individual level, some couples’ timid nature also negatively influenced the uptake of family planning measures.

Women predominantly take the responsibility for using family planning measures in male-dominated decision-making societies. Moreover, young men feel that the current family planning programs have very little space for men to engage even if they were willing to participate. Communication in the community and in between the couples seem to be influenced by the presence of strong societal and cultural norms and practices. These practices seem to affect family planning related teaching at schools as well. This research shows that both young men and women are keen on getting involved with initiatives and campaigns for supporting local governments in strengthening the family planning programs in Nepal.

Citation: Bhatt N, Bhatt B, Neupane B, Karki A, Bhatta T, Thapa J, et al. (2021) Perceptions of family planning services and its key barriers among adolescents and young people in Eastern Nepal: A qualitative study. PLoS ONE 16(5): e0252184. https://doi.org/10.1371/journal.pone.0252184

Editor: Mary Hamer Hodges, Helen Keller International, SIERRA LEONE

Received: June 27, 2020; Accepted: May 12, 2021; Published: May 26, 2021

Copyright: © 2021 Bhatt et al. 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: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

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

Abbreviations: BPKIHS, B. P. Koirala Institute of Health Sciences; FP, Family Planning; FGD, Focus Group Discussion; IDI, In-Depth Interview; mCPR, Modern Contraceptive Prevalence Rate; SRH, Sexual and Reproductive Health

An unmet need for family planning results in unintended pregnancies and illegal abortions. This has major health and social implications and is often the leading cause of maternal and child mortality in low-income countries [ 1 , 2 ]. An estimated 214 million women of reproductive age lack access to contraception resulting in an estimated 67 million unintended pregnancies, 36 million induced abortions, and 76,000 maternal deaths each year [ 3 ]. Family planning (FP) is a key intervention to limit these adverse health outcomes [ 4 – 6 ]. Such interventions can prevent 90% of abortions, 32% of maternal deaths, 20% of pregnancy-related morbidity globally, and reduce 44% of maternal mortality in low-income countries [ 1 , 7 ]. FP reduces adolescent pregnancies, prevents pregnancy-related health risks, and helps to prevent HIV/AIDS [ 8 ]. Access to contraception promotes education, raises the economic status of women, and gradually empowers them resulting in improved health outcomes and better quality of life [ 3 , 5 , 9 , 10 ].

Global data show that only 32% of married women from low-income countries currently use modern contraceptives [ 9 ]. According to the Nepal Demographic Health Survey 2016, the total fertility rate was 2.3 births per woman, which is declining and approaching replacement fertility. This is an important achievement. However, the modern contraceptive prevalence rate (mCPR), which is 43%, is still below the target in Nepal [ 11 ]. Nepal has consistently failed to reach the target of mCPR for the past 20 years. The future projection of mCPR for 2030 is 60% [ 5 ], which may be a distant dream if the barriers and enablers are not identified on time to strengthen the current efforts.

Expanding the coverage and access to effective contraceptive methods are essential to meet the Sustainable Development Goals and to achieve universal access to reproductive healthcare services by 2030 [ 11 , 12 ]. For this, the government of Nepal has started a FP program with a focus on increasing the use of FP services and reducing the unmet need [ 5 , 11 ]. However, various factors negatively influence the delivery of FP services including lack of information, limited awareness of dissemination activities, lack of trained staff, and various cultural and religious factors [ 13 ].

Family planning is a choice for many youth, but they often experience barriers such as negative provider attitudes, long distances to healthcare facilities, and inadequate stock of preferred contraceptives [ 13 , 14 ]. Nepali youth are reluctant to use modern contraceptives due to misconceptions about long-term fertility risks, fear of side effects and overall lack of deeper knowledge [ 15 , 16 ]. Besides, FP decisions are mostly dependent on male household members, including husbands and other elder members [ 17 , 18 ]. Married women whose husbands are away as migrant workers face unique contraceptive challenges. When their husbands return home for a few weeks in a year, these women are not prepared with their contraceptives, which can result in unwanted pregnancies [ 18 ].

The extrapolation of the available literature on FP use among adults from Nepal and elsewhere suggests that youth is an under-researched population when it comes to FP There is also a dearth of evidence on perception and key barriers to the use of FP measures in this population. Hence, this study aims to identify the perceptions of the FP services and barriers to the use of FP among the youth in Nepal to assist policymakers in designing appropriate interventions to strengthen the family planning programs in Nepal.

Material and methods

Ethical considerations.

The study received ethical approval from the Institutional Review Committee of B.P. Koirala Institute of Health Sciences, Dharan, Nepal as per the Undergraduate Research Proposal review process (URPRB/01/015). We obtained informed written consent from all participants aged 18 and above. For minors, we obtained assent from the parents of the participants with the participants’ permission. For those who could not read, the information sheet was read aloud by a volunteer, verbal consent was given, and a thumbprint, in the presence of a witness, was used in place of a signature. To maintain the confidentiality of the information and the privacy of the participants, only selected participants and the moderators attended the sessions. Personal identifiers and locator information were not collected, and any identifying information accidentally mentioned was removed from the text before the analysis.

Study setting

The study was conducted among the participants from Hattimuda village of Morang district in Province One of Nepal. Hattimuda village is a community service area of B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. BPKIHS is a public-funded health sciences university, which follows a teaching district concept adopted as a part of its community-based medical education curriculum. BPKIHS also runs a tertiary hospital service for the population of eastern Nepal [ 19 ]. There is a public health facility in Hattimuda village that provides primary health care services including FP services such as the distribution of contraceptives. The nearest secondary and tertiary levels of healthcare services are available 18 kilometers away in Biratnagar, which is the provincial capital and the headquarters of Morang district. According to the 2017/18 annual report of the Department of Health Services, the contraceptive prevalence rate of Morang district is 54.6% [ 5 ] whereas the unmet need for FP in Province One as per the Nepal Demographic Health Survey 2016 is 25% [ 11 ].

Study design

This was a qualitative study with an exploratory design to gather a deeper understanding of the perception of FP and its barriers. Focus group discussions (FGD) and in-depth interview (IDI) methods were used. The overall study lasted from November 2017 to October 2018.

Study population and sampling technique

Adolescents and young people between 15 and 24 years of age from Hattimuda were included in the study. We used the maximum variation sampling method to enroll participants. Pretesting, including one FGD and four IDIs, was conducted among residents in another village of the same district. The pretesting guided the selection of participants for FGDs and IDIs. Accordingly, FGDs were conducted among adolescents and young people, separately for male and female participants to allow for free expression of views during the discussion of potentially sensitive issues. Moreover, the respondents recommended that people at the forefront of the community such as the village leaders, schoolteachers, community health volunteers, religious leaders, youth leaders, and students be selected for the interviews to gather more information. Along with the recommendations from the pretesting, brainstorming was done with community volunteers to generate a list of people who understood the issues of adolescents and young people. More volunteers were added to the list upon the recommendation of the initial respondents. Thus, participants representing diverse backgrounds in terms of gender, profession, education, and social status, were selected. The IDIs were done among 25 prominent people in the community, which included leaders, school teachers, female community health volunteers, healthcare professionals working at the health post and FP service centers, and youth leaders from youth clubs. Health care providers were included in the interviews as their views would be invaluable due to their experience as FP service providers and as witnessing the health issues faced by youth. The teachers are regarded highly for their knowledge and opinions in Nepali communities. So, they were selected for the IDI to provide more insight into the educational barriers to FP and to help in youth mobilization for FP activities. Considering the vital role of local leaders in influencing the implementation and regulation of population-level activities in the village, they were selected for IDI. Six focus groups were conducted with a total of 48 respondents ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0252184.g001

Data collection

The Focus Group Discussions (FGD) and In-depth interviews (IDI) were conducted by the researchers within the team with prior experience in qualitative research methods. The interview team included an undergraduate medical student, two postgraduate resident doctors, a public health graduate, and a public health academic researcher. Before data collection, an orientation session was conducted for the interviewers using the interview schedule and the topic guide. The IDI guidelines and interview schedules were developed from the literature review and were modified after pretesting. Validation of the tools was ensured by using the Item Objective Congruence (IOC) index and consultation with academics with experience in FP research. Using a semi-structured open-ended questionnaire, the participants were assessed on their knowledge and perceptions regarding sexual and reproductive health (SRH) and FP, SRH problems faced by youth, challenges and barriers to use of FP services, the role of youth in combating the perceived challenges, and suggestions for enhancing the use of services. Data were considered to have reached saturation when the responses from participants became repetitive and/or no new responses were received.

Focus group discussions.

A representative group of youth from diverse backgrounds who could provide credible information about practices and factors affecting the use of FP in the community was selected. Separate FGDs were held for girls and boys to allow for free expression. A moderator was responsible for guiding the discussion and a note-taker for taking the notes, including recording non-verbal responses and ensuring the audio recording. A total of 6 FGDs, each containing 8 homogenous participants, were conducted. Each individual participated once in the FGD. Every member of the group could make their contribution to any question posed before proceeding to another question. Each FGD lasted for 60–90 minutes on average. The discussion was done in the Nepali language as preferred by participants and later translated into English during transcription.

In-depth interviews.

In-depth interviews with the key stakeholders were conducted using the Interview Schedule after obtaining the informed consent and audio-recorded with participant permission. A total of 25 IDIs were conducted for the average duration of 30–45 minutes, at a location convenient to the participant, which included their homes and offices.

Data management and analysis

A framework method of thematic analysis was used. The analysis included stages of transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting the data into the framework matrix, and interpretation of the data. The data collected from the focus groups and interviews were transcribed verbatim. The notes taken were used as a guide to segregate the responses by different respondents during the discussion. An independent researcher conversant in the Nepali and English languages cross-checked the transcripts for accuracy and preservation of original meaning during translation. Preliminary codes were assigned to the available data and then organized into thematic units that were continually revisited and revised as necessary. To ensure consistency of data and findings, two authors were involved in data analysis and reporting. The recordings were stored and accessed by the research team only and were destroyed after the analysis and final report preparation.

Operational definition

According to UNFPA, all persons within the age of 15–24 years are considered youth [ 20 ].

The baseline characteristics of the participants can be seen in Table 1 .

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https://doi.org/10.1371/journal.pone.0252184.t001

The responses from the IDIs and FGDs revealed four broad themes. Within each broad theme were several substantive sub-themes that emerged from the data. The themes and subthemes are summarized in Table 2 below.

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https://doi.org/10.1371/journal.pone.0252184.t002

Theme 1: Knowledge and perceptions of FP

A) knowledge and sources of information on fp..

Participants demonstrated awareness of some form of FP. However, some knew nothing about it. Health workers were commonly referred to as the sources of information, while some also mentioned peers, radio, television, and books. Male participants openly disclosed their sources of information on FP while some female participants were reluctant to share their sources.

b) Perceptions of FP.

Perceptions of FP varied among participants. Some male participants inferred FP measures as women’s business and did not show any interest in talking more about it. Some referred to FP as using condoms during intercourse, while others referred to oral pills and injectable hormones as FP. Some female participants looked at FP as a way of avoiding unwanted pregnancies.

“My sister used to say that she has been using injection (Depo-Provera) to control unwanted pregnancy . I think FP is about the same . ”- 19 years Female , FGD participant

Theme 2: Preference for FP methods and decision-making

Some female participants reported preference for traditional methods of contraception such as coitus interruptus and calendar method over modern methods. These people used modern methods of FP to start with, which they discontinued later due to the side effects. Participants also stated that the health facilities that provide FP services were far, and hence they had no alternative other than natural methods. Male participants hardly mentioned visiting any health facilities for FP purposes.

“Most of our clients who come for it (FP) are women. Even condoms are collected by women. Men rarely come alone or as couples for FP services.” - 35 years old Female, FP service provider, IDI participant

Yet husbands were responsible for the decision-making about FP and choices of methods for most couples. Some participants (both male and females) mentioned that women rather than men should use permanent FP measures. They believed that men being the breadwinner of the family, should not undergo sterilization, for example, as it would make them physically weak.

“Though I love my wife and I am concerned about her. But I have no options. I must work in a factory. I need to lift heavy weights there. All the major house chores are also done by me. These things (sterilization) would make me weak. How can I earn my livelihood then?”- 22 years Male, FGD participant

Some female participants expressed their concerns regarding the use of permanent FP methods. They mentioned that they had already been through various phases of pain, be it during menstruation, pregnancy, or delivery which has made them weak. Thus, they prefer their husbands to undertake any measures.

In contrast, unmarried participants stated that they would rather discuss and decide together with their partners regarding which method to choose in the future. Despite this interest, women were not sure how to engage their husbands in discussion. Some female participants said that they could not persuade their future husbands to use contraceptives as it would be disrespectful, whereas a few male participants believed it was a woman’s responsibility to use FP methods.

“It (FP) is stuff to be done by the women . So , there is no doubt about who would be doing it . Moreover , people would laugh at me if I do it -20 years Male , FGD participant “ Women have already gone through much pain in bringing up and taking care of the children and again keeping this stuff (FP) in their head is unjustifiable . As such, in comparison to the female operative procedure, I have heard that the male one is simple, less time consuming, and does not bring many complications . So, why not we men take the lead on this? ” -25 years Male, Youth leader, IDI participant

Theme 3: Barriers and challenges in the use of FP

A) supply-side barriers and challenges..

Participants indicated that contraceptive services are not always accessible nor affordable in rural areas. Health facilities are far, and many people feel reluctant to travel in a hot climate. Participants who were reluctant to travel said they were doubtful that the health facilities would have the methods in stock even if they managed to walk the distance. Others who were reluctant said they would be unable to afford the contraceptives from a private medical store regularly. A few participants raised the issue of privacy and unavailability of all services at the health centers. Similarly, young males from the community complained that the services at the health post were focused only on mothers and married couples, while the boys and the unmarried people were not given much attention. For this, they suggested changing the term to something other than FP because they believed that FP should include not only those who had families.

Participants expressed their frustration that FP and SRH services in their village had not been running well for more than a year. They felt that the government was not doing anything about it either. Some students expressed the need for an integrated curriculum at school covering every aspect of SRH and FP that would ensure adequate and proper knowledge of such crucial subjects. Despite the students’ desire to learn and understand FP, their teachers are often reluctant to talk about FP in detail. The participants also indicated that family members, in general, forbid girls and women from getting involved in FP awareness activities.

“Though we are eager to learn about those lessons (reproductive organs and health), our teacher skips them. They tell us to read it by ourselves.” -18 years Female, FGD participant

b) Demand-side barriers and challenges.

A few participants were confused about which method to choose, how to use it properly and did not even know where to seek FP services locally.

“My husband works abroad. Last year, when he came home during Dashain (festival), we had (intercourse). Later, he returned to his workplace. Meanwhile, I came to know that I was pregnant, after 3 months. I was shocked to hear that. We already had 3 children; 2 of them were unplanned. I did not have enough information about contraceptive measures in this situation. Had I known about them; I would have used them. I had serious trouble travelling to get it aborted.” - 24 years Female, FGD participant

Some female participants expressed their reluctance to use FP methods due to their own or other people’s past experiences and the fear of side effects, including vaginal bleeding, spotting, abdominal pain, nausea, vomiting, headache, acne, and infertility. These female participants expressed the need for a single-use FP method with fewer side effects for women which could be used without their husbands’ consent. The male participants were worried about the risk of unwanted pregnancy due to the breaking of condoms and a few participants also expressed concern that they experienced allergic reactions after the use of condoms. Moreover, they were concerned about not having any alternative methods of contraception other than condoms.

“I have a much bitter experience. I was using Depo injection before. But I started having over bleeding for which I was admitted to the hospital for a few days. Later, I was switched to implants but they also did not suit me. In between I also used pills, but they aggravated my acne and I was feeling nauseated every day. Uff…. I am fed up now. I swear, I won’t ever use any methods.” - 19 years Female, FGD participant “I have heard that keeping these things (Copper-T) in the uterus can cause cancer. Better to avoid it.” - 20 years Female, FGD participant “There aren’t many choices for men. I think using a condom during sex is like tying plastic around the tongue and eating food.” - 21 years Male, IDI participant

Religious and ethnic variation affected use of FP. Participants reported that people belonging to upper caste groups used FP measures more than lower caste groups. Likewise, people who had migrated from the hilly areas used FP services, whereas people from the local ethnic community did not use as they were less aware of it. FP decisions among young people seem to be influenced largely by religious beliefs, stigma, and the perceived role of men and women based on existing social norms. Some participants regarded children as a gift from God and denied using any FP methods. Some believed using FP was going against the law of nature, religion, and culture; thus, they would not avoid childbirth, but rather celebrate every birth. Some indicated that if couples did not have children within 1–2 years of marriage, then people would question the woman’s fertility. Most couples preferred sons to daughters as they believed sons would look after them and their property, while the daughters would be married and sent away, resulting in avoidance of FP measures until they have a son. Some couples even wished to have two sons because if anything unfortunate happened to one, the other son would still be with them to carry the generation forward.

“My aunt gave birth to a son after 5 successive daughters. She is pregnant again this time in the hope to have a son. She says that she cannot trust to have only one son because if anything happens to their only son, then she will have no one to pay tribute after her death.”- 22 years Female, FGD participant

Participants also said that people felt shy talking about FP openly. Female participants also felt uncomfortable asking for contraceptives with male health personnel at the health post. Similarly, teachers felt uncomfortable teaching about reproductive health and FP as their children and relatives could be present as students in the classroom. Participants indicated that some students would laugh and smile, making it difficult for the teachers to run the classroom sessions smoothly.

It was reported by a FP service provider that some men opposed their wives using any FP measures as they perceived that the use of FP measures allowed their wives to become promiscuous when they go abroad for work.

“Some husbands working abroad forbid their wives from using any FP measures because they fear the use of FP measures may provoke a sexual relationship with someone else in their absence”- 30 years Female, Health professional providing medical abortion services, IDI participant

Theme 4: Role of youth and suggestions to improve FP

The youth were interested in getting involved in a “peer to peer education” approach to increase awareness among the community about FP use. This approach would include peer training programs, role-plays/dramas, and counseling sessions to break the key barriers linked with such services. Activities ranging from redesigning the school’s curriculum to strengthening FP services in primary care centers, and from launching mobile outreach clinics to facilitating “spousal communication” were intended to change attitudes and support gender equality in sexual and reproductive health. Participants emphasized forming youth centers and collaborating with other youth clubs in the village. Furthermore, they suggested bringing religious leaders, teachers, doctors, and politicians as advisors of the youth centers would be beneficial as they are influential members of the community.

“I feel bad for my sister who is not given much importance from my parents. She got married against her choice due to her parents’ pressure. Now, they are forcing her to have kids. She is just 15 and if she gets pregnant, what will happen to her health and her child, how can she take care of a baby? I had a long debate with my father yesterday. I have now decided to start a youth club to promote awareness regarding FP and preventing early marriage and teenage pregnancies.” - 23 years Male, FGD participant

Male participants indicated that family planning programs are effective only when men prioritize women’s autonomy. Moreover, they expressed disappointment with the local government for not encouraging the involvement of men in FP programs in their village. To help address this issue, they expressed their interest in supporting the local government in bringing inclusive FP programs to their village.

“For a long time, women have been using those (Contraceptives) by hiding. We are always in fear about what others would say if they came to know about us using it. This can be addressed through male involvement and support.” -24 years Female, FGD participant

This qualitative study provides in-depth information on the understanding and perceptions of youth in Eastern Nepal regarding FP. This study generated findings regarding knowledge and perceptions of rural residents regarding FP and its methods; decision-making and preference among participants; supply-side and demand-side barriers and challenges regarding the use of FP measures; steps that can be taken to improve their use; and the role of youth in increasing FP coverage. Although most participants knew something about FP, a few female participants were completely unaware of it. And while some participants agreed that all married couples should be using FP measures, some unmarried male participants believed that those measures should be exclusively for women. These men said that they would let their wives use them after getting married. Current FP methods for men are either coitus-dependent, such as condoms or withdrawal, or permanent, such as vasectomy. Limited choices for men may have resulted in misconceptions that contraceptives are mostly for women.

Men often claimed to be the sole decision-maker of the family on important matters, including those related to family health and contraception. In most circumstances, men solely decide the FP measure to be used without having a discussion with their partner. This might be one of the reasons why women are bound to adopt a FP method that is not necessarily their choice. Besides, this problem is further reinforced by the limited options of FP methods available for men other than condoms and permanent sterilization. These findings are supported by other studies in South Asia, where family planning measures are mostly considered women’s responsibility [ 21 – 24 ]. Health workers, peers, and mass media were the most common sources of information regarding FP similar to prior studies in India [ 21 , 24 ] and Nepal [ 22 ]. Participants in this study seemed to assign FP responsibility to the other gender in terms of using FP. This could mean that there is a gap in communication within the couples when deciding about FP. There is a need for further research to identify ways to improve communication among couples.

Religious and ethnic variation influence FP use. People belonging to privileged ethnic groups used FP measures more than underprivileged groups. This is despite family planning services being free for all citizens in Nepal. In this study, people who had migrated from hilly regions knew about and used FP services more than those belonging to the ethnic community in the local region. This is an area for further research to understand differences in knowledge and perceptions regarding FP between the population groups. This can be argued as a limitation of the current FP promotion programs, which may not have considered the different needs of people from different religious and ethnic backgrounds [ 25 ]. A few participants reported that their holy scriptures forbade them from using FP methods as they viewed children as a gift from God; any artificial process interrupting pregnancy or preventing the possibility of life is a religious offense for them [ 26 ]. Previous studies from Nepal have shown that this belief has long been rooted in some communities [ 27 – 29 ].

Apart from religious beliefs, fear of side effects, having experienced adverse health consequences after using hormonal contraceptives, and fear of potential infertility in the future are reasons for reluctance using FP methods among women [ 30 ]. Besides, we can speculate that language and cultural barriers, and fear of discrimination especially by male counterparts negatively influence the use of FP measures among some women despite their strong interest in using them. The use of IEC materials in raising awareness and empowering married couples for shared decision-making could help generate demand [ 28 , 29 ]. Local cultural taboos restrict open communication about safer sex measures and sexual health in Nepal, prohibiting young girls and boys from receiving adequate information and guidance regarding sexual and reproductive health and FP [ 31 ].

Most of the married women and men stated that the decision-makers of the family are men. The husband decides whether or not to use contraception, or more specifically, whether or not to let their wives use it. However, unmarried participants expressed their willingness to decide mutually with their spouse regarding FP use in the future [ 21 , 32 ]. Most women in this study seemed comfortable letting their male partners decide on contraceptives. This attitude could be explained by the patriarchal dominance in decision-making [ 19 , 33 , 34 ].

Some men mentioned that condoms inhibit their sexual pleasure, which is why they prefer women to use other methods instead. A study conducted in Far West Nepal and another nationwide study reported similar concerns among men [ 31 , 35 ]. Adolescent girls stated that they were not comfortable talking to a male health worker about FP or to a female worker in the presence of a male health worker, which has also been reported elsewhere [ 36 ]. Some women said that their husbands forbade the use of contraceptives because they thought that contraceptives would allow their wives to become promiscuous and that using FP was a sign of infidelity. This issue, however, was not raised by any men in the study. Some women reported violence as a consequence of using contraceptives without their husband’s consent. Prior qualitative studies also reported that women may suffer domestic violence for opposing their husbands. Studies suggest that a multi-sectoral action involving stakeholders from health, women’s rights, and education sectors is imperative to further research and address this issue [ 29 , 36 , 37 ].

Supply constraints (distance to a provider for getting contraceptives, out of stock, limited choices of contraceptives, unaffordable methods, etc.) could aggravate the unmet need for contraception. These constraints are similar to all regular supplies faced by the health system in Nepal. However, supply-side interventions such as increasing the number of health facilities distributing FP services, policy focusing on consistent operating hours, and full stock of a wide variety of FP methods could largely improve uptake and increase contraceptive coverage [ 18 , 38 ].

Most female participants did not speak up when asked about their perception of the role of men in FP. On the other hand, male participants explained that the role of the youth could be disseminating FP information, conducting awareness campaigns, organizing dramas and role-plays to educate people about the religious and cultural barriers of FP use, etc. With appropriate training, the young men said they would be willing to work for FP advocacy in the community.

Reproductive health leaders and planners should identify men who are willing to share decision-making authority with their wives and devise behavioral change interventions [ 39 ]. Male participation could support the FP programs and also help empower women [ 40 ]. The participants in the study expressed the need for the current FP programs to consider the community members as key stakeholders in planning FP programs. There is a need to further explore possible ways of working with the rural, marginalized communities and hard-to-reach or specific ethnic groups to improve their update of FP services [ 41 ]. There is evidence that mass media messages increase the likelihood of FP use, which could be considered by advocacy and dissemination programs [ 42 ]. Evidence from maternal and newborn health care research shows that interventions that engage men result in more equitable couple communication and shared decision-making. This may be a relatable concept to be considered for FP programs as well [ 43 ].

We urge those in charge of the health and sexual education curriculum to find ways to encourage teachers to give equal attention to these topics, including FP education, as they would to any other. It was reported that teachers were reluctant to teach about FP as they perceived the young students felt discomfort around this topic. Further research to identify innovative youth-friendly methods to teach sexual and reproductive health topics to students may be helpful. Youth groups should be regarded as important stakeholders in the redesign of school health curricula, particularly for their insight into culturally sensitive and otherwise effective ways for delivery. Health professionals, members of local organizations, and community leaders pointed to the necessity of addressing unmet FP needs and the stigma associated with FP use through community education approaches that take into account cultural norms and beliefs [ 44 ]. Interventions focusing on reproductive health education curricula involving school teachers could be considered [ 45 ]. Strengthening health systems, bridging service gaps, improving the integration of contraceptive services and counseling with routine health care are important strategies for increasing contraceptive uptake in eastern Nepal [ 22 ].

Among the study’s limitations was the fact that it was conducted in a single village in eastern Nepal. Our findings might differ if the sample had been drawn from other parts of the country. Although participants spoke fluent Nepali, some phrases used in local dialects could not be perfectly translated into Nepali or English. These responses could have been affected by social desirability as the participants may have felt constrained from speaking freely with people from health institutions. To help reduce these obstacles we held open meetings and drop-in sessions with the support of community youth to disseminate the purpose of the study and build rapport with the young people in the village before we approached them for the study. Moreover, participants were assured anonymity and confidentiality, which may have increased their willingness to participate in the research.

Conclusions

There appear to be information and communication gaps between women and men regarding FP services and programs. The information gap could be addressed by exploring ways to increase information uptake in schools through redesigning the curriculum delivery. Mass media may be used to disseminate appropriate health education regarding FP. Health institutions could consider approaches to create FP information and service centers that are male-friendly. The communication gap may be more deeply rooted in the culture and traditions of Nepalese society. In a mostly patriarchal society, further identification of motivations for men to participate in FP related activities could be challenging. However, it is promising that men may be willing to support their partners for FP decision-making and engage in strengthening FP programs through the “peer to peer” approach via youth-led centers and community clubs. Program managers and policy makers need to take into account the fact that youth are willing to contribute to ongoing FP programs. Doing so would help bridge the information and communication gaps between school education and practice. Innovative research to further explore perceived benefits by youth on the uptake of family planning, sexual and reproductive health services is needed.

Supporting information

https://doi.org/10.1371/journal.pone.0252184.s001

https://doi.org/10.1371/journal.pone.0252184.s002

Acknowledgments

We extend our sincere thanks and regards to Dr. Agata Parfieniuk, Kirsty Lunney, and Anu Regmi for their invaluable contributions to the manuscript. We acknowledge the support received from Dr. Meika Bhattachan, Dr. Avinash Kumar Sunny, and Dr. Pawan Upadhyaya during data collection. The authors acknowledge the support received from the BPKIHS and participants for their participation in the study. Special thanks to Dr. Bibisha Baaniya, Dr. Garima Pudasaini, Dr. Soniya Gurung, Dr. Shristi Nepal, Bisha Baaniya, and Arshpreet Kaur for their generous support throughout the study.

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