research paper of family planning

• Research article
• Open access
• Published: 09 October 2021

Understanding family planning decision-making: perspectives of providers and community stakeholders from Istanbul, Turkey

• Duygu Karadon   ORCID: orcid.org/0000-0003-1086-8607 1 ,
• Yilmaz Esmer 1 ,
• Bahar Ayca Okcuoglu 1 ,
• Sebahat Kurutas 1 ,
• Simay Sevval Baykal 1 ,
• Sarah Huber-Krum 2 ,
• David Canning 2 &
• Iqbal Shah 2  

BMC Women's Health volume  21 , Article number:  357 ( 2021 ) Cite this article

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Metrics details

A number of factors may determine family planning decisions; however, some may be dependent on the social and cultural context. To understand these factors, we conducted a qualitative study with family planning providers and community stakeholders in a diverse, low-income neighborhood of Istanbul, Turkey.

We used purposeful sampling to recruit 16 respondents (eight family planning service providers and eight community stakeholders) based on their potential role and influence on matters related to sexual and reproductive health issues. Interviews were audio-recorded with participants' permission and subsequently transcribed in Turkish and translated into English for analysis. We applied a multi-stage analytical strategy, following the principles of the constant comparative method to develop a codebook and identify key themes.

Results indicate that family planning decision-making—that is, decision on whether or not to avoid a pregnancy—is largely considered a women’s issue although men do not actively object to family planning or play a passive role in actual use of methods. Many respondents indicated that women generally prefer to use family planning methods that do not have side-effects and are convenient to use. Although women trust healthcare providers and the information that they receive from them, they prefer to obtain contraceptive advice from friends and family members. Additionally, attitude of men toward childbearing, fertility desires, characteristics of providers, and religious beliefs of the couple exert considerable influence on family planning decisions.

Conclusions

Numerous factors influence family planning decision-making in Turkey. Women have a strong preference for traditional methods compared to modern contraceptives. Additionally, religious factors play a leading role in the choice of the particular method, such as withdrawal. Besides, there is a lack of men’s involvement in family planning decision-making. Public health interventions should focus on incorporating men into their efforts and understanding how providers can better provide information to women about contraception.

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There is considerable literature on the decision-making process related to fertility, and various factors have been proposed as predictors of family planning decision-making. Women’s characteristics, such as age, parity, level of education, level of income, occupation, and work status are the most frequently cited factors [ 1 , 2 ]. Additionally, previous studies have analyzed diverse factors that influence family planning decision-making within the family, such as power relations [ 3 ] and dominance of male partners [ 2 , 4 ]. Various studies in Turkey have found that many men are motivated to use family planning and would like to share responsibility for family planning decision-making (to use or not use any family planning method) [ 5 , 6 ]. However, there is also a tendency to view family planning as “woman's domain,” which refers to deciding whether to avoid pregnancy or not [ 7 ].

We would like to emphasize that cultural values also play an important role in impacting the use of family planning. Among these cultural factors, perhaps religious values top our list. Previous studies have also included ethnicity, male preference, traditional family values as well as the economic value of children as potential causal factors in determining family planning decisions. The present study aims at identifying significant contextual factors that are likely to influence use of family planning such as socio-cultural and religious norms.

In the 1960s, Turkey adopted a national family planning policy that advocated the use of both traditional and modern contraceptive methods (i.e., sterilization, intrauterine devices (IUDs), implants, injectables, pills, condoms, emergency contraception, lactational amenorrhea (LAM), and standard days method), and expanded access to contraception through health clinics. According to the 2018 Turkey Demographic and Health Survey, women are very knowledgeable about contraception: 97% of all Turkish women know at least one method of contraception [ 8 ]. Further, almost half of married women use a modern contraceptive method [ 8 ]. The most commonly used modern methods are male condoms (19%), IUDs (14%), and female sterilization (10%) [ 8 ]. However, while the use of modern contraceptives increased steadily in the 1980s and 1990s, the prevalence rate has stagnated since the 2000s. Further, a sizable proportion of women continue to rely on traditional methods of family planning, such as withdrawal [ 8 ].

The dominant (almost exclusive) religion in Turkey is Islam. The government, which has been in power since 2002, actively promotes policies that encourage high fertility and discourage contraception and abortion. The Turkish Ministry of Health is responsible for designing and implementing health policies and overseeing all private and public healthcare services in the country. All residents of Turkey who are registered with the Sosyal Güvenlik Kurumu (SGK) Footnote 1 can receive free medical treatment in hospitals contracted by the agency. The services are provided by government hospitals, Aile Sağlığı Merkezi (ASM), Footnote 2 Ana Çocuk Sağlığı ve Aile Planlama Merkezi (AÇSAP), Footnote 3 maternity, and children’s hospitals, training and research hospitals, university hospitals, private hospitals, and private polyclinics. Family planning and abortion services are provided both in public, and private sectors, and modern methods may be accessed for free in government-funded primary health care units and hospitals or from pharmacies and private practitioners for a fee [ 9 ]. In general, most women and couples obtain modern contraception from public sector sources, and pharmacies are the leading source of oral contraceptives and male condoms [ 8 ]. Women and men can also purchase emergency contraception, hormonal and copper IUDs, three-month contraceptive injections (Depo-Provera), and one-month contraceptive injections (Mesigyna) from pharmacies. IUDs cannot be inserted at pharmacies but are taken to health facilities to be inserted. Male condoms can also be purchased from markets and beauty shops.

The Turkish national curriculum does not provide sex education and the subject is rarely discussed in schools [ 10 ]. Since there is no formal education on reproductive health, most people are informed about family planning though friends, relatives as well as printed or social media. Basic information, education, and communication materials about contraception are provided by health facilities.

This study aims to delineate the factors that influence family planning decision-making processes from the perspectives of community stakeholders such as prayer group leaders, parent-teacher association members, and family planning service providers. We attempt to understand and explain these factors within the context of social and political tensions in Turkey most important of which are ethnic and secular-religious cleavages.

Study procedures

We used purposive sampling [ 11 , 12 ] to interview eight family planning service providers and eight community stakeholders in Bagcilar, Istanbul. Our sample includes fifteen females and one male participant. We determined the number of interviews based on the principles of theoretical saturation (i.e., the criterion for judging when to terminate interviewing at the point when no new information was being generated [ 13 ].

Bagcilar is one of the largest districts in Turkey with a population of 745,125 in 2019 [ 14 ]. We sampled key informants from different professional backgrounds, with different social status within their respective communities, and based on their role in influencing reproductive health. This enabled us to understand broader community and provider perspectives about women’s health concerns. In-depth interviews were conducted between April and May 2019.

We partnered with a local research firm that had extensive experience in conducting qualitative studies in the area. The research firm and research team generated a list of potential community stakeholders (such as members of local government, religious leaders, women’s groups, and community groups) and the research team made visits to the study area to organize the interviews. We identified service providers from public and private hospitals that offered family planning services in the study area, from a health facility assessment that we conducted less than six months prior. To map the availability of and access to family planning and abortion services, we conducted a facility survey in public and private facilitates that provided reproductive health services in the study area. The facility survey captured data on service availability and facility readiness (including staffing, hours of operation, and payment of user fees), services provided (including counseling, physical examination and contraceptive, and abortion methods), and commodity supplies. These were supplemented with in-depth interviews with key informants. The research firm used separate standardized scripts to recruit family planning providers and community stakeholders. The recruitment script included details about the study, its aim, and contact information for the principal investigators. The research firm scheduled a time for interview with providers and community stakeholders who were willing to participate in the study.

All respondents spoke Turkish and interviews were conducted by a trained Turkish female interviewer who was employed by the research firm. The interviewer had a university degree and was employed as a fieldwork director by the local research firm at the time of the interview. After a refresher training session about principles and techniques of qualitative research, ethics and confidentiality, and role-playing exercises with a supervisor, the interviewer piloted two different semi-structured interview guides (see selected questions in Table 1 ) (one interview with a family planning service provider and one interview with a community stakeholder). The interview guides were developed for this study in English and translated into Turkish (see Additional files 1 and 2 ). A randomly selected sample (approximately 5%) of the transcripts were back-translated and reviewed by the research team to ensure that translations were consistent and of high quality. The service provider interview guide included several topics related to accessing family planning, factors influencing decision to use contraception, and barriers to and facilitators of family planning use in the community. The community stakeholder interviewer guide captured information on socio-cultural beliefs influencing community preferences and attitudes regarding family planning. Topics were related to the availability and accessibility of contraceptives, the demand for contraception and abortion services, the influence of attitudes and beliefs on contraception and abortion accessibility, decision-making, and behavior of women regarding gender norms and decision-making between couples. The Turkish version of the interview guide was amended based on questions and feedback obtained during training and pilot test.

All participants received written information about the study and provided oral consent to participate. We did not collect any identifying information from participants. Face-to-face interviews were conducted in a private space (i.e., private rooms at the facilities for family planning service providers and community stakeholders’ homes), and audio recorded with permission from the participants. The interviewer took field notes during the interview. On average, interviews lasted approximately one hour. After interviews were completed, the research team transcribed each interview in Turkish and then translated it into English for coding and analysis. Transcripts were double-coded by the research team to ensure accuracy. We did not share transcripts with participants. Before data collection we received ethical approval from the Boards of Harvard School of Public Health and Bahcesehir University.

We used ATLAS.ti (Version 8.0, Scientific Software Development, Berlin) to manage and analyze the data. We further used an inductive, thematic analytical approach, guided by the principles of the constant comparative method to identify key themes arising from the data [ 12 ]. First, four researchers reviewed eight transcripts and developed an initial list of codes and general themes (see Additional file 3 ). Specifically, we used in vivo coding in ATLAS.ti to code participants’ spoken words and used their own words as codes. For example, one participant commented, “ One of my clients said that she would not use birth control pills because it was a sin.” The final title of the code became “sin” and similar statements referring to abortion as a sin were grouped together to create the theme. Next, four members of the study team read two transcripts aloud together and open-coded all text, in line with the principles of open coding and an inductive approach [ 12 ]. We reviewed all codes together (more than 200 codes), merging similar codes and grouping codes into themes and sub-themes. Next, once all major themes and sub-themes were agreed upon, we generated a final codebook, which included 51 sub-codes in six main coding groups, including demographics, family planning, abortion, socially-oriented perspectives, quality of services, and family planning programs. The study team double coded all transcripts. Two members of the study team were assigned to each interview in order to enhance the quality of the analysis.

Several key themes emerged from the data related to family planning decision-making. All themes were identified by two members of the study team. We decided to characterize emerging dominant themes related to most frequently discussed topics across all interviews.

Participants’ profile

Background characteristics of participants are shown in Table 2 . There were six physicians/gynecologists and two midwives in the group of family planning providers. The service providers in our sample had been providing family planning services for between one and 22 years. Regarding community stakeholders, two were associated with Ak Parti—the religiously conservative, ruling political party- as members Footnote 4 and representatives, Footnote 5 two were local parent-teacher association members, one was a neighborhood representative’s assistant and another was a member of a local prayer group. Additionally, there was a pharmacist and a pharmacist’s assistant in the group of community stakeholders. The pharmacist and the pharmacist’s assistant were assigned to the community stakeholder group since they frequently provided informal advice to women about contraceptive use and other reproductive health-related topics.

We wanted to understand family planning decision-making process in relation to decisions about whether to avoid pregnancy or not. Three main themes identified by the study team emerged from the transcripts, including the decision-making process, the role of male partners, and the role of religious beliefs on reproductive health decisions, that provide insight into how women and couples decide to use contraception, how they learn about contraception, and the types of contraceptives women and couples prefer (Table 3 ). In general, we found that there was considerable demand for modern contraceptives among women. The majority of respondents mentioned the increasing awareness about modern contraceptive methods, most notably young women wishing to delay or space childbearing and women who wish to limit births once they achieve their ideal family size. Providers’ narratives implied that they are supportive of these growing modern contraceptive trends and actively encouraged young women to take actions to meet their reproductive needs.

Decision-making process: preferences and access

Respondents differed in what they perceived as the most preferred contraceptive method for women. While they discussed a variety of modern contraceptive methods used by women in their communities, many agreed that traditional methods, such as withdrawal or periodic abstinence, were preferred. They frequently believed these traditional methods to be more effective than other modern methods, and also explained that women prefer these methods to avoid side effects and also for convenience in use. A gynecologist who had been serving in this position for four months said:

If you leave it to the clients, they will still use the withdrawal method. It does not matter if they are educated or not. Nearly 70% of them still use the withdrawal method… They think it is safe. They say they have been using it for five years and nothing happened, so they continue [to use it] . (Interviewee 15, Family planning provider)

Most respondents agreed that the use of contraception is a woman’s decision. A parent-teacher association member noted that “… women have to think about [birth control] as they are the ones who take care of the children. So the women make the decisions.”  (Interviewee 8, Community stakeholder). Moreover, another participant summarized the situation with the following comment: “ Because they [women] don’t want to get pregnant. It is always the women who endure the hardships of pregnancy, so they make the decisions” (Interviewee 11, Community stakeholder). Although most respondents agreed that women are more likely than men to be involved in the choice of a preferred contraceptive method, decision-making within a family is multi-layered. Some respondents reported that mothers-in-law and fathers-in-law are also important actors who exert an influence on family planning matters. A physician who had been providing family planning services for approximately nine years explained:

I had a few clients whose mothers-in-law wanted their daughters-in-law to have more children. And this affects the spouses or the husbands and they think about having another child. As they live together, the mother-in-law or even the father-in-law influences [their decisions to have another child] . (Interviewee 6, Family planning provider)

All participants reported that modern contraceptive methods are widely available and easy to access from health care centers and pharmacies. The majority of respondents (both providers and community stakeholders) reported that women trust and respect family planning service providers. Nevertheless, with regard to obtaining information, women trust the contraceptive experience of other people like their friends and family members and therefore mostly rely on second hand information. A community stakeholder commented:

First, they [women] talk among themselves. For example, she asks me how I manage birth control, how I prevent pregnancy. I say that I use the pill or injections or that my husband uses a method. She says that if it is good, she will do it too. Then she goes to the health center to ask the nurses…It is the culture of the women here, nothing else. It is better for them to hear it instead of searching and learning, I think . (Interviewee 1, Community stakeholder)

A few participants discussed the influence that the characteristics of providers can have on decision-making. The narratives suggested that decision-making is influenced by accessibility and quality of services. One community stakeholder said:

If the doctor is male, women are shy, but just a little…Their husbands don’t let them [go]. They say “If the doctor is male, you can’t go… When we go there again with our husbands, and the doctor will say that I have been here before. Then I will have problems with my husband” they say . (Interviewee 1, Community stakeholder)

Most participants did not report difficulties with accessing contraception for any particular group of women, and they agreed that unmarried women and adolescent girls can access modern contraception. A few reported that modern contraceptive methods are available, but it is difficult for single women to obtain them, which is an indication of barriers to access among this sub-group of women.

As far as I know, single persons wouldn’t get them from somebody they know [meaning a provider, pharmacist, or friend]. It is easily accessible, but the social pressure is serious. So, it is easily accessible, but it is hard to get . (Interviewee 3, Community stakeholder)

Our findings suggest that there is no single explanation for family planning decisions among women in the study setting. Various factors influence family planning decisions, and factors such as the source of information, characteristics of service provider, and marital status play a role.

Role of male partners

Most respondents stated that demand for modern contraceptive services is stronger among women compared to men. The majority of respondents reported that men do not favor modern contraceptive use, but do not actively object to using them. It was evident from participants’ narratives that family planning decisions remain a “woman’s domain”—that is, it is women who typically decide whether to avoid pregnancy or not. Additionally, family planning service providers reported that men have very limited involvement with pregnancy planning and fertility decisions and that women often do not trust men to be involved in such decisions.

Men are not trusted to be involved with family planning by women. Men are fine with [women’s decisions] …I think this responsibility is given to the women in Turkey. Men do not care about it much . (Interviewee 15, Family planning provider)

A gynecologist who has provided family planning services for 14 years said:

…men have birth control methods such as withdrawal and condoms but generally the women come here to consult about the methods. But a lot of men use birth control too. When the women use IUD or the pill and experience side-effects, I think the men understand and they resort to methods such as withdrawal and condoms . (Interviewee 10, Family planning provider)

Participants reported that men are more likely to desire more children compared to women, but the burden of childrearing falls on women. A local midwife who had provided services for ten years in the community explained:

When [women] bear a child, most husbands do not help with childcare. It is as if the child belongs only to the mother; supposedly, he is the father. When the child is sick, the mother takes care of him/her; and when the mother is sick, the father cannot take care of the child… Men generally say that they are unable to take care of children. So, women want birth control methods to avoid consecutive births . (Interviewee 14, Family planning provider)

A local pharmacist who has been in that position for 36 years also indicated that men desire to have more children than their wives. She said:

…especially the husbands want more children, so the women sometimes get these [family planning methods] without telling their husbands . (Interviewee 3, Community stakeholder)

The role of religious beliefs

Participants reported few barriers to contraception, and the narratives suggest relatively few reasons for non-use. However, a frequent theme was the importance of religious beliefs on reproductive health decisions. A few participants reported that women believe that modern contraception, in general, or use of certain methods in particular, are sinful behavior. A gynecologist who had been in that position for 20 years said:

…our religious belief is against it; according to our faith, family planning is forbidden. What can you do with this person? He/she wouldn’t do it even if it were free . (Interviewee 9, Footnote 6 Family planning provider)

Further, a parent-teacher association member and a gynecologist reported that:

Some spouses consider [birth control] to be a sin. We hear it from our friends … Interviewee 8, Community stakeholder) Actually, there is prejudice against most of the birth control methods in our society… Modern contraception is considered a sin. They [referring to the people in the community] do not want birth control. Women do not want IUD. They use the withdrawal method . (Interviewee 13, Family planning provider)

Additionally, beliefs about the moral status of contraception seem to be influenced by women’s social networks. A pharmacist described the effects of shared beliefs around contraceptive decision-making, thus:

One of my clients said that she would not use birth control pills because it was a sin. A couple of months later, she got pregnant and had to have an abortion. I asked her who had recommended it; it turned out to be someone I knew. Then I called that person and said “Why are you misinforming people?” She told me that it was a sin. I told her “Isn’t abortion a sin? She had to have an abortion.” She said that it was not alive until it was three months old. I told her “Look, you don’t have the knowledge about it but you have opinions. You are misinforming people and playing with their lives. A lifeless thing does not grow; it is alive since the first moment that sperm fertilizes the egg. Do not misinform people, please. Send the people to the health centers or doctors but don’t misinform them.” She was offended but I think that the conversation was effective. (Interviewee 3, Community stakeholder)

The narratives suggest that there is contradiction between faith and behavior. In particular, women think that contraception could be against the will of God, but act in accordance with the dictates of modern life.

The findings from this study highlight the major factors that influence family planning decision-making. According to the 2018 Turkey Demographic and Health Survey, 99.5 percent of married women of reproductive age know at least one method of contraception [ 8 ]. Our results are consistent with the existing literature which shows that contraceptive methods (either modern or traditional method) are widely known in the community. Thus, a key finding from the study is that women, and particularly married women, are aware of at least one method of contraception. Therefore, high levels of knowledge of contraceptives provide opportunities for programs to address barriers that could hinder translation of such knowledge into practice.

We found that, according to the perceptions of key informants, traditional methods were preferred over modern methods, and most respondents explained that women prefer traditional methods mostly due to the absence of side effects and ease of use. There is widespread perception that modern methods might have undesired side effects. Additionally, there are religious reasons such as couples’ consideration of natural, easy use the method with more minor side effects for traditional methods being the most preferred methods. According to Cebeci et al., however, even religious beliefs should not be identified as the dominant barrier to contraceptives; they rather affect the choice of particular methods such as withdrawal [ 7 ]. The effect of religious beliefs on contraceptive choice may be the reason why couples continue to rely on traditional methods. There is, however, a need for studies to better understand the motivations for preference for traditional methods in the study setting and how women could be supported to ensure that such methods meet their reproductive needs.

Participants reported that family planning is a “women’s domain” although sometimes other family members, such as mothers-in-law and fathers-in-law, may influence decision-making. A study among married individuals in Umraniye which is another district of Istanbul also found that family planning decision-making was perceived as a “women’s issue” by male partners [ 7 ]. Yet, decision-making is not limited to women and women’s partners; family members are also involved in their contraceptive choices. These patterns underscore a need for a better understanding of intra-family relations and opportunities that such relations provide for supporting women in the study setting to realize their reproductive goals.

Our findings show that although women trust family planning providers on contraceptive issues, they have more confidence in the previous family planning experiences of other people like their friends, neighbors, or relatives. This underscores the significance of women’s social networks as a source of information as well as a determinant of behavior. As Yee and Simon found, women identified their social networks as one of the most influential factors in the family planning decision-making process, especially about side-effects, safety, and effectiveness, and most of them considered that information more reliable than other sources of information [ 15 ]. Husbands, however, do not tend to share information about contraception with one another. Thus, husbands may look to their wives to receive accurate and reliable information about contraception [ 16 ]. Understanding how women’s and men’s social networks influence contraceptive use in this setting may be key to increasing contraceptive use among women who do not want a pregnancy. Intervention studies might also consider leveraging women’s social networks to provide education about contraception (e.g., peer educators or women’s groups).

Related to the accessibility and quality of services that influence decision-making, our findings show that women prefer female to male physicians and consultants in matters related to contraception. In addition, some of the community stakeholders reported prejudice in accessibility to contraceptive methods against unmarried women. Pharmacies provide male condoms, pills, and emergency contraception without a written prescription in Turkey. The pharmacy sector provides more than 45% of the male-condom and pills [ 8 ]. Many unmarried women find it more convenient to obtain contraceptive supplies from pharmacies, despite contraception not being free at pharmacies. This is likely because many single women prefer to avoid social pressure in healthcare facilities and fear being ostracized for engaging in what is regarded as illegitimate sex. The finding that many women in the study setting prefer obtaining contraceptives from pharmacies suggests a need for improving the capacity of pharmacists to provide contraceptive information and counseling to clients.

Various studies in Turkey have found that a variety of perspectives need to be taken into account to fully understand family planning decision-making processes. On the one hand, men report that family planning is a shared responsibility [ 6 ], and that pregnancy planning should be done jointly between partners [ 17 ] which is consistent with existing evidence showing that male involvement and shared decision-making is a key element of reproductive decisions [ 5 , 18 ]. On the other hand, several studies show that men and women are not resistant to contraception, although women are perceived to be the ones making family planning decisions [ 7 , 19 ]. Our findings show that men are not much involved in family planning decision-making and it is often women who decide whether to avoid pregnancy or not. While some respondents suggest that men might be opposed to contraception, the majority reported that men were simply indifferent. Additionally, lack of men’s involvement likely stems from pro-natalist views. The findings suggest a need for a better understanding of couple-level contraceptive decision-making and how best to engage men in supporting women’s reproductive needs.

Studies show that various factors influence fertility decisions, including the number of living children [ 20 , 21 ], level of education of parents and especially of female partners [ 22 ], and socio-cultural norms and religious attitudes [ 17 ]. However, men, in almost every setting, desire more children than women [ 17 , 23 ]. In general, both family planning service providers and community stakeholders in our study reported that men desire more children compared to women. However, the burden of childrearing falls on women, which reflects gender roles in the family. Men’s desire for children could be associated with a need to continue the family line and enhance their social value [ 24 ], making sense in terms of the social value of having a child primarily for men [ 25 ]. This a further indication of the need for understanding the perspectives of men in the study setting and how best to involve them in supporting women’s reproductive needs.

Our findings showed that women placed greater importance on religious beliefs although in practice, such beliefs did not have a direct influence on decisions regarding family planning. Although women believed that contraception could be against the will of God, this did not stop them from using the methods. This is consistent with findings from another qualitative study which showed that religious beliefs were not barriers to contraception, but such beliefs influenced the choice of methods [ 7 ]. Religion does not often dissuade women and men from wanting small families, but instead of using the most effective methods, they instead rely on methods that they perceive to be in alignment with religious beliefs or methods that are not as bad as others. Although most respondents in our study reported that contraception is perceived as a sin, women still used methods. It is possible that religious values may encourage the use of traditional methods, such as withdrawal, that have a long and historical tradition of being used in this setting. Cebeci and colleagues found that, in addition to people’s consideration of withdrawal as a natural, easy to use method with less side effects compared to modern methods, some considered it the method encouraged by Prophet Muhammad, which indicates that modern methods are perceived as harmful [ 7 ]. The findings underscore a need for family programs in the study setting to incorporate empowerment principles in client counseling in order to address misconceptions about modern contraceptives influenced by religious beliefs.

Our findings may be influenced by the manner in which participants were selected. In particular, community stakeholders and service providers were purposively selected based on their familiarity with women’s reproductive health-related topics, including family planning, and the sample included only one male participant. All interviews were conducted in Turkish and translated into English for analysis. Although some meanings could be lost in the process, a small sample of the transcripts were back-translated to determine the extent of such loss. There was no loss in meanings due to translation from one language to another. Additionally, all interviews were conducted in a private space to reduce the risk of social desirability bias. By its very nature, our sample has limited external validity which prevents us from making inferences about patterns in the study setting or the country as a whole. Although our findings, based on a limited purposive sample with key informants, are consistent with the findings of other studies using larger samples with more diverse groups of women, further qualitative research with representative samples of reproductive age women is needed to determine the extent to which our findings are consistent with the prevailing patterns in the country as a whole.

Our study sheds light on the factors that play a role in women’s contraceptive decisions in Turkey, a country with a strong national family planning policy but characterized by political-religious differences in beliefs about use of family planning. Our first take is that women (as well as couples) have a strong preference for traditional methods and particularly withdrawal. Religious factors in particular and socially conservative values in general play an important role in the choice of method. However, it should also be noted that the strong preference for traditional methods is a more general phenomenon that is not limited to the prevalence of religious and conservative values.

Second, in most cases, men play a minimal, if any, in family planning decisions. This is of both practical and academic interest especially in a male-dominant culture. From a policy viewpoint it points out to the need of educating not only women but also men about the availability, advantages, disadvantages and possible risk of available methods.

Third and last, the link between values and family planning decisions at all levels seems to be evident and this relationship deserves further investigation.

Availability of data and materials

Anonymized data can be availed upon reasonable request to the first author.

Social Security Institution.

Family Health Centers.

Maternal and Child Health and Family Planning Centers.

AK Parti member is also member of parent-teacher association.

They are not politicians, but they act as liaisons between community members and the political party.

Male participant.

Abbreviations

intrauterine devices

lactational amenorrhea

Sosyal Güvenlik Kurumu

Aile Sağlığı Merkezi

Ana Çocuk Sağlığı ve Aile Planlama Merkezi

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Acknowledgements

The authors thank the family planning service providers and the community stakeholder who participated in the study.

This study was funded by an anonymous donation to Harvard TH Chan School of Public Health. This funding source had no role in the design of this study, data collection, analyses, interpretation of the data, or decision to submit the manuscript for publication.

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Duygu Karadon, Yilmaz Esmer, Bahar Ayca Okcuoglu, Sebahat Kurutas & Simay Sevval Baykal

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DK drafted the first version of the manuscript. DK, BAO, SSB, and SK conducted an open coding of all transcripts and grouped the codes into themes. Data analysis was conducted by DK and BAO. YE, SHK, IS, and DC reviewed the manuscript for substantial intellectual content and contributed to the interpretation of the data. All authors read and approved the final manuscript.

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This study was approved by the Declaration of Helsinki and all procedures involving human participants were approved by the Ethics Board of Bahcesehir University and the Institutional Review Board at Harvard University (Protocol #: IRB17-1806). All participants received written information about the study and provided oral consent to participate in the research. Oral consent procedures were approved by the Ethics Board of Bahcesehir University and the Institutional Review Board at Harvard University. Before each interview, the consent script was read aloud to women. Enumerators asked participants to provide oral consent to take part in the study and recorded the answer on the tablet. Oral consent was obtained, rather than written consent, to protect the privacy of respondents.

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Additional file 1:.

Key Informant Interview Guide-Community Stakeholders.

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Key Informant Interview Guide-Family Planning Service Providers.

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Coding tree.

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Karadon, D., Esmer, Y., Okcuoglu, B.A. et al. Understanding family planning decision-making: perspectives of providers and community stakeholders from Istanbul, Turkey. BMC Women's Health 21 , 357 (2021). https://doi.org/10.1186/s12905-021-01490-3

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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

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

The views expressed in this article are those of the author(s). Publication in Gates Open Research does not imply endorsement by the Gates Foundation.

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

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• Open access
• Published: 01 April 2021

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

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

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

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

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

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

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

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

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

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

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

Study design and the participants

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

Data collection and analysis

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

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

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

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

Sources of knowledge about family planning methods (%)

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

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

Contraceptive method currently used among participants (%)

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

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

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

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

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

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

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

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

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

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

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

Availability of data and materials

Available from the corresponding author on reasonable request.

Abbreviations

Primary health care

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Acknowledgements

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

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Family & Community Medicine Joint Program, Hail, Saudi Arabia

Ghzl Ghazi Alenezi

Academic Affairs & Postgraduate Studies, General Directorate of Health Affairs, Najran, Saudi Arabia

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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 Article

Family planning awareness, utilization and associated factors among women of reproductive age attending psychiatric outpatient care, a cross- sectional study, Addis Ababa, Ethiopia

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

* E-mail: [email protected]

Affiliation Department of Psychiatry, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

Roles Conceptualization, Formal analysis, Funding acquisition, Methodology, Visualization, Writing – review & editing

Affiliation Department of Obstetrics and Gynecology, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

Roles Conceptualization, Data curation, Funding acquisition, Supervision

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Writing – review & editing

Affiliation Department of Public Health, St Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia

Roles Conceptualization, Formal analysis, Investigation, Methodology, Software, Validation, Writing – review & editing

Affiliation School of Public Health Addis Ababa University, Addis Ababa, Ethiopia

Roles Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, Visualization, Writing – review & editing

• Tigist Zerihun, 
• Delayehu Bekele, 
• Elizabeth Birhanu, 
• Yoseph Worku, 
• Negussie Deyesa, 
• Markos Tesfaye

• Published: September 4, 2020
• https://doi.org/10.1371/journal.pone.0238766
• Reader Comments

Women with mental illness have a special need for family planning as they carry a high risk of unplanned pregnancy, sexual violence and, the poor obstetric outcomes due to their mental illness, as well as teratogenicity from exposure to psychotropic medications lower antenatal care utilization.

To assess knowledge, and utilization of family planning and associated factors among women attending psychiatric outpatient clinics in Addis Ababa.

A cross-sectional study was conducted among 423 women attending the outpatient psychiatric clinics of three general and one specialized mental hospital in Addis Ababa, the capital city of Ethiopia. A structured and pretested questionnaire were administered by psychiatric nurses. Multiple logistic regression analysis was conducted to identify factors associated with utilization of family planning methods.

Four hundred twenty-two participants who had follow up at the psychiatric outpatient departments participated in the study. Almost 88% of participants had an unintended pregnancy. Only 68% of study participant had ever heard about Family planning. Just over one third (38.6%) reported current use of at least one method of Family planning. Of those not using family planning 73.3% had no intention to have children. And 38.8% did not have any intention to use Family Planning in the future. Fear of drug-interaction with psychiatric medication was the most common reason not to use contraceptives. Having one or two children was associated with higher utilization of family planning [adjusted odds ratio (95%, confidence interval) 2.05 (1.06, 3.99)].

Conclusions

In this study, the majority of women with mental illness were not using family planning methods. The Awareness of the Family planning methods is lower than the national average. Education and counselling about family planning for women attending psychiatric outpatient departments should be strengthened.

Citation: Zerihun T, Bekele D, Birhanu E, Worku Y, Deyesa N, Tesfaye M (2020) Family planning awareness, utilization and associated factors among women of reproductive age attending psychiatric outpatient care, a cross- sectional study, Addis Ababa, Ethiopia. PLoS ONE 15(9): e0238766. https://doi.org/10.1371/journal.pone.0238766

Editor: Nülüfer Erbil, Ordu University, TURKEY

Received: January 25, 2019; Accepted: August 24, 2020; Published: September 4, 2020

Copyright: © 2020 Zerihun 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: after discussion with the institutional ethics review committee chair we upload the data set as Supporting Information.

Funding: This study was supported by St Paul's Hospital Millennium medical college . The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

Introduction

Although family planning (FP) is essential for all women of reproductive age, it is particularly important for women with mental illness since they carry a high risk of unplanned pregnancy, vulnerability to sexual violence and poor obstetric outcome due to the mental illness as well as possible teratogenicity from exposure to some psychotropic medications and lower antenatal care utilization [ 1 – 6 ]. In addition, women with mental illnesses also need special consideration when using hormone- based contraceptives due to possible interactions with psychotropic medication although they can safely use other available methods [ 7 ].

Even though FP coverage is increasing worldwide, in the countries of sub Sharan Africa and other developing countries, the prevalence of contraceptive use remains low and the unmet need for FP services is high [ 8 – 11 ]. The situation in Ethiopia is similar [ 11 , 12 ]: According to Ethiopian demographic health survey report, contraceptive coverage has increased from 6.3% in 2000 to 36% in 2019 among married women [ 13 , 14 ]. Nevertheless, the unmet need is estimated to be more than 16% [ 15 ]. In the national survey of 2011, 25% of women surveyed did not want to have more children in the near future pregnancy. However, they were not using any form of contraceptives [ 16 ].

FP utilization is affected by many factors in low income settings, such as socio- cultural norms in which men dominate decision making because of the lower social status of women, education, residency, and income [ 17 , 18 ].

Women with mental illness may face additional barriers due to poor access for health care, low levels of FP awareness, high levels of stigma and various disease related issues [ 19 ]. However, there is little information regarding FP awareness and utilization among women with mental illness in low income countries.

Materials and methods

Study design and setting.

We employed a facility-based cross-sectional study design. We obtained ethical approval from the institutional review board of St Paul’s Hospital Millennium Medical College. The study was conducted in Addis Ababa (AA) City administration from September to December 2016. According to the 2007 census, Addis Ababa has a population of 2,687,593 people of which 34.8% are women of reproductive age and 28.4% are using contraception [ 1 ]. The data was collected from the outpatient psychiatric clinics of three general Hospitals (St. Paul’s Hospital, Yekatit 12 Hospital, and Zewditu Memorial Hospital), and one Psychiatric Hospital (Amanuel Mental Specialized Hospital). These hospitals deliver mental health services by psychiatrists or psychiatric residents.

Sample size determination.

The sample size was calculated based on the following assumptions: proportion of patients who utilize FP service (𝑃 = 50%) taken to obtain the maximum sample size, 𝑍 = 1.96 at 95% confidence interval, 𝑑 = the level of precision (0.05), and nonresponse rate = 10%; this gave a total required sample size of n = 422.

Sampling procedure.

In this study, we enrolled a total of 422 participants. The study was recruited consecutively from psychiatric outpatient clinics of the four Hospitals (three general and one psychiatric Hospitals). All consenting women aged 18–49 years were included who presented in the study period. Critically ill women and women who were unable to respond to the interviews were excluded after assessment by psychiatric nurses for their capacity to consent.

Data collection methods and instrument

An interviewer-administered structured questionnaire was used to collect the data. The questionnaire was developed in English after reviewing similar studies carried out previously using multi-culturally validated tools [ 20 , 21 ] with adaptation to fit to the purpose of the study. The domains of questions included in the tool were: “socio-demographic characteristics”, “sexual history”, “desire for children”, “family planning awareness”, “family planning use and fertility intentions”, “discussion about FP with health care provider “and perspectives on the quality of FP services”. The questions were translated into Amharic, the local language spoken by respondents, and back translated to English. The final Amharic questionnaire was administered by trained experienced female psychiatric nurses, with an emphasis on a respectful and non- judgmental approach and facilitating the women to be at ease. And the Participants were interviewed after they had completed their follow up visit as an exit interview. Validation was not done in this particular group of participants.

Data quality was controlled by designing a fully structured questionnaire which was pre-tested in five percent of participants in different setup. Interviewers and supervisors were trained for two days. The collected data were examined for completeness and internal consistency each day by supervisors.

Data analysis

The data were coded and entered using epidata version 3.1 and exported to the Statistical Package for Social Sciences (SPSS) version 20 to be cleaned and analysed. Descriptive statistics were calculated for all variables. In bi-variate analysis, crude odds ratio and confidence intervals were calculated and used to select candidate variables for multivariate analysis using a significance level of p<0.05. Multivariable logistic regression was used to obtain adjusted odds ratios and corresponding 95% confidence interval (CIs). The strength of association was interpreted using the adjusted odds ratio and 95% CI.

Ethical considerations

Ethical approval was obtained from Saint Paul’s Hospital Millennium Medical College, Institutional Review Board. Informed written consent was obtained from each study participant after informing them about the objectives, risks, and benefits of the study. Participants were informed about their right to participate voluntarily voluntary participation and their right to withdraw from study. We ensured the privacy of the participants during data collection and ensured anonymity of the collected data.

Socio-demographic characteristics of respondents

A total of 422 women of reproductive age participated with a response rate of 99.76%. The age distribution of respondents showed that 59% of the participants were in the age group of 18 to 34 years. The mean age of respondents (with one standard deviation) was 32.1 ± 6.7 years. Almost one third of the participants were single (32.93%; n = 139). Four out of ten women were either illiterate or had only primary level education ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0238766.t001

Reproductive health characteristics of study participants

Two thirds of the participants (66.1%; n = 279) had a history of pregnancy. Of these women (87.8%; n = 245) had experienced an unintended pregnancy, with (77.6%; n = 190) having an unintended pregnancy for their most recent pregnancy was unintended. More than one third of all respondents, (36.2%; n = 153), have been pregnant at least once after they had been diagnosed as having mental illness. Of these (58.2%; n = 89) pregnancies were unintended and (84.3%; n = 75) had an induced abortion. This is higher compared to only (30.3%; n = 128) of all participants who had a lifetime history of induced abortion. The most common reasons for induced abortion was that the pregnancy was unintended (53.1%; n = 68), the pregnancy arising from forced sexual intercourse (28.9%; n = 37) and fear of the effect of psychotropic medications on the foetus (14%; n = 18). One out of three participants had sexual intercourse before age of eighteen, which can be considered as increased risk of teenage pregnancy ( Table 2 ).

https://doi.org/10.1371/journal.pone.0238766.t002

Family planning related characteristics

Two third (68%; n = 287) of study participants had ever heard about FP methods. The most commonly known methods were the oral contraceptive pill (29.6%; n = 48) the injectable (depot contraceptive) (29%; n = 47), condoms (22.8%; n = 37), contraceptive implant (10%; n = 16), and intrauterine device (5%; n = 8) and six participants (4%) reported knowledge of other FP methods, including natural methods. The most frequently mentioned source of information about FP was health professionals (52.6%; n = 151), a friend or neighbours 20.2% (n = 58), school10.5%(n = 30) and the media 5.2% (n = 22) Types of modern FP methods where information was available were as follows: Pills (30.6%; n = 198), injectable (27.4%; n = 198), intrauterine device (14.7%; n = 95), condoms (14.6%; n = 88) and implants (9%; n = 60) respectively ( Table 3 ).

https://doi.org/10.1371/journal.pone.0238766.t003

Utilization of modern family planning methods

Just over half (56.6%; n = 239) reported that they had ever used FP methods with (38.4%; n = 162) currently using at least one method of FP. The most frequently used method of contraception were pills (29.7%; n = 50) and injectables (26.7%; n = 45). On the other hand, (22%; n = 37), (11.3%; n = 19), and (0.4%; n = 8) of women were using condoms, implant and intrauterine devices respectively. Out of all users, only six of participants used traditional methods with modern contraceptive intrauterine devices or tubal ligation.

In women who were not currently using FP, (60%; n = 156) did not have any intention to use contraception (38.1%; n = 99) did have an intention to use FP in the future and (1.2%; n = 5) were not sure. The reasons for the non-utilization of family planning methods among women are summarized as follows. The most common reason not to use FP was fear that the psychotropic medication was incompatible with the contraceptives (37.8%; n = 61). The second most common reason was fear of contraceptive side effects (20.5%; n = 32) and thirdly (17.9%; n = 28) fear of stigma associated with using FP services as a person with mental illness. Twenty-five women (16.0%) wanted to get pregnant the rest (6.4%; n = 10) they chose to abstain.

Factors associated with current utilization of modern contraceptive methods

On bivariate analysis, lower number of children, higher FP awareness, previous use of FP, total number of pregnancies, and were associated with utilization of FP. History of unwanted pregnancy and induced abortion associated with lower utilization of family planning ( Table 4 ). Other sociodemographic characteristics including age, education, marital status, income and occupation was not associated with current family planning utilization.

https://doi.org/10.1371/journal.pone.0238766.t004

On multivariable analysis, women who had one or two children had twice the odds of using FP than those who had more than three children adjusted odds ratio (AOR) = 2.05,95% CI: 1.06, 3.99). Women who do not intend to have children were less likely to use FP (AOR = 0 .31, 95% CI: 0.19, 0.51).

In this study women with mental illness utilized FP less than the general population when compared to estimates from previous studies: 38.3% in this study compared to 55.5% of women of reproductive age using any modern contraceptive methods in a study conducted in Addis Ababa [ 13 ]. In this context, more than half (58.1%) of the study participants reported having had unwanted pregnancy, indicating high unmet need for FP.

Several studies in Ethiopia suggest that awareness of FP in the general population may have increased substantially despite the low prevalence of use [ 13 , 22 – 24 ].

In this study, 60% of respondents mentioned at least one type of family planning method which is lower than findings from other studies conducted in Ethiopia [ 12 , 25 ]. The reasons for the lower levels of FP coverage in women with mental illness were not explored in the study, but may be explained by poorer access to sexual and reproductive health service and lower educational level of participants.

In the general population in Ethiopia, the order of frequency of methods known and used are injectables, implant, pills, intrauterine device and pills. This is slightly different from this study in which the pill and injectables were the most frequently reported methods [ 26 ]. In the current study, awareness about long acting reversible methods including norplant and intrauterine device was very low which is consistent with findings from previous studies carried out in Addis Ababa and a northern regional city [ 27 , 28 ] but differs from findings from study carried out in a southern regional town [ 27 ]. Differences in the sociodemographic, sample size, and study design may have contributed to these differences.

Although declining, traditional methods for family planning are still important, particularly in developing countries such as Ethiopia. However, they were only mentioned by a few participants. This is consistent with a recent report in national survey in which only 1% of participants reported use of these methods [ 14 ].

In this study, the common sources of information about FP accessed by women were a health facility, friends or neighbors whereas the mass media was a common source in other studies. Nevertheless, the list is consistent with a recent study conducted in Addis Ababa where 70% of the information sources were from a health care facility [ 25 ]. This might be because the participants in the study were recruited from health facility.

In this study current use of FP was 38.5% of married and 38.3% of sexually active un married women. This finding is higher than for married and lower than sexually active unmarried community study in Ethiopia which reported 36% and 58% respectively [ 13 ]. The current study finding is also lower than estimated reported a study carried out in Addis Ababa (55% -62%) [ 23 ] and higher than a community study from south central Ethiopia findings 25.4% [ 16 , 29 ].

As the gap between knowledge and use of FP is a measure of unmet need, hence efforts at improving awareness will eventually improve the level of use [ 29 ]. The study findings suggest that much more efforts will have to be made to improve awareness about FP in women with mental illness of this group. Only 68% of the women who participated in our study had ever heard about FP methods. This finding is lower than the estimated of 96.5% reported by other studies in the country [ 30 ]. Therefore, improving the awareness in this group of women may help to promote FP utilization.

The most common reasons that are known to be responsible for non-use of family planning in this study included stigma, fear of the side effects of methods, myths about family planning and fears of drug -drug interaction. The findings of this study are similar to a study carried out in Nigeria except that spousal opposition was prominent in the Nigerian studies [ 10 , 31 , 32 ]. These reasons pose a serious challenge for routine FP services if the provider has limited knowledge about mental health.

The frequent use of hormonal contraceptive injectable and pills reported in this study contrasts with their third position in the national report [ 14 ]. Long-term contraceptive methods were utilized less frequently by participants, which is similar to reports by other studies from Ethiopia and other African countries [ 26 , 33 ]. Only a few participants reported use of condoms as a contraceptive. The male condom requires the motivation of the sexual partner to use and transfers the burden of fertility regulation from the woman to the male partner. Condoms may be less effective for FP than other methods but offer the benefit of lowering the risk of STDs in high-risk women like those with severe mental illness [ 24 , 25 ]. The need to educate the male partner on the appropriate use and limitations of condoms should be emphasized, particularly what to do in cases of inappropriate use to avoid unintended pregnancies [ 17 ]. Although small number of women in our study participants knew sterilization, none used it conforming to the national trend; sterilization is a poorly accepted or used method in Ethiopia [ 27 , 28 , 34 ]. There is a lot of work that needs to be done to motivate women to use the more effective means of contraception. Women who are motivated to use family planning should be encouraged to use effective methods. In the case of our study participants, discrepancies between awareness and use when compared to the general population may have resulted from the potential hindrances reported by the participants that the regular FP service outlets are unappealing or inaccessible to these patients.

Some of the barriers may be related to stigma, lack of knowledge about psychotropic medication and contraceptive interactions and other illness-related issues. Factors related to the partner were not mentioned as the reason for low FP use; this contrasts with community-based studies in Ethiopia and other similar settings [ 13 , 28 , 35 ].

The other reason could be that women with severe mental illness have frequent contact with mental health workers and low level of interaction with the general health service as reported in a Nigerian study. There is consensus of the need for an individualized approach for advising women with mental illness on FP methods, since inappropriateness may be personalized on the basis of certain problems. For example, the probability of inconsistency of use, deficient cooperation, or poor hygiene may negate use of an intrauterine device and the risk or the presence of depression may discourage the use of the hormonal contraceptives [ 6 ].

On the other hand, when compliance cannot be guaranteed and there are no contraindications then injectables can be used [ 36 , 37 ]. It has been suggested that all patients should be given equal opportunity to use at least a method based on merits. When the patient is indecisive about all methods, then condoms are suggested; in fact, some experts have suggested that it should be used irrespective of any method used because of the protection provided against STDs [ 37 ].

The most common reason for using FP in Ethiopia is for limiting birth rather than spacing of births. This contrasts with the reason from Ghana where spacing was the main reason followed by prevention [ 9 ]. In this study, the majority of the women had no desire for future children. A substantial number of participants using reversible contraceptive methods, these methods were not compatible with their desire to limit the number of children. This study highlights the importance of specific FP education in health facilities for this community rather than providing general awareness creation only.

According to this study having fewer children was associated with FP service utilization which is in contrary to the study done in Addis Ababa [ 23 ]. In this study history of induced abortion was not associated with FP utilization which is consistent with the study from southern Ethiopia [ 22 , 38 ]. The other factor inversely associated with FP utilization was intention to have children in the future which is consistent with other studies in Addis Ababa [ 13 ].

Factors that were shown to be associated with FP utilization in previous studies in Ethiopia such as, age, education, marital status, income and occupation of women were not associated with FP utilization in this study [ 17 , 18 , 30 , 38 ]. This may indicate that factors that affect FP utilization in such a vulnerable population as women with mental illness could be different from the general population.

Limitations

There are some limitations of this study. The study did not obtain information about FP from the male partners. As it is a cross-sectional study it could be difficult to establish cause and effect relationship between the variables. The study was conducted in hospitals where clients thought to have better access for information so the findings may not be generalizable to women with mental illness who do not attend Psychiatric facilities.

In conclusion, despite its limitations, this study is the first of its kind in Ethiopia to investigate FP among women with severe mental illness in a Hospital setting. Most women with mental illness were not using FP methods. There was low awareness of the FP methods among women with mental illness attending psychiatric outpatient clinics. Family planning education and counselling on family planning for women attending psychiatric care should be strengthened.

Supporting information

https://doi.org/10.1371/journal.pone.0238766.s001

https://doi.org/10.1371/journal.pone.0238766.s002

https://doi.org/10.1371/journal.pone.0238766.s003

Acknowledgments

We want to thank All participants and Dr. Charlotte Hanlon for editing the English and reviewing the final manuscript.

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Retirement planning – a systematic review of literature and future research directions

• Published: 28 October 2023

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• Kavita Karan Ingale   ORCID: orcid.org/0000-0003-3570-4211 1 &
• Ratna Achuta Paluri 2  

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Rising life expectancy and an aging population across nations are leading to an increased need for long-term financial savings and a focus on the financial well-being of retired individuals amidst changing policy framework. This study is a systematic review based on a scientific way of producing high-quality evidence based on 191 articles from the Scopus and Web of Science databases. It adopts the Theory, Context, Characteristics, and Method (TCCM) framework to analyze literature. This study provides collective insights into financial decision-making for retirement savings and identifies constructs for operationalizing and measuring financial behavior for retirement planning. Further, it indicates the need for an interdisciplinary approach. Though cognitive areas were studied extensively, the non-cognitive areas received little attention. Qualitative research design is gaining prominence in research over other methods, with the sparse application of mixed methods design. The study’s TCCM framework explicates several areas for further research. Furthermore, it guides the practice and policy by integrating empirical evidence and concomitant findings. Coherent synthesis of the extant literature reconciles the highly fragmented field of retirement planning. No research reports prospective areas for further analysis based on the TCCM framework on retirement planning, which highlights the uniqueness of the study.

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Ingale, K.K., Paluri, R.A. Retirement planning – a systematic review of literature and future research directions. Manag Rev Q (2023). https://doi.org/10.1007/s11301-023-00377-x

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DOI : https://doi.org/10.1007/s11301-023-00377-x

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Family planning in India: The way forward

Poonam muttreja.

Population Foundation of India, New Delhi, India

Sanghamitra Singh

Given the magnitude of the family planning programme in India, there is a need to strengthen the coordination of all its aspects, focusing on planning, programmes, monitoring, training and procurement. The quality of care in family planning must be a major focus area to ensure the success of family planning programmes. Despite serious efforts and progress, India has yet to achieve its family planning goals. Furthermore, there is a need for greater male participation both as enablers and beneficiaries and also address the sexual and reproductive needs of the youth. It is imperative for the government to ensure the prioritization of family planning in the national development agenda. Family planning is crucial for the achievement of the sustainable development goals, and subsequent efforts need to be made to improve access and strengthen quality of family planning services.

Introduction

Over the years, social scientists have argued the relationship between demographic change and economic outcomes, and it is now well established that improving literacy and economic conditions for individuals lowers birth rates, while low fertility in turn plays a positive role in economic growth. Family planning (FP) programmes impact women's health by providing universal access to sexual and reproductive healthcare services and counselling information. FP also has far-reaching benefits which go beyond health, impacting all 17 sustainable development goals (SDGs) 1 ; however, the focus is on goals 1, 3, 5, 8 and 10. FP has been recognized as one of the most cost-effective solutions for achieving gender equality and equity (goal 5) by empowering women with knowledge and agency to control their bodies and reproductive choices by accessing contraceptive methods 1 . A women's access to her chosen family planning method strongly aligns with gender equality. Birth spacing can have great implications on health, for instance, reduction in malnutrition (goal 2) and long-term good health (goal 3) for the mother and the child 1 . Access to contraceptives helps in delaying, spacing and limiting pregnancies; lowers healthcare costs and ensures that more girls complete their education, enter and stay in the workforce, eventually creating gender parity at workplace.

Today, the demographic dividend is in India's favour and FP can and should be used to leverage it. Longer lives and smaller families lead to more working-age people supporting fewer dependents. This reduces costs and increases the country's wealth, economic growth (goal 8) and productivity of the people. Ultimately, these result in reduction in poverty (goal 1) and inequalities (goal 10) leading to the achievement of the SDGs through a multiplier effect.

Research shows that adequate attention to family planning in countries with high birth rates can not only reduce poverty and hunger but also avert 32 per cent of maternal and nearly 10 per cent of childhood deaths, respectively 2 . There would be additional significant contributions to women's empowerment, access to education and long-term environmental sustainability 2 . The United States Agency for International Development (USAID) estimates that ‘every dollar invested in family planning saves four dollars in other health and development areas, including maternal health, immunization, malaria, education, water and sanitation’ 3 , 4 . Thus, investing in family planning is the most intelligent step that a nation like India can take to improve the overall socio-economic fabric of the society and reap high returns on investments and drive the country's growth.

With over half of its population in the reproductive age group and 68.84 per cent of India's population residing in villages, opportunities are plenty but so are the challenges 5 . It is still an unrealized dream of the healthcare system to be able to reach the last mile, especially women belonging to scheduled castes and tribes (SC and ST) in distant and remote parts of the country. As a result, the mortality among these groups is high. Scheduled tribes in India have the highest total fertility rate (3.12), followed by SC (2.92), other backward class (OBC) (2.75) and other social groups (2.35) 6 . Contraceptive use is the lowest among women from ST (48%) followed by OBC (54%) and SC (55%) while female sterilization is the highest among women from OBC (40%) followed by SC (38%), ST (35%) and other social groups (61.8%) 6 . There is an urgent need for universal and equitable access to quality health services including contraceptive methods.

Favourable policy environment to meet high unmet need for contraception

An estimate done by the Ministry of Health and Family Welfare (MoHFW), Government of India, states that if the current unmet need for family planning is met over the next five years, India could avert 35000 maternal deaths and 12 lakh infant deaths 7 . If safe abortion services could be ensured along with increase in family planning, the nation could save approximately USD 65000 million 7 . Yet, the fourth National Family Health Survey (NFHS-4) 8 states that almost 13 per cent of women have an unmet need for family planning including a six per cent unmet need for spacing methods 9 . The consistency in these numbers since the NFHS-3 in 2005-2006 6 suggests that despite increasing efforts to create awareness on the subject, there is an existing gap between a woman's desired fertility and her ability to access family planning methods and services.

There is a direct correlation between the number of contraceptive options available and the willingness of people to use them. As shown in Fig. 1A , it has been estimated that the addition of one method available to at least half of the population correlates to an increase in use of modern contraceptives by 4-8 percentage points. Fig. 1A shows a projection of the rise of modern contraceptive prevalence rate (mCPR) in India, based on the trends observed by Ross and Stover 10 and using the current mCPR of 47.8 for India (from NFHS 4) 8 as the base value.

Effect of number of contraceptive methods on modern contraceptive prevalence rate (mCPR). (A) The graphic is a projection of the rise in modern contraceptive prevalence rate (mCPR) in India with every additional contraceptive method. This estimation is based on the mCPR of 47.8 from the National Family Health Survey 4 (NFHS-4). Source : Refs 8 , 10 . (B) Evidence on contraceptive method mix in developing countries South/South-East Asia. The mCPR has been represented on a scale of 100 percentage points to depict the distribution of contraceptive method mix for each country. Source : Refs 8 , 13 , 14 .

Expanding the basket of contraceptive choices led to an increase in overall contraceptive prevalence in Matlab, Bangladesh, where household provision of injectable contraceptives in 1977 led to an increase in contraceptive prevalence from 7 to 20 per cent 11 , 12 . As of 2015, injectable and pills together accounted for about 73 per cent of the modern contraceptive usage in Bangladesh, which has an mCPR of 55.6 per cent 13 . In addition to Bangladesh, Fig. 1B shows the mCPR of other neighbouring South East Asian countries such as Bhutan, Indonesia, Nepal and Sri Lanka where the availability of seven (or more) contraceptive methods corresponds with a higher mCPR. India, with five available methods of contraception (as of 2015), recorded the lowest mCPR among these countries ( Fig. 1B ) 8 , 13 , 14 .

In India, efforts have been made over the years by the government to create a favourable policy environment for family planning, in the form of several important policy and programmatic decisions. At the London Summit on Family Planning held in 2012, the Government of India made a global commitment to provide family planning services to an additional 48 million new users by 2020 14 . According to the FP 2020 country action plan 2016 14 , the government aims at focusing on mCPR, keeping in mind the current annual mCPR increase rate of one per cent as compared to the 2.35 per cent annual increase required to reach the FP2020 goals for India 14 . As a signatory of the SDGs in 2015, India has committed itself to achieving good health and well-being (goal 3) as well as gender equality (goal 5) by 2030 15 .

In 2015, the announcement of the introduction of three new contraceptive methods - injectable contraceptive, centchroman and progestin only pills by the government of India 16 indicated a much-needed shift from the terminal method of female sterilization, which accounted for two-thirds of contraceptive use in India until 2015-2016, to more modern limiting methods of contraception 9 . Introduction of new contraceptive methods has always been marred by controversies surrounding their efficacy, side effects and safety. Consistent efforts need to be made to educate not just the users but also the service providers in every aspect surrounding a newly introduced method so that their capacities are strengthened. The users will also benefit from the strengthening of service providers; they will have better, more accurate access to information surrounding various contraceptive options, enabling them to make more informed choices. The third and equally important partner is the media. Greater efforts need to be made by both the government and civil society organizations to educate media to promote unbiased reporting and avoid creating panic on introduction of new methods.

Like any medical solution, contraceptive methods can also have side effects but it is imperative to note that the ability to access the available range of contraceptive choices is every woman's reproductive right. Implementation of pilot programmes is of utmost significance and relevance to generate further evidence on the efficacy of various contraceptives in different contexts. This enables a better understanding of the impediments in introduction as well as sustained usage of new contraceptives. To prevent early discontinuation and also dispel-related myths and misconceptions, women will need proper counselling on the usage and side effects of contraceptives.

Empowering community health workers to ensure better quality of care

India has close to 900,000 Accredited Social Health Activists (ASHAs) who are the access point for meeting the health needs and demands of the remotest sections of the population, especially women and children 17 . In addition to the ASHAs, other community health workers such as the auxiliary nurse midwife (ANM), reproductive, maternal, new born, child and adolescent health (RMNCH) counsellors and adolescent health counsellors are crucial in covering for the shortage of specialized healthcare providers in the country. Capacity building of community health workers can be of significance in reaching the last mile. The training of frontline workers has to be technical and beyond; there needs to be greater emphasis on trainings around community mobilization and counselling for contraceptive technologies, addressing myths and misconceptions prevailing in the communities regarding modern methods of contraception.

Quality of care (QoC), consisting of its crucial components such as access to contraceptive choices, quality counselling services, information and follow ups, can ensure that the unmet need of millions of women across the country is met, and there is an accelerated reduction in fertility. Efficient responsiveness to users not only creates demand but also ensures return of the clients, ensuring long-term effectiveness and sustainability of the programme. To ensure that quality services reach the last mile, services need to be geographically convenient. And finally, quality services cannot be provided in the absence of adequate infrastructure and competent and unbiased service providers and frontline workers.

The landmark verdict in the Devika Biswas versus Union of India case in 2016 made a number of recommendations to ensure a diligent functioning of the Quality Assurance Committees at the State and district levels 18 . The judgment took cognizance of “The Robbed of Choice and Dignity” report of the multiorganizational fact-finding mission led by Population Foundation of India (PFI) on the sterilization deaths in Bilaspur, Chhattisgarh in November 2014 19 . It also directed the State and Union government to move away from a fixed target-based approach for family planning. And finally, it made specific recommendations to the government to improve the quality of services being provided under the family planning programme. This was a significant move to advance women's reproductive rights and choices in the last several decades and ensures a promising way forward for family planning in India.

Recognizing family planning as a human rights issue

Women's health goes beyond providing technical solutions or increasing the availability of contraceptive methods. Of tremendous significance is a woman's agency, choice and access to quality reproductive services. Access to quality family planning is not only a human right; it is extremely important for individual and societal well-being, and for the nation's development as a whole.

Addressing critical indicators such as child marriage and early pregnancy

Child marriage violates the basic rights of children and especially the right to enjoy a free and joyful childhood. India is among the countries with the highest number of girls married before the age of 18 20 . Early marriage is typically followed by immediate childbearing. A systematic review of 23 programmes from Africa, Bangladesh, Nepal and India conducted by PFI showed that social pressure to prove fertility, insufficient knowledge on contraceptives and limited decision-making power among women were the main reasons for the high levels of early pregnancy 21 . The country needs policies in place that empower women, rather than those that restrict access to contraception.

According to NFHS-4, eight per cent women between 15 and 19 yr of age were either already mothers or pregnant 8 . NFHS-4 data also reveals that between 2005-2006 and 2015-2016, the percentage of women (between 20 and 24 yr) married before 18 yr of age dropped by 21 per cent, while there was a 12 per cent decrease in the percentage of men married before the age of 21 8 . While these figures depict a positive trend, one cannot ignore the fact that over one out of four (27% of girls) were married before the age of 18.

The government and civil society organizations should continue to work on the issue of child marriage by adopting different strategies including, but not limited to, raising awareness, behaviour change communication (BCC), community participation, conducting empowerment programmes for adolescents and not merely offering cash incentives.

Easy access to safe abortion services for women

The World Health Organization has stated that ‘every eight minutes a woman in a developing nation will die of complications arising from an unsafe abortion’ 22 . An estimated 15.6 million abortions occur annually in India 23 . Only five per cent of abortions in India occur in public health facilities, which are the primary access point for healthcare for poor and rural women 23 . Unsafe abortions account for 14.5 per cent of all maternal deaths globally 24 and are most common in developing countries in Africa, Latin America and South and Southeast Asia, with restrictive abortion laws, while the unmet need continues to be high. Such abortions are preventable by ensuring access to quality family planning, safe abortion and counselling services as well as by providing comprehensive sex education 25 .

The social stigma surrounding abortion compels women to resort to unsafe abortion methods at the hands of unqualified service providers. In the Indian context, a study conducted in Bihar and Jharkhand found that abortion providers in both the public and private sectors favoured offering abortion and counselling services to married rather than unmarried women 26 . The same study pointed out that only 31 per cent of all participating providers agreed that all women regardless of marital status should receive information on contraception on request 26 . This act of restricting abortion services to women based on their marital status highlights the prejudice of providers against unmarried women and leads to high instances of unsafe abortions in the country.

The Medical Termination of Pregnancy Act (MTP), 1971 intends to provide safe and easily accessible abortion services to women with unwanted pregnancies on the approval of a medical practitioner, provided the pregnancy is within 20 wk gestation 27 . In India, unsafe abortion is routinely performed by unregistered medical practitioners without any medical training as well as by women who prefer to self-medicate themselves. Such practices often lead to severe health complications. According to International Centre for Research on Women, 59 per cent of women in Madhya Pradesh surveyed revealed that they had an abortion because they did not want any more children. In addition, 22 per cent confessed using abortion as a proxy to contraception and as a means of birth spacing 28 .

To improve access to safe abortion services, a draft amendment bill to the MTP Act, 2014 has been proposed by the Ministry of Health and Welfare, which allows abortion between 20 and 24 wk if the pregnancy involves risk to the mother and child or has been caused by rape 29 . It would also allow Ayurveda and Unani practitioners to carry out medical abortions. While increasing the time limit is in line with the technological advancements and would give the couple adequate time to decide, it can also lead to an increase in sex-selective abortions in the country.

Finally, there is a paradox when it comes to men's attitude towards abortion which needs to be acknowledged and addressed. Men need to be more involved in every dimension of sexual and reproductive health and family planning, right from being users of contraception to being supportive partners to their significant other as she makes a crucial decision about abortion.

Enhanced male engagement in family planning

In many parts of the world including India, family planning is largely viewed as a women's issue. A disproportionate burden for the use of contraception falls on Indian women. Female sterilization accounts for more than 75 per cent of the overall modern contraceptive use in India ( Fig. 1B ). In contrast, India's neighbouring countries such as Bangladesh, Bhutan, Indonesia, Nepal and Sri Lanka exhibit a more balanced method mix scenario which subsequently translates into a higher mCPR ( Fig. 1B ).

As per NFHS-4 data, the two methods of contraception available to men - vasectomy and condoms - cumulatively account for about 12 per cent of the overall mCPR suggesting that women are the driving force behind the family planning vehicle in India 8 , and 40.2 per cent men think it is a woman's responsibility to avoid getting pregnant 30 . Most family planning programmes focus on women as primary contraceptive users while men are viewed as supportive partners, despite evidence depicting interest from male users to existing programming 31 . There needs to be greater recognition of the fact that decision-making on contraceptive use is the shared responsibility of men and women and programmes should cater to men as FP users. Family planning initiatives should address beliefs, myths and misconceptions surrounding contraceptive services as well as other barriers that refrain active male participation 32 . The family planning programmes should restructure their communication methods and strategies in a manner that includes men as both enablers and beneficiaries, hence making them responsible partners.

It is also important to reach men and adolescent boys as users not just in family planning programmes but also in government policies and guidelines as well as in research to create more male contraceptive options 31 .

Addressing the sexual and reproductive needs of the youth

Youth (15-34 yr) account for 34.8 per cent of the total Indian population, of which an enormous number still do not have access to contraceptives 33 .

According to a 2006-2007 subnational youth survey in India, while most youth had heard of contraception and HIV/AIDS, there was lack of detailed information and awareness 34 . While 95 per cent of youth had heard of at least one modern method of contraception, accurate knowledge of even one non-terminal method was considerably low among young women, with only 49 per cent reporting positive knowledge 34 . Likewise, while 91 per cent of young men and 73 per cent of young women reported having heard about HIV/AIDS, only 45 per cent of young men and 28 per cent of young women had comprehensive awareness of HIV 34 . The recently released findings of the UDAYA study in the States of Uttar Pradesh and Bihar by the Population Council revealed low levels of knowledge regarding sexual and reproductive health across all adolescents 35 , 36 . In both States, among older adolescents (15-19 yr), slightly less than a quarter of unmarried boys and girls and one in two married girls knew that a girl could become pregnant even when she had sex for the first time 35 , 36 . Correct knowledge of oral and emergency contraceptives was considerably low across all adolescent groups in both States which indicated an urgent need to improve awareness, strengthen service deliveries and evaluate outreach strategies 35 , 36 .

In its 2016 report, the Lancet Commission acknowledged the ‘triple dividend’ of investing in adolescents: ‘for adolescents now, for their future adult lives, and for their children’ 37 . According to an estimate by the Guttmacher Institute, 38 million of the 252 million adolescent girls aged 15 to 19 years in developing countries are sexually active and do not wish to be pregnant over the next two years 38 . These adolescents include a staggering 23 million with an unmet need for modern contraception 38 . It is more important now than ever to make a shift from one-size-fits-all approaches and cater to the needs of married and unmarried adolescents.

Increased investment in family planning

The National Health Policy 2017 talks of increasing public spending to 2.5 per cent of the GDP, which is a welcome sign 39 . However, much higher health allocations are necessary to take forward the nation's family planning agenda in favour of reproductive health and rights. The Government's newly launched Mission Parivar Vikas Programme focuses on improving access to contraceptives and family planning services in 145 high fertility districts in seven States 40 . In addition to higher health allocations, the government needs to ensure efficient and complete utilization of funds already allocated to family planning activities.

India spent 85 per cent of its total expenditure on family planning on female sterilization with 95.7 per cent of this money going towards compensation, 1.45 per cent on spacing methods and 13 per cent on family planning-related activities such as procurement of equipment, transportation, Information Education and Communication (IEC) and staff expenses in 2016-17 41 . According to our analysis of the National Health Mission (NHM) Financial Management Report 41 , the total budget available for family planning activities under the NHM was ₹12220 million in India during 2016-2017. Of the total money for family planning, 64 per cent was directed for providing terminal or limiting methods, nine per cent towards ASHA incentives for FP activities, 5.3 per cent for training, 5.5 per cent for procurement of equipment, 3.7 per cent for spacing methods and 3.6 per cent towards BCC/IEC activities for family planning ( Fig. 2 ) 41 . The total spending was ₹7415 million indicating that only 60.7 per cent of the total money available for family planning activities was spent during 2016-2017. Of the total expenditure for FP activities, 68 per cent was spent on terminal or limiting methods of which compensation for female sterilization constituted 92.7 per cent; 13.3 per cent was incurred for ASHA incentives, 3.7 per cent was incurred for spacing methods of which incentives to providers for post partum intrauterine contraceptive device (PPIUCD) insertion constituted 73.2 per cent and compensation for intrauterine contraceptive device (IUCD) insertion at health facilities constituted 14.2 per cent, 2.8 per cent on interpersonal communication (IPC)/BCC activities and two per cent was spent for training ( Fig. 2 ).

Allocation, expenditure and utilization of FP budget 2016-2017. POL, petroleum oil and lubricants; RMNCH, reproductive, maternal, newborn, child, health; FP, family planning; bcc, behaviour change communication; IEC, Information, Education and Communication; IUCD, intrauterine contraceptive device. Source : Ref. 41 .

Investing in behaviour change communication (BCC)

The above mentioned numbers suggest that although family planning programmes in India have made significant progress, the budgetary spending and allocation is still skewed towards terminal methods, with inadequate emphasis on training of service providers and investment in BCC/IPC. The issues surrounding family planning and sexual and reproductive health emerge from deep-seated social norms, which cannot be uprooted overnight. It is imperative to strategize effectively to work with communities to influence social norms.

Social and Behaviour Change Communication (SBCC) can address sociocultural norms such as sex selection, early marriage, unwanted pregnancies, domestic violence and gender inequality. PFI's transmedia edutainment intervention, Main Kuch Bhi Kar Sakti Hoon - I , (A Woman, Can Achieve Anything, MKBKSH) is one such example 42 . PFI's experience with MKBKSH Season 1 and 2 shows that entertainment education (EE) initiatives have tremendous reach and potential to change the knowledge, perception and behaviour among viewers.

In addition to SBCC, interpersonal/spousal communication has the potential to significantly improve family planning use and continuation. In countries with high fertility rates and unmet need, men have often been considered unsupportive partners as far as family planning is considered 32 suggesting lack of adequate spousal communication. SBCC is a key avenue in the existing communication within the family planning programme in a country like India where frontline workers reach populations where other media cannot reach. It is the time to not just increase investments in health and family planning but to fully utilize the currently available budget and rearrange the existing allocations in favour of reversible contraceptive methods and SBCC to challenge and change existing sociocultural norms.

The success of India's family planning programme is shouldered by researchers, policymakers, service providers and users, who will need to do their part to ensure equitable access to quality family planning services. The praxis of family planning is simple and the availability of a basket of contraceptive choices can play a crucial role in stabilizing population growth. An effective and successful family planning programme requires a shared vision among key stakeholders, which include the government, civil society organizations and private providers. These stakeholders should ensure that the sexual and reproductive needs of youth and adolescents in the country are fulfilled. In addition, greater male participation as active partners and responsibility bearers can certainly ensure increased use of contraception. The time to act is now. And this should begin with a concerted effort from everyone to empower women, expand family planning choices and strive for greater gender equality so that every individual can lead a dignified life.

Financial support & sponsorship:

The study was supported by Bill and Melinda Gates Foundation.

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