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Background: Young adolescents and unmarried women in low and middle income countries face challenges in accessing family planning services. One factor likely to limit contraceptive use is the attitude and opinion of local stakeholders such as community leaders and health workers. Much of the existing evidence on this topic focuses on women who have already started childbearing. Using primary qualitative data, we explored individual, community and health provider’s perceptions about using modern contraceptives to delay the first birth in a high fertility setting. Methods: A descriptive qualitative study was conducted in Tandahimba district in southern Tanzania between December 2014 and March 2015. We conducted 8 focus group discussions with men and women and 25 in-depth interviews (18 with women, 4 with family planning service providers and 3 with district-level staff). Participants were purposively sampled. Data transcripts were managed and coded using Nvivo 11 software and we employed a thematic framework analysis. Results: Three main themes emerged about using modern contraceptives to delay first birth: (1) the social and biological status of the woman (2) the type of contraceptive and (3) non-alignment among national policies for adolescents. Use of modern contraceptives to delay first birth was widely acceptable for women who were students, young, unmarried and women in unstable marriage. But long-acting reversible methods such as implants and intrauterine devices were perceived as inappropriate methods for delaying first birth, partly because of fears around delayed return to fecundity, discontinuation once woman’s marital status changes and permanently limiting future fertility. The support for use of modern contraceptives to delay a first pregnancy was not unanimous. A small number of participants from both rural and urban areas did not approve the use of contraceptive methods before the birth of a first baby at all, not even for students. There was lack of clarity and consistency on the definition of ‘young’ and that had direct implications for access, autonomy in decision-making, confidentiality and consent for young people. Conclusions: Women who wish to delay their first birth face challenges related to restrictions by age and method imposed by stakeholders in accessing and provision of modern contraceptives. There is a need for a clearly communicated policy on minimum age and appropriate method choice for delayers of first birth.
The study was conducted in Tandahimba district in southern Tanzania. Tandahimba district covers an estimated population of 227,500 people served by 34 health facilities (33 primary care facilities and one hospital) [30, 31]. In 2015, 87% of health facilities were offering any modern method of family planning, 58% had samples of family planning methods in stock, and only 18% had at least one staff trained in family planning services [32]. Characterised as a predominantly rural area with limited infrastructure, over 90% of the population depends on agricultural activities especially cashew nuts for their subsistence [33]. The area has a total fertility rate of 4 and a median age at first birth of 19 years [29]. Estimates of modern contraceptive use are high compared to Tanzanian mainland at 50% among currently married women (32% mainland) and 70% among sexually active unmarried women aged 15 to 49 years (46% mainland) [29], but the neonatal and maternal mortality rates are also high at 47 newborn deaths per 1000 live births [29] and 712 per 100,000 live births [34] respectively. A study in southern Tanzania reported that four percent of all sexually active women aged 13–49 years wanted to delay their first birth and this group of women overlap substantially, but not exclusively, with the adolescent age group (10–19 years) [35]. Forty one percent of these women who wanted to delay their first pregnancy had unmet need for modern contraceptives [35]. The implementation of family planning services in the study area is guided by the national policy, strategies and guidelines [26, 27]. This was a descriptive, qualitative study. Between December 2014 and March 2015, we conducted eight focus group discussions (FGDs) with men and women, 25 in-depth interviews (IDIs): 18 with women, four with family planning service providers and three with district-level staff. Eight FGDs, four in urban settings and four in rural settings with 6–12 participants per group were conducted. In each setting one FGD was held with each of the following: men above 20 years; men below 20 years; women above 20 years; and women below 20 years. Participants were purposively sampled from the community to reflect the range of people living in the community, and a total of 71 people took part in the FGDs (Table 1). A topic guide covering issues such as: use of contraceptives in their communities; community acceptability of modern contraceptives for women who would like to delay their first birth; and type of contraceptive methods appropriate for the delayers, was used to guide the discussions. Each discussion lasted between 60 and 90 min. Women’s FGDs were facilitated by the female principal investigator (YS) and the FGDs with men were facilitated by an experienced male research assistant who also received a five days training that included pilot testing of the topic guides specifically for this study. Four FGDs were conducted in the village executive offices in their respective villages and four were conducted in a classroom at one of the primary schools in their area. Characteristics of participants in community focus group discussion and in-depth interview ¥ for currently married/cohabiting; −Not applicable; ≠ Information was not requested from the participants We conducted 18 semi-structured in-depth interviews with women who did not take part in FGDs (Table (Table1).1). The women were purposively sampled from the community based on their age (above or below 20 years), use of modern contraceptives (current use or non-use), and place of residence (urban or rural) to reflect the range of women living in the community. Women were asked about eligibility to use contraceptives; if they approve use of modern contraception to delay first birth; appropriate types of contraceptive methods for delayers of first birth; and if their husbands or partners approve use of contraceptives to delay first birth. The interviews were conducted in a place preferred by the respondent, most often her home. We conducted four semi-structured in-depth interviews with family planning service providers (Table 2). The providers were purposively selected from different types and levels of health facilities (one from each of hospital, public health centre, mission health centre, and a rural dispensary). Where there was more than one family planning provider employed we purposively selected the staff member allocated to provide services on the day of interview (one from nine family planning providers employed at the hospital, one from six family planning providers employed at the public health centre and one from two family planning providers employed at the mission health centre. The rural dispensary employed only one staff member for all services. The service providers were also asked about: eligibility to receive modern contraceptive methods and the methods that they recommend for women who would like to delay their first birth. Interviews with the service providers were conducted in their offices early in the morning before their clients started coming for services or late afternoon when the staff had finished attending all clients. Characteristics of family planning providers and district stakeholders participating in in-depth interviews – not applicable; DRCHco District Reproductive and Child Health co-ordinator, DHSWO District Hospital Social Welfare Officer We conducted semi-structured interviews with: 1) one District Medical Officer (DMO); 2) one District Reproductive and Child Health coordinator (DRHco) who oversees reproductive and child health services in the district; and 3) one District Hospital Social Welfare Officer (DHSWO) (Table (Table2).2). In-depth interviews with DMO and DRCHco asked about provision of family planning services and policy and guidelines that govern the service provision in their district. The DHSWO was interviewed to understand his involvement in family planning services in the district. All IDIs were facilitated by the female principal investigator and lasted for up to one hour. Village or street leaders assisted in the sampling of FGD and IDIs participants in their communities. The FGDs and interviews were all conducted in Swahili language and recorded and transcribed verbatim. A few transcribed interviews were translated into English and shared with a non- Swahili speaker involved in the study (TM) for comments during the initial stage of data collection. Results were translated from Swahili to English by the principal investigator during the final interpretation of the data presented in this study. Data analysis took place alongside data collection. Data transcripts were managed and coded using NVivo 11 software. We employed a thematic framework analysis method [36] in which themes were derived from the research questions as well as emerging from the discussion and interview data [37]. The analysis included five steps. The first step involved familiarization with the data during which the principal investigator listened to the audio recordings and read through the field notes and transcripts. The second step involved coding a few transcripts and identifying initial themes which were shared with TM, discussed, and the work refined until no new themes were generated. All data were coded by the principal investigator. The third step involved organising codes reflecting prominent themes within the data set. The fourth step involved creating a framework matrix for each theme and charting data for each code, IDIs and FGDs within that theme (comparison of both within and between interviews), and fifth step involved data mapping and interpretation through reviewing the matrices and looking at relationships between the codes and the interviews (IDIs & FGDs) [38, 39].
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