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Background: Family planning (FP) has the potential to improve maternal and child health outcomes and to reduce poverty in sub-Saharan Africa. However, substantial unmet need for modern contraceptive methods (MCMs) persists in this region. Current literature highlights multi-level barriers, including socio-cultural norms that discourage the use of MCMs. This paper explores women’s choices and decision-making around MCM use and examines whether integrating FP services with childhood immunisations influenced women’s perceptions of, and decision to use, an MCM. Methods: 94 semi-structured interviews and 21 focus group discussions with women, health providers, and community members (N = 253) were conducted in health facilities and outreach clinics where an intervention was delivering integrated FP and childhood immunisation services in Benin, Ethiopia, Kenya, Malawi and Uganda. Data were coded using Nvivo software and an analytical framework was developed to support interpretative and thematic analyses on women’s decision-making about MCM use. Results: Most women shared the reproductive desire to space or limit births because of the perceived benefits of improved health and welfare for themselves and for their children, including the economic advantages. For some, choices about MCM use were restricted because of wider societal influences. Women’s decision to use MCMs was driven by their reproductive desires, but for some that was stymied by fears of side effects, community stigma, and disapproving husbands, which led to clandestine MCM use. Health providers acknowledged that women understood the benefits of using MCMs, but highlighted that the wider socio-cultural norms of their community often contributed to a reluctance to use them. Integration of FP and childhood immunisation services provided repeat opportunities for health providers to counter misinformation and it improved access to MCMs, including for women who needed to use them covertly. Conclusions: Some women chose to use MCMs without the approval of their husbands, and/or despite cultural norms, because of the perceived health and economic benefits for themselves and for their families, and because they lived with the consequences of short birth intervals and large families. Integrated FP and childhood immunisation services expanded women’s choices about MCM use and created opportunities for women to make decisions autonomously.
The intervention was implemented in predominantly rural communities at health facilities and outreach clinics by non-governmental organisations (NGOs) between January 2015 and January 2018 (Table (Table1).1). The scale of the interventions ranged from implementing integrated services in 14 health centres in one region in Uganda to 114 health posts across two districts in Ethiopia. The integration model varied by country and site; but broadly the intervention had similar components and objectives. They all sought to improve access to and uptake of FP services by co-locating, to varying degrees, messaging, counselling and the provision of MCMs with childhood immunisations. In this study, co-location is taken to mean that women could access both childhood immunisations and MCMs during the same health visit, however, these two services were often administered by different health providers and/or at different points in time during that visit. MCMs included condoms, oral contraceptive pill, injectables, implants and the intra-uterine device. However, the availability of these methods varied by site and country. In general, the intervention components in each country included: health provider training on FP counselling and MCM administration; raising awareness in communities about FP through existing structures (including community and religious leaders, and peer influencers, such as expert clients or male champions); supplying a range of short- and/or long-acting MCMs; and, supporting ongoing provision of routine childhood immunisations. Integrated family planning and childhood immunisation interventions by country 1 health zone: Adjohoun-Bonou-Dangbo (ABD) health zone 19 health centres; 1 hospital National: 12.4 Ouémé department: 15.2 [17] Oueme department: Among FP users: 35/57.2 Among non FP users: 19.2/75.7 Services delivered at health facilities Midwives and nurses give FP counselling and administer MCMs Peer influencers mobilise women in the community to attend FP and immunisation services 2 districts: Bambasi and Assosa districts, Benishangul Gumuz Regional State (BGRS) 114 health posts National: 35.3 BGRS region: 28.4 [18] Benishangul-Gumuz: Among FP users: 75.9/14.4 Among non FP users: 55.1/22.3 Services delivered at health posts and during 45-day post-partum home visits Community health workers (HEWs) give FP counselling and administer MCMs (except implant removals) Peer influencers (HDA) act as role models to encourage women to use MCMs, dispel harmful myths 2 districts: Garba Tulla, Isiolo county and Pokot West/Pokot South, West Pokot county 19 health facilities National: 53.2 Isiolo: 26.3 West Pokot: 14.2 [19] Services delivered at health facilities Nurses provide FP counselling and administer methods Community health workers (CHVs) deliver health messages and mobilise women in the community to attend FP services Peer influencers (male champions) act as role models and share the benefits of using MCMs to space children 3 districts: Blantyre, Mwanza, Thyolo 24 outreach clinics National: 58.1 Southern region: 54.4 [20] Southern region: Among FP users: 75.3/15.7 Among non FP users: 50.5/36.1 Services delivered at routine monthly outreach clinics Community health workers (HSAs) provide FP counselling and short-acting methods; nurses provide long-term methods but are not always present 1 region: Karamoja 14 health centres National: 34.8 Karamoja: 6.5 [21] Karamoja region: Among FP users: 71.2/27.7 Among non FP users: 59.6/28.8 Services delivered at health facilities Midwives provide FP counselling and administer methods Community health workers (VHTs) deliver messages about FP and mobilise women to attend FP services using referral cards Peer influencers act as role models to encourage women to use MCMs, dispel harmful myths IRC International Rescue Committee, HEWs Health Extension Workers, HDA Health Development Army, CHVs Community Health Volunteers, HSAs Health Surveillance Assistants, VHTs Volunteer Health Team Regional data from the Demographic and Health Surverys (DHS) of countries included in this study indicates that among married women who are currently using FP, a high proportion of women reported being involved in decision making about FP, either jointly with their husband or making the decision themselves (range from 90.3 to 98.9%). However, among women who reported not using FP, women’s involvement with decision-making was lower (range from 77.4 to 94.9%)—data on decision making was not asked in latest DHS for Kenya. Unmet need for FP, defined as women who want to space or limit births but are not currently using FP, among married women ranged from 12.4% in the Eastern province in Kenya to 33.7% in the Oueme region of Benin [17–21]. Purposive sampling was used to select key stakeholders involved, or with an interest, in the intervention including implementing NGOs, health administrators, health providers (community- and facility-based), peer influencers, religious leaders, male community members, and women who self-reported as MCM users and non-users. Participants were selected through a consultative process with the implementing NGO in each country. Using this process, key stakeholders were identified based on an initial programme theory of how the intervention works [22] followed by maximum variation sampling amongst identified categories of stakeholders [23]. Providers were selected based on having experience in delivering either immunisation or FP services in health facilities where the intervention was perceived to have been more, or less, well received based on monitoring data collected by the implementers. They were approached in the study setting, at either health facilities or outreach clinics where the intervention was implemented, and asked to participate in the study. Interviews were conducted on site and were visible to others but out of earshot. In total, 94 SSIs and 21 FGDs with 253 participants were conducted between October 2017 and March 2018. SSIs were used, when possible, because of the sensitive nature of the topics being discussed and to enable the interviewer to explore themes and gain individual perspectives in greater depth. FGDs were used to explore collective views and were conducted as part of the evaluation, when feasible, to understand where different groups of stakeholders might have similar or divergent views regarding aspects of FP. For instance, FGDs were sought with male community members to generate a rich discussion around the wider socio-cultural factors that influence perceptions about FP generally, and, MCM use specifically. Using a mix of SSIs and FDGs with women participants enabled both a deeper understanding of women’s individual perceptions towards FP and MCM use and opportunities to understand how perceptions about socio-cultural norms and FP practices may differ or not. Data from SSIs assisted the researchers in recognising if and when groupthink might be present in the FGDs [24]. Interview and discussion guides were developed for SSIs and FGDs, which were informed by local implementers. Questions were standardised across sites and countries to enable uniformity in the analysis framework, however, where specific contextual elements arose, interviewers were trained to explore those threads in greater detail. For both SSIs and FGDs, topics discussed with health providers included: workload, socio-cultural norms, healthcare access, delivery of integrated services and perceptions of women’s use or non-use of MCMs. For women, topics included: reasons for use or non-use of MCMs; barriers to MCM use; access to FP services; and, community-level acceptance of MCM use. And for community members topics included: socio-cultural norms, acceptance of FP, and perceptions of the integrated delivery of FP and immunisations. Interviews and discussions were conducted in each country by SK and a local researcher who was a trained interviewer and could facilitate a deeper understanding of the contextual factors that arose during the interviews and discussions. In Benin interviews were conducted in French and Ouémé; in Ethiopia in Amharic and English; in Kenya in Borana, Pokot and English; in Malawi in Chichewa and English; and in Uganda in Karamojong and English. All interviews were audio recorded, transcribed verbatim and then translated into English by experienced transcribers and translators. To guide analysis an analytical framework was developed based upon the Sexual and Reproductive Health Empowerment framework by Karp et al. [25], which illustrates a woman’s empowerment journey across three phases: (1) existence of choice—where women have the capacity to recognise and set their reproductive goals, and how contraceptive use aids in achieving their reproductive goals, (2) exercise of choice—where women make decisions to act on those reproductive goals, and (3) achievement of choice—when women act to achieve their desired reproductive outcomes. Karp’s framework is useful because it acknowledges that reproductive desires are separate and distinct from the decision to use an MCM, which enables a deeper examination of the factors influencing women’s reproductive desires and their decisions to use an MCM to achieve their goals. In this paper, women’s decision-making about MCM use is explored within the context of integrated FP and childhood immunisation services. Our analytical framework (Fig. 1) builds upon the Karp framework for this purpose suggesting that women’s existence of choice (reproductive preferences/desires) and exercise of choice (decision to act on those desires) are influenced by women’s perceptions of MCMs and by external influences—such as a husband’s perceptions of MCMs, the socio-cultural context and access to MCMs. And further, it suggests that integrated FP and immunisation services may influence women’s reproductive desires and their decision-making about MCMs. Analytical framework The translated transcripts from the SSIs and FGDs were imported into NVivo 11.2 for coding and analysis. Transcripts were anonymized but the type of stakeholder attributable to each quote was retained to aid analyses. The data were coded and the primary analysis was conducted by JH and then discussed amongst the evaluation team to ensure a consensus was reached where ideas and opinions differed. It was agreed among the research team that data saturation was reached once no additional themes or sub-themes were being generated from the data [24]. The primary analyses were country specific with one coding framework used across all countries. The data were initially coded based on the major themes from the interview topic guides and included: (1) the actors involved in delivery and uptake of FP services; (2) the cultural and social context; (3) the delivery of the intervention; (4) decision-making of health providers and women; and (5) outcomes relating to the uptake of FP services and the use of MCMs. An iterative process was used, and additional themes and patterns were identified [26]. Interpretative syntheses were conducted to explore overarching themes across all five countries [27] including a thematic analysis that involved mapping themes to the analytical framework to identify: (1) internal motivations for MCM use and (2) external forces influencing the decision to act on the reproductive desires and (3) the role of integrated services in shaping women’s choices about MCMs and their decision-making on use. The Standards for Reporting Qualitative Research guidelines were used to ensure rigorous reporting of the study [28].
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