Factors influencing the use of modern contraceptive methods among rural women of child bearing age in the Democratic Republic of the Congo.

CONTEXT: This study reports the unique findings of factors influencing the use of modern contraceptives (MC) among women of childbearing age in Minembwe, a rural community of the Democratic Republic of the Congo. AIMS: The study aimed at assessing the contributing factors to the use of MC in African rural communities. METHODS AND MATERIALS: This descriptive study used a structured questionnaire to collect primary data distributed to women after obtaining their consent. STATISTICAL ANALYSIS USED: The data collected were analyzed using IBM-SPSS version 21.0.
RESULTS: Totally, 370 respondents comprising 53.2% women of over 30 years of age. All the 18 health facilities were stock out for both implants and injectable contraceptives during the study period. There were only 3 Medical doctors, 84 Nurses, and 180 other healthcare workers in a population of 86,153 including 18,092 women in reproductive age. About 22.0% spend between 31 and 45 minutes walking to the nearest healthcare facility. The majority (85.7%) of the women did not use any contraceptive. The major factors influencing the uptake of MC are religion inclination (67.4%) disapproval by husbands (40.9%), fear of health problems/side effects (32.6%), and the urge to have more children (20.5%).
CONCLUSIONS: There is a need to further enlighten women of rural African communities on the need to use MC methods for birth control and other benefits. There is a need to enlighten the religious and traditional leaders and the community to support the use of family planning in order to minimize maternal and child mortality rate.

Introduction

Family planning has proven to globally reduce maternal and child mortality rate, the major reason it is seen as a means of achieving goals 4 and 5 of the Millennium Development Goals (MDGs).[12] There are several reported benefits of FP, including; prevention of unwanted pregnancies or abortions, protection against sexually transmitted diseases.[23]

In Sub-Saharan Africa, the use of FP is still very low despite the numerous benefits attached to its uptake;[4] the low uptake of FP still reflects in high rates of unwanted pregnancies, maternal mortalities, high rate of abortions as well as unplanned births.[56]

Several studies from different region of Sub-Saharan Africa have reported the factors responsible for the poor adoption of family planning among African women, including lack of or inadequate information on various forms of family planning methods and their performances, and side effects of contraceptive methods.[378]

This study was conducted in Minembwe, a rural area of the Democratic Republic of the Congo (DRC), area of not less than 16,000 women of childbearing age (15–45) and characterized by poor education and a disparity in education by gender. The study aims at assessing the factors influencing the uptake of modern contraceptive methods.

Subjects and Methods

Methods

Study area

Minembwe is among the 516 health zones of the Democratic Republic of Congo and also part of the thirty-four (34) health zones of South Kivu province.[9] The population of Minembwe is estimated as 30,000, and is part of the rural and enclave areas of DR Congo, within the South Kivu province and administrative zone of Fizi. The people of Minembwe are mostly uneducated and are characterized by the disparity in education by gender. Participants were drawn from 8 of the 18 health facilities after randomization of the villages. The interviewed populations involved health facilities in the zone as well as the corresponding Referral Hospital.

A descriptive cross-sectional method was used in this study, data collection was done with the aid of a structured questionnaire—translated from the French language into Swahili and Kinyamulenge widely spoken by the people of this highlands. A total of 375 women were randomly selected for the study. Women were included in this study if they were in the reproductive age 15–45, having resided in Minembwe health zone at least for 2 years preceding the study period, and being willing to participate (give a consent).

The sample size was calculated as the formula below.

Where n=sample size

Z= standard normal deviation with 95% confidential interval = 1.96; d = absolute precision = 0.05.

Therefore, from the above sample size is:

Sample Size –where the population is less than 50,000.

Data were entered into IBM-SPSS version 21.0. The confidence interval of 95% was used and significant value set at P < 0.05. Ethical approval was obtained from the administrative and health authorities of the study area and also from the Universite Eben-Ezer de Minembwe ethical review board. All the aspects of the study were carefully explained to the participants and were made to sign an informed consent form.

Results

There were 370 respondents with the mean age of 32 years, more than half (53.2%) were above 30 years of age while the young women (age ≤30 years) constituted 46.8%.

Services delivery and access to FP services

All the 18 health facilities offer modern contraceptives, but all reported to have stock out of both implants and injectable contraceptives. There were 267 health workers out of which 3 (1.1%) were medical doctors, 84 (31.5%) nurses and 180 (67.4%) other healthcare workers. About 35.7% of the women spend between 16 and 30 minutes getting to the nearest health center and approximately 22.0% spend between 31 and 45 minutes [Table 1].

Table 1

Availability of PF Services in MINEMBWE Health Zone

	Parameter	Total	Percent %
Accredited Contraceptive Method	Oral contr.	18	100.0
	Implants	18	100.0
	Injectable	18	100.0
	Condom	18	100.0
HF with Contraceptive Methods in stock during survey	Oral contr.	18	100.0
	Implants	0	0.0
	Injectable	0	0.0
	Condom	18	100.0
Health providers types	Med. Doc	03	1.1
	Nurses	84	31.5
	HCW	180	67.4
	Total	267	100.0
Distance to the nearest Health Facility	≤15 mins	114	30.8
	16-30 mins	132	35.7
	31-45 mins	81	21.9
	45-60 mins	37	10.0
	>60 mins	6	1.6

Association between perception and the use of family planning

Some socio-demographic characteristics of women in this study were found to be significantly associated with the positive attitude of women towards FP (P < 0.05). The observed characteristics include religion, occupation, information about FP and the health of reproductions [Table 2].

Table 2

Socio-Demographic Characteristics Associated with the attitude towards Family Planning

n=370	Attitude towards FP
	Frequency	Positive % (n)	Negative % (n)	χ2	p
Age category
<=29 Years	134	64.9 (87)	35.1 (47)	2.124	0.145
>=30 Years	236	57.2 (135)	42.8 (101)
Education level
No educated	96	65.6 (63)	34.4 (33)	1.709	0.191
Educated	274	58.0 (159)	42.0 (115)
Religious
Catholic	45	75.6 (34)	24.4 (11)	5.165	0.023*
Protestants	325	57.8 (188)	42.2 (137)
Employment Status
Farmer and breeder	326	56.4 (184)	43.6 (142)	14.462	<0.001*
Other work	44	86.4 (38)	13.6 (6)
Marriage status
No husband	38	55.3 (21)	44.7 (17)	0.396	0.529
With Husband	332	60.5 (201)	39.5 (131)
Household size
≤6 persons	154	63.6 (98)	36.4 (56)	1.453	0.228
≥7 persons	216	57.4 (124)	42.6 (92)
Number of living children
≤4 children	189	66.7 (126)	33.3 (63)	7.155	0.007*
≥5 children	181	53.0 (96)	47.0 (85)
Have you ever heard about reproductive Health?
Yes	103	36.9 (38)	63.1 (65)	31.754	<0.001*
No	267	68.9 (184)	31.1 (83)
Have you ever heard about FP
Yes	122	43.4 (53)	56.6 (69)	20.791	<0.001*
No	248	68.1 (169)	31.9 (79)

*Significant at P<0.05

Only 53 (14.3%) were using a contraceptive method at the time of the survey. The most commonly used contraceptive methods were injectable contraceptives (Depo Provera, 37.7%) and implants (22.6%). The main motivations for using contraceptive methods are births spacing (50.0%) and avoiding unplanned pregnancy (26.4%), [Table 3].

Table 3

Response of women who used a contraceptive method in during the survey

	Category	Frequency	Percent %
Using contraception during survey	Yes	53	14.3
	No	317	85.7
	Total	370	100.0
Contraceptive methods used	Injectable Contraceptives	20	37.7
	Intra-Uterine Devices (IUD)	3	5.7
	Implants	12	22.6
	Female Sterilization (Tubal Ligation)	1	1.9
	Oral contraceptives (Pills)	1	1.9
	Condom	6	11.3
	Periodic Continence	5	9.4
	Withdrawal (Coitus interrupts)	3	5.7
	Breastfeeding and amenorrhea (LAM)	2	3.8
	Total	53	100.0
Reasons for using Contraceptive	Avoid pregnancy	19	26.4
	Birth spacing	36	50.0
	Birth control (limit)	1	1.4
	Not specified	16	22.2
	Total	72	100.0
Satisfied with the Method used	Yes	60	83.3
	No	12	16.7
	Total	72	100.0

Reason for Non-Usage of Contraceptive Methods

The majority (85.7%) of the women did not use any contraceptives during this survey. The most cited reasons were religion inclination (67.4%), the decision of their husbands to disallow its use (40.9%), fear of health problems/side effects (32.6%), and the urge to have more children (20.5%) [Table 4].

Table 4

Reasons for non-usage of Contraceptive methods

Reasons	Percent %
The use of contraceptive methods is a sin. It is forbidden by our religion.	67.4%
I may be perceived by the community as a social deviant	8.7%
I will be discriminated against by the community, family and members of my church	13.1%
contraception is for Prostitutes	3.4%
Contraceptive methods are responsible for hormonal dysfunctions (weight loss or weight gain)	8.7%
Modern contraceptives cause abortions for the next desired pregnancies	15.4%
Modern methods of FP leads to the sterility of women	8.4%
The contraceptive method I used in the past created health problems	6.4%
Women who use modern contraceptive methods suffer from health problems	32.6%
I (still) want to have children	20.5%
My husband does not allow me to use contraceptives	40.9%
The health facilities are very far from our village	1.7%
Contraceptive methods are not affordable	0.7%
Health workers display a discriminatory attitudes towards women who express the desire to use contraception	1.0%
Health workers don’t have sufficient skills to offer FP services	4.0%
Lack of Confidentiality by Health workers	2.3%
Health facilities don’t provide a suitable shelter to ensure confidentiality of PF’s services delivery	0.7%

Discussion

This study was conducted to determine the factors that influence the use of modern contraceptive methods in Minembwe. At the time of the study, only 14.3% of the women were using modern. The prevalence of the use of modern was a bit lower than 18.0% reported by Apanga et al. in Ghana and 19.0% reported by the Demographic and Health Survey in the Democratic republic of The Congo [DHS-DRC].[310] However, if only modern contraceptive prevalence is considered, this study shows that it is higher in MINEMBWE (11.6%), compared to those observed in the last three DHS-RDC reports in 2003, 2010, and 2014 where the prevalence was 6.5%, 5.4%, and 8%, respectively.[10]

Among the few that used modern contraceptives, the main motivations for using contraceptive methods were births spacing, avoiding unplanned pregnancy while only very few use contraceptive methods to limit births.

Healthcare-related barriers to uptake of modern contraceptives

Major challenge identified in this study is the access to adequate family planning services. The 18 health facilities offer only offer Oral contraceptives (Pills), Injectable Contraceptives (Depo Provera), implants (Norplant), and a condom. During this study, the facilities only had pills and condoms; meaning that those who were using other methods were unable to access FP or could only use the available ones. Also, there were only 3 medical doctors in a population of 86,153 including 18,092 women of reproductive age; making the ratio of service providers to the population 1:28,718 and 1:6,031 i.e. one Medical Doctor for 28,718 people including 6,031 women. One nurse covers 1,026 people with 215 women and one healthcare worker covers 479 people including 100 women.

Over 30% of the women walk for over 30 minutes to the nearest health facility. This might be an important reason for the low usage of FP among Minembwe women. Difficulty in accessing family planning service due to the long distance between health facilities and homes has also been reported in other studies.[1112]

Some women were of the opinion that healthcare workers usually display a discriminatory attitude towards women who express the desire to use contraception and others said that there were no suitable shelters in healthcare facilities to ensure confidentiality of PF service delivery.

Religion and culture as barriers to uptake of modern contraceptive methods among women of Minembwe

About 85.7% of the women did not use any contraceptives during this survey. Several reasons which justify their hostile attitude towards modern contraceptive methods were mentioned. The reasons included religious belief; the majority of the people of Minebwe are either Protestants or Catholics. They believe that family planning is a form of abortion-which is against the law of God; they rather see whoever uses contraception as a sinner who works against the will of God for procreation. These arguments were also found in similar studies in different contexts, but similar settings in Ghana Nigeria, Ethiopia and in DRC, where FP use is very low as in this case.[413141516171819]

Cultural belief and gender inequality is another identified barrier to FP uptake. The majority of women did not use any form of contraception because their husbands disapproved of it. This is in line with some previous findings in other parts of Africa.[31119] Some did not use it because of discrimination from the community, including members of their families and the church. Some even believed that only prostitutes use contraception.

Lack of adequate and correct information as a major barrier to the use of modern contraception in Minembwe

Due to poor information, about one-third of the women refused to use any form of modern contraception because of the belief that family planning causes health-related problems. They believed that women who use modern contraceptive methods suffer from health problems while some believed that family planning makes women permanently sterile, so, whoever uses contraception will not be able to get pregnant or give birth anymore. These findings are also in line with studies from a different region of Sub-Saharan Africa.[3718]

Conclusion

This study found a very low prevalence of the use of modern contraceptive methods in Minembwe which is due to factors such as religion inclination, husband disapproval, cultural belief, and poor or inadequate health facilities as well as inability to access healthcare facilities. There is a need to further enlighten women of rural African communities as well as religious and traditional leaders on the need to use modern contraceptive methods for birth control and other benefits.

Financial support and sponsorship

Self sponsored.

Conflicts of interest

There is no conflicts of interest.