Family planning among married women in Hodan district, Mogadishu (Somalia). Level of utilization and factors associated with the utilization

Table of Contents

DEDICATION

ACKNOWLEDGEMENT

Table of Contents

ABSTRACT

CHAPTER ONE: INTRODUCTION
1.2 Statement of the problem
1.3. General objective of the study
1.4 Specific objectives
1.5. Research questions
1.6 Significance of the study
1.7 scope of the study
1.8 Operational Definition
1.9 Conceptual framework

CHAPTER TWO: BACKGROUND

CHAPTER THREE: LIT ERATURE REVIEW
3.0 INTRODUCTION
3.1 HEALTH SYSTEM FACTORS AND UTILIZATION OF FAMILY PLANNING SERVICES
3.1.1 Availability of family planning services
3.1.2 Quality of family planning services offered
3 .1.3 Integration of family planning services with other services
3.2 CULTURAL FACTORS AND UTILIZATION OF FAMILY PLANNING SERVICES
3.2.1 Spouse refusal and effect on FP use
3.2.2 Influence of culture disapproval on FP use
3.3 SOCIO-DEMOGRPHIC FACTORS AND UTILIZATION OF FAMILY PLANNING SERVICES
3.3.1 Education level and FP use
3.3.2 Knowledge about FP methods and FP use
3.3.3 Age and FP use
3.4 Summary

CHAPTER FOUR: METHODOLOGY
4.0 Introduction
4.1 Research Design
4.2 Study area
4.3 Target population
4.4 Sample Size
4.5 Sampling Procedure
4.6 Exclusion and Inclusion Criteria
4.6.1 Inclusion Criteria
4.6.2 Exclusion Criteria
4.7 Study Variables
4.8 Data collection methods and instruments
4.9 Validity and Reliability of the study instruments
4.9.1 Validity
4.10 Data Gathering Procedures
4.11 Data processing and analysis
4.12 Ethical consideration
4.13 Limitations

CHAPTER FIVE: RESULTS
5.0 Introduction
5.1 Demographic characteristics of the respondents
5.2 Prevalence of family planning services
5.3 Health System Factors
5.4 Cultural factors
Table 4.5.1 Demographic characteristics associated with the level of utilization family planning services
Table 4.5.2 Demographic characteristics associated with the level of utilization family planning services
Table 4.6 Cultural factors associated with the level of utilization of family
Table 4.6 Cultural factors associated with the level of utilization of family
5.1 Health system factors associated with the level of utilization of family planning services

CHAPTER SIX: DISCUSSION
6.1 Discussion

CHAPTER SEVEN: CONCLUSION AND RECOMENDATION
7.1 Conclusion
7.2 Recommendation

APEENDIX A: REFERENCES
APPENDIX B: QUESTIONNAIRE
APPENDIX C: RESEARCH WORKPLAN
APPENDIX D: RESEARCH BUDGET
APPENDIX E: HODAN DISTRICT MAP
APPENDIX F: MAP OF MOGADISHU

QUESTIONNAIRE

ACKNOWLEDGEMENT

I praise the almighty God for his loving kindness and grace which accompanied me during the entire research period.

I thank all my lecturers at Benadir University School of Health Science in general and school of Public Health in particular, from whom I have learned much throughout my training in the field of Public Health. I am deeply grateful to my class mates with whom we shared lectures and experiences. Through the questions constructive and critical comments of my supervisor, Dr. Ali Sheikh Mohamed Omar who guided me to the overall content of my study proposal and this dissertation report.

I would like to thank the entire Hodan District administration and residents for all the support they availed to me from the very first time I visited the District.

I wish to thank my immediate family; my wife, my children and all the other family members for having endured my irregular presence at the times they could have needed me most. Spcial thanks goes to my dear uncle Mr Sharif Mohamed Abdalla Hussein who financially and morality supported me throughout my educational process. Finally, this book could not have been written without the valuable information voluntarily given by the study participants and the research assistants. I would therefore like to register my sincere thanks to them.

ABSTRACT

Background: Nearly all (99%) of maternal death occur in the developing countries. However, family planning (FP) could prevent as many as one in every three maternal deaths by allowing women to delay motherhood, space birth, avoid unintended pregnancies and abortion and stop childbearing when they reached their desired family size. East Africa is a region with increasing utilization of family planning methods among married women of fertile age (CDC, 2016). Yet, Somalia is the lowest for contraceptive utilization among other countries of the region due to various factors which need to be scientifically investigated.

Objective The objective of this study was to assess the level of utilization and factors associated with the utilization of family planning among married women of reproductive age (15-49years ) in Hodan district, Mogadishu - Somalia. .

Method A community based cross-sectional study design was conducted among currently married women of reproductive age (15-49) .The data were collected from 228 study subjects by face to face interview technique by using structured questionnaire. Univariate analysis was done to determine frequencies of utilization of family planning services. Using odds ratios, bivariate analysis was then done to assess factors associated with the utilization of family planning services among married women in Hodan District, Mogadishu – Somalia.

Resul ts. Study results showed that level of education (OR 3.2, P-value 0.0141), how many children preferred (OR 5.1, P-value 0.0051) were found to be significant. Also, the results showed that Does you culture encourage family planning (OR 1.4, P-value 0.0276)., Will you advise a friend or relative to practice family planning (OR 2 .1, P-value 0.0153), Does your health facility offers family planning services (OR 2.2, P-value 0.0243) were found to be significant. The results also showed that the following variable such as does your health facility offers family planning services (OR 3.1, P-value 0.0234) , what is distance from your home to the health facility (OR 6.0, P-value 0.0442). and Do you wait for long time at the clinic before you are served (OR 7.0, P-value 0.00421) were found to be significant.

CHAPTER ONE: INTRODUCTION

In 1994, 179 nations came together in Cairo at the International Conference on Population and Development (ICPD) to address issues of population growth and sustainable development. These nations emphasized the importance of social and economic development and individual and family well-being of achieving reproductive health for all. During the conference a Programme of Action was developed to set out a series of recommended actions targeting population growth and development. Included in this Programme of Action was a pledge from all 179 nations to transform and fund reproductive health services around the world including the assurance that everyone who wanted to limit or space their children could do so with appropriate access to relevant services (Daulaire et al. 2002).

The ICPD redefined the term reproductive health. Specific attention should be drawn to the part of the definition of reproductive health that clearly states that both men and women have the right “… to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods for the regulation of fertility which are not against the law (World Bank, 2015).

In rural parts of Haiti, men and women do not have access to family planning, which likely leads to unmet needs and increased unwanted pregnancies. Six years after the conference in Cairo the Global Health Council set out to measure progress made toward achieving the ICPD goals that were set in 1994 (World Bank, 2007).

This report, entitled Promise to Keep; The Toll of Unintended Pregnancies on Women’s Lives in the Developing World, supports the idea that unmet needs for contraception lead to unintended pregnancies (Daulaire et al. 2002). According to this report, between 1994 and 2000, 1.3 billion women globally experienced a total of 1.2 billion pregnancies with more than 300 million of them being unintended (Daulaire et al. 2002).

The Global Health Council also reported that during this sixyear time period over 700,000 women died from unintended and unwanted pregnancies due to problems with pregnancy, labor and delivery. Of the 700,000 deaths, more than 400,000 were attributed to botched abortions.Maternal mortality is not the only problem that stems from unintended pregnancies (World Bank, 2015).

According to the World Health Organization, (WHO) “for every maternal death an estimated 30 additional women suffer pregnancy-related health problems that are frequently permanently debilitating” (WHO 1997) as cited in Daulaire et al. 2002). Overall, an estimated 17 million women suffer from pregnancy-related health problems which include uterine rupture, prolaspe, hemorrhage, vaginal tearing, urinary incontinence, pelvic inflammatory disease and obstetric fistula (a muscle tear that allows urine or feces to seep into the vagina) (World Bank, 2015).

These conditions are more likely to occur among women who are on the cusp of childbearing age, very young or very old, suffering poor health, malnutrition or have had multiple live births The cost associated with such debilitating problems can lead to social and economic isolation aswell as increasing the risk of maternal mortality during future pregnancies (Daulaire et al. 2002).

According to the most recent data available, contraceptive prevalence among married women of reproductive age are higher in the more developed regions (70%) than in the less developed regions (62%) with a world average of 63%, for e.g. in Norway (88%), in UK (82%), in France (76%), in Canada (74%) and (72%) in Northern American, (United Nations,2009).

Family planning contraceptives are tools that we use to prevent the conception, child spacing, or unwanted pregnancy. They include the following a) Hormonal (pills, Depo-Provera, Norplant, IUD,) B) Barrier methods (male and female condoms) c) Vasectomy and tubal ligation. Family planning allows couples to decide how many children to have and when to have them. The careful planning of births saves lives, for example the use of contraceptive can prevent at least 25% of all maternal deaths by allowing women to delay motherhood. By spacing birth at least two years apart family planning can prevent an average of one in four infant deaths in developing countries (CSA, 2011).

Globally in 2015, about 12 per cent of women aged 15-49, married have an unmet need for contraception. Data suggest significant differences among countries and across regions. West and Central Africa has the highest level of unmet need at 24 per cent, about 2.5 times higher than in Asia and the Pacific, the region with the lowest unmet need at 10 per cent. Since 2000, the unmet need for family planning has declined in all regions except West and Central Africa, where the rate remains relatively stable. The fastest decline has been in East and Southern Africa, dropping 16 per cent from 28.2 per cent to 23.6 per cent, followed by Latin America and the Caribbean, decreasing 16 per cent from 12.8 per cent to 10.7 per cent. East and Southern Africa has doubled its annual rate of reduction from 0.5 per cent over 1990-2000 to 1.2 per cent over 2000-2015, making it the only region with a faster decline in the past decade compared to 1990-2000 (UNFPA, 2016).

According to the most recent data available, contraceptive prevalence among women of reproductive age who are married varies between 3 per cent in Chad and 88 per cent in Norway (World Bank, 2007).

Globally, contraceptive prevalence is estimated at 63 per cent and it is somewhat higher in the more developed regions (72 per cent) than in the less developed regions (3 per cent at minimum), In the majority of the less developed regions contraceptive prevalence is 50 per cent or more (WHO, 2015).

The major exceptions are sub-Saharan Africa, Melanesia, Micronesia and Polynesia, where the estimated levels of contraceptive prevalence are still below 40 per cent. As a region, sub-Saharan Africa has the lowest level of contraceptive prevalence, with only 22 per cent of women of reproductive age who are married using some method of contraception (WHO, 2015).

Over half of the 48 countries in sub-Saharan Africa with data available have a level of contraceptive prevalence below 20 per cent and they are located mainly in Western Africa and in the Horn of Africa (Wallchart, 2011).

The desired number of children in Somalia is high, contributing to the high total fertility rate of 6.7. Contrary to other countries in the region, there is no marked difference in total fertility rate (TFR) between urban and rural communities (TFR urban 6.0 vs. rural 7.1).

Male condoms are controversial as they are seen as being connected to infidelity and immoral behaviour. Public burning of condoms has happened occasionally in several zones. In general FP seems to be a politically sensitive issue more than a cultural one (Unicef, 2009).

Overall demand and uptake of FP services is low. Fifteen percent of women use any method, including traditional or natural periods and only 1% use a modern method. Of the 1% that use modern methods, pills are the most common (0.8%) followed by injections of medroxyprogesterone acetate (0.2%) and IUD (0.1%) (WHO, 2015).

Condom use was at 0.0% for contraceptive purposes. Of traditional methods, lactation amenorrhea is among the mostused methods at 13% among married women. As the exclusive breastfeeding rate for children between 0-5 months is only 9%, there is a low protective effect even for women using this method (Unicef, 2009).

Family planning saves lives and can improve the health of women, children and society as a whole. According to Bernstein et al. (2006) gaining control of one’s reproductive choices and fertility has health benefits for both mother and child.

In 2000, about 90% of global abortion related and 20% of obstetric related mortality and morbidity could have been averted by the use of effective contraception by women wanting to either postpone or stop having children. In some cases, a mother’s death is considered to be the death of the household (Daulaire et al.2002). Daulaire et al. (2002), reports that children of deceased mothers are likely to be farmed out to relatives, forced on to the street, and have a greater risk of dying themselves. In addition, using family planning to increase the interval at which women bear children not only has benefits to the mother, but also to the child (Daulaire et al. 2002).

Children born within eighteen months of each other (live births) are at a greater risk of fetal death, low birth weight, prematurity, malnutrition and being small size for gestational age in both rich and poor communities (Bernstein et al. 2006).

According to SDCs, family Planning 2020 (FP2020) is a global partnership that supports the rights of women and girls to decide, freely, and for themselves, whether, when, and how many children they want to have. FP2020 works with governments, civil society, multilateral organizations, donors, the private sector, and the research and development community to enable 120 million additional women and women and girls to have access to rights based family planning services and supplies by 2020 (WHO, 2015).

Family planning is one aspect of the targets around universal access to sexual and reproductive health found in the SDGs (3.7 and 5.6). If your country is a FP2020 focus country or commitment maker, you can leverage the SDGs as a way of increasing the political priority of family planning, as well as ensuring the two SDG targets are being fulfilled. You can also use the Costed Implementation Plans (CIPs) – multi-year roadmaps designed to help governments achieve family planning goals – to strengthen your advocacy for the implementation of both the SDG and FP2020 commitments (WHO, 2015).

To aid in the measurement of maternal mortality and reproductive health, two benchmark indicators were created and include. the percentage of births attended by trained health care personnel; and knowledge of how to prevent HIV/AIDS. A question that arises is, whether developing countries have family planning programs that decrease fertility and stabilize population growth. (Dixon-Mueller & Germain 2007).

Cutwright and Kelly (1981) compare various studies on what has to happen first, development or family planning programs and which way is more effective Some people have argued that enhanced living standards and life expectancy, education, and women’s emancipation are the most effective ways to reduce fertility and curb populations growth, though of course contraceptive methods should be available (Wallchart, 2011).

However, it has been noted that having family planning programs and services available speeds up fertility decline and slows population growth (Bernstein et al. 2006).

Some believe that fertility will decrease and population growth will slow when people change their opinions about modern contraception use and small family size. This change must be accompanied by knowledge of methods, access to services, affordability, counseling services especially clarifying misinformation regarding health concerns and sides effects. This leads to the next issue, whether providing family planning services to women who want them increases the overall health of women and children in developing countries (Wallchart, 2011).

However in half of the 75 poor developing countries, mainly in Africa but including Haiti, contraception use remains low while fertility, population growth, and unmet needs for family planning remain high (Bernstein et al. 2006).

So what are the factors involved with population growth? In an article entitled, Family Planning: the Unfinished Agenda (Bernstein et al. 2006) the authors describe three factors that may account for future population growth: population momentum; unwanted births (as a result of unmet needs for contraception); and the desire for a large family (USAID, 2014).

Population momentum refers to birth rates in many developing countries that are sustained at raised levels because of the high proportion in the population of individuals of reproductive age. Unwanted births, due to an unmet need for contraception, are the second factor that largely accounts for future population growth. Bernstein et al (USAID, 2014).

(2006) note that “elimination of such births would reduce population growth by about 20%” (pg.1811). The final factor contributing to population growth is the desire for large families. The authors state that many couples report that they want or need more children than the number that could stabilize population growth (USAID, 2014).

This factor accounts for another 20% of the population growth that could be reduced in developing countries. Connecting family planning initiatives with development initiatives may assist in decreasing population momentum, unwanted births, and the desire to have large family, which may in turn decrease population growth.a study among urban IDPs in Somaliland, only 3% of contraceptive users had received it from a pharmacy, 75% had received the services from a MCH and 1% from a private hospital (Bernstein et al. 2006).

Asked where they would seek services if the need arose, 75% of women would seek FP at MCH level, 20% would go to a hospital and 1% would go to a pharmacy. Qualitative surveys have established that FP is increasingly recognized by women, especially in urban areas, and that men as decision-makers appear to be the biggest obstacle to the uptake of modern FP services. (Health Unlimited Somalia, 2008).

Misconceptions as to modern methods regarding intent, safety, and efficacy are widespread. Despite low use of condoms among women for contraceptive purposes (0.0%), qualitative surveys show demand for condoms for protective purposes but within confidential delivery-systems (Somali JHNP, 2014).

1.2 Statement of the problem

The use of family planning contraceptives protects the mother by preventing the risk factors that contribute maternal mortality and morbidity, by simply providing contraceptives to the eligible women. One of the targets of the Somali ministry of health with respect to improving maternal and child health is to increase the contraceptive prevalence rate 66% by the year 2015 (Unicef, 2009).

In order to achieve this target, the Ministry has given priority to the provision of family planning services in the community. Although east Africa is a region with increasing utilization of family planning methods among married of fertile age, yet, utilization of family planning services among married women in Somalia is still more Challenging. Somalia is the lowest for contraceptive utilization among other countries of the region due to various factors which need to be scientifically investigated (Federal Ministry of Health, 2011).

Therefore, this study seeks to assess utilization and the factors associated among the married women of reproductive age (15-49) in Hodan District Mogadishu- Somalia.

1.3. General objective of the study

To assess the level of utilization and factors associated with family planning services among married women of reproductive age (15-49years ) in Hodan District Mogadishu-Somalia in order to contribute high utilization of family planning services.

1.4 Specific objectives

(1) To assess level utilization of family planning among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia.
(2) To determine health system factors affecting utilization of family planning services among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia.
(3) To identify cultural factors affecting utilization of family planning services among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia.
(4) To find out socio-demographic factors affecting utilization of family planning services among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia.

1.5. Research questions

1. What is the level of utilization of family planning among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia?
2. What are the health system factors affecting utilization of family planning services among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia?
3. How cultural factors affect utilization of family planning services among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia?
4. To what extent socio-demographic factors affect utilization of family planning services among married women of reproductive age (15-49 years) in Hodan District, Mogadishu – Somalia?

1.6 Significance of the study

Improving modern FP service utilization, in addition to contributing towards fertility control, is important to reduce the maternal, child and infant mortality in the area and ultimately improves the socio- economic development of the local community and the nation as a whole .Having many children is common practice in most developing countries like Somalia especially with the fact of Somali region (WHO, 2015).

The identification of the prevalence and possible associated factors that determine the utilization of modern contraceptives in the study area will have greater input for designing programs, proper implementation and evaluation of their contribution regarding family planning methods. The study will also may give baseline to the concerned bodies like: regional health bureau, zonal and woreda policy makers, partner NGOs, as well as reference documentation for next researchers.

The findings of the study will provide up to date information to future researchers and academicians about the factors affecting utilization of family planning services among women of reproductive age (15-49 years) in Somalia; thus, contributing to the body of knowledge about the subject under investigation.

Study results will also be useful for local community in general and study participants in particular for creating conscious awareness about the importance of family planning services for reproductive age women.

1.7 scope of the study

Time Scope

This study was conducted between August, 2016 to June, 2017. The study will almost 11 months to complete.

Content Scope

This study was focus on factors affecting utilization of family planning services among women of reproductive age (15-49 years). The study specifically concentrated on health systems cultural and socio-demographic factors affecting utilization of family planning services among women of reproductive age (15-49 years).

Geographical Scope

This was conducted in hodan district, Mogadishu – Somalia. Hodan district provides optimum location for the study because it is one of the largest districts in Mogadishu – Somalia with the greatest number of population estimated 92,400 (Degmada).

1.8 Operational Definition

Family planning: the process of planning to decide the number of children at the right time you want by your will to protect unwanted pregnancy by using modern contraceptives

Family planning methods:-a system of medicine (hormonal) , materials (condoms) and minor surgery (sterilization) to limit or space the child-Birth, which included the old traditional system of birth control ( Abstinence, withdrawal, )

Married Women: A currently married women or union with husband living together making a family –household

Reproductive age women: - Between (15-49) aged women

Family Planning utilization:- Those married who using modern FP during data collection

Availability of Family Planning Services: percent of facilities offered temporary clinical methods of contraception, and percent offered counseling on the rhythm method.provide permanent methods (male or female sterilization).

Quality of family planning services: the standard of family planning services as measured against the outcome; or the degree of excellence of family planning services.

Integration of family planning services: the act or process of integrating family planning services with other services offered at health facility.

Spouse: A spouse is a life partner in a marriage. The term is gender neutral, whereas a male spouse is a husband and a female spouse is a wife.

Culture disapproval: the act or state of culturally disapproving; a condemnatory feeling, of family planning services.

Level of education: It refers to the level of schooling that a person has reached or the level of educational attainment of the person.

Age: a period of human life, measured by years from birth, usually marked by a certain stage or degree of mental or physical development and involving legal responsibility and capacity.

Knowledge: Knowledge is a familiarity, awareness, or understanding of someone or something, such as facts, information, descriptions, or skills, which is acquired through experience or education by perceiving, discovering, or learning.

1.9 Conceptual framework

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CHAPTER TWO: BACKGROUND

As per the WHO definition, family planning is the practice that helps individuals or couples to avoid unwanted pregnancies, bringing about unwanted babies at the right time, regulating the interval between pregnancies, controlling the time at which birth occurs in relation to the ages of the parents and determining the number of children in the family.( WHO,2001).

In developing countries the prevalence of modern contraceptive utilization among married women is in a middle way for example a study done in Turkey in 2008,among 427 women selected from 29874 of married reproductive aged women 60.4% are using modern family planning methods.;( Cayan.A, Karam.Z, .2013). Another study done in Rwanda April 2013 shows the modern contraceptive prevalence among married reproductive aged women had been increasing from 45 %( 2010) up to 64 %( 2013), (Clement uwirageye, 2013)

In previous study done in 2011 on geographical variation on modern contraceptive prevalence among married women across Ethiopia was 27.3% with variation in urban 49.5% and rural 22.5% and by regions which Addis-Ababa is the Highest 56.3% and still Somali region is lowest 3.8%; (Lakew et al. 2013. But the latest Ethiopian health survey (MINI-EDHS) revealed that the prevalence of modern contraceptive methods among currently married women in Ethiopia is 40.4%, which defers significantly among regions Addis-Ababa is the Highest(57%) and Somali region is lowest 2%, urban are 56% and Rural 37% (CSA,2014).).

There are middle range regions in Ethiopia for modern family planning utilization among married women, A cross-sectional community based study done in Adigrat town, Tigrai-northern Ethiopia between December-2011 up to January 2012 shows intention to use long acting and permanent contraceptives was 48.4% (Gebremarium and Adisse,2014) .

Countries with a large population and high density relative to available resources suffer tremendously from high fertility rates. High fertility rates are strongly associated with inadequate spacing between births, which in turn is associated with high maternal and infant mortality (Unicef, 2009).

An estimated 600 000 maternal deaths occur worldwide each year, 99% of them in developing countries. The World Health Organization estimates that 13% of these are due to unsafe abortions. Worldwide, approximately 50 million women resort to induced abortion each year, frequently resulting in mortality and adverse health consequences. Other causes of high maternal death rates in developing countries include complications of pregnancy and complications of childbirth (UNFPA, 2016).

In Sudan, maternal and infant mortality and fertility indicators are among the highest in the Region. Maternal mortality is estimated at 600 per 100 000 live births and infant mortality at 70 per 1000 live births;the fertility rate is estimated at 4.6 children per woman (Unicef, 2009).

The total fertility rate of a nation is directly related to the prevalence of contraceptive use. On average, for every 15 percentage points increase in contraceptive use in the community there is a reduction of 1 birth per woman. This suggests that countries with high total fertility rates tend to have low contraceptive use and vice versa. Unintended pregnancies have significant consequences and occur most frequently in adolescents, low-income groups and women from minority groups. Improving contraceptive compliance among high-risk adolescents is a key to reducing the rates of unintended pregnancy in this group of the population (UNFPA, 2016).

National family planning programmers and services in developing countries have been associated with notable increases in contraceptive use and consequent declines in fertility. Oral contraceptives and condoms are the base of many programmers, but some earlier programmers relied, and continue to rely heavily, on methods such as the intrauterine device (IUD), that are less prominent in programmers that started later. Over time newer methods such as injectables and implants have found their own niches. The main trend has been towards permanent methods; sterilization, which has become simpler and more demanded, now accounts for half of all contraceptive use. Family planning services were introduced in Sudan in 1965 with the foundation of the Sudan Family Planning Association, which provides services throughout the country (Lutalo et al, 2015).

The total fertility rate for the age group 15–49 years suggests a sharp fall in fertility level in recent years.Total fertility was 6.5 births per woman during the 10–14 years before the 1999 safe motherhood survey, 6.2 births per woman 5–9 years before the survey, and 4.9 births per woman 0–4 years before the survey (JHNP, 2012-16).

This supports efforts to empower married couples to receive information about a range of contraceptive methods and access to the methods of their choice. However, availability and accessibility to services still vary greatly, especially between urban and rural areas (CSA, 2014).

While many Sudanese women have heard of family planning, research indicates significant unmet needs. Although nearly 20% of married women in Sudan reported not wanting another child, contraceptive use is still low. The proportion of women using modern methods of contraception in Northern Sudan increased slightly from4% in 1977–1978 to 6% in 1989 and 7% in 1992–1993 (Clement Uwirageye ,2013 ).

Family planning practice is determined by many factors that can be considered obstacles to the use of family planning services. Caldwell and Caldwell emphasized the cultural imperatives of African communities that are important in maintaining high levels of fertility . In many African cultures it is taboo to be childless: high fertility, therefore, enjoys both community and divine approval. A woman’s age, residence (urban or rural), education and income may have substantial effects on contraceptive use and are likely to affect how women choose family planning services (Cayan, 2013).

Behaviour regarding contraception is known to vary widely according to education, which is likely to be positively correlated with the use of private sector services. Significant rural–urban difference exists in fertility levels in Sudan. On average, age. specific fertility rates are lower in urban than in rural areas, which suggests greater use of contraception by urban women (Bulta, 2014).

CHAPTER THREE: LIT ERATURE REVIEW

3.0 INTRODUCTION

This chapter was present a mix and diversified literatures relating to the factors affecting utilization of family planning services among women of reproductive age (15-49 years). This chapter have gone deep into the presentation of relevant concepts, ideas and opinions from different scholarly articles, books and reports about health systems, cultural and socio-demographic factors affecting utilization of family planning services among women of reproductive age (15-49 years).

3.1 HEALTH SYSTEM FACTORS AND UTILIZATION OF FAMILY PLANNING SERVICES

3.1.1 Availability of family planning services

Health services and in particular private FP service delivery play a big role in sexual and reproductive health behaviors, outcomes of risk perception and in this regard use of FP by PLWHA. In one study, results showed that the proximity of a private health facility in urban areas which likely reflects increased availability of FP methods, was positively associated with current use (odds ratio, 2.1) as was the presence of a higher number trained FP service providers (odds ratio 1.7) (World Bank, 2007)

In a study on contraceptive use and incidence of pregnancy in Ivory Coast among 546 HIV positive women followed up for 2 years after delivery and given FP counseling and free contraceptives, results showed high proportions of women using modern contraception varying from 52 to 65% and low pregnancy incidence (calculated as the number of pregnancies for 100 women-years at risk) of 5.70 (95% CI: 4.17-7.23). Findings in this study indicated that FP counseling and regular follow-up was accompanied by a high rate of contraceptive use and a low pregnancy incidence among PLWHA after delivery (Brou et al., 2009).

In Rakai, Uganda, a community randomized trial of enhanced FP efforts in an HIV surveillance program showed a statistically significant higher use of hormonal contraceptives (23.2% vs. 19.9%) [p=0.009] and lower pregnancy rates (12.4% vs. 15.7%) [p=0.002] in the intervention arm as compared to the control arm. Investigators found that using trained volunteers and social marketing of contraceptives can improve contraceptive uptake among PLWHA (Lutalo et al., 2000).

A major goal of family planning programmes is to help couples achieve their reproductive intentions. To assist clients to achieve these goals family planning services should be tailored to meet clients’ needs. Effective delivery and uptake of modern family planning methods depends a lot on the competency and attitudes of the providers particularly for the long acting and permanent methods (Bulta, 2014).

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