Exploring the multilevel factors influencing women’s choices and utilisation of family planning services in Mufulira district, Zambia: A socio-ecological perspective

Abstract:

Family planning services are useful in helping couples and individuals realize their basic right to decide freely and responsibly if, when, and how many children to have. The study aimed at exploring the multilevel factors influencing women’s choices and utilisation of family planning services in Mufulira district of Zambia. A qualitative explorative study design that utilised two focus group discussions (n = 20) and in-depth interviews (n = 30) involving women of reproductive age was conducted in Mufulira district, Zambia. Convenient sampling was employed to select participants. In-depth interviews and focus group discussions were recorded, translated, and transcribed verbatim. Content analysis was utilised through code classification and theme identification. Data were imported into NVivo.x64 for coding and node generation. The study revealed overarching themes at the individual level such as distrust of hormonal contraception, misconceptions about the side effects of contraception, perceived side effects of contraceptives, perceived risk of infertility, and lack of adequate information on contraception. At the interpersonal level, themes were mainly centred on male partner influence such as male partner preference for a large family size, fear of partner infidelity, disruption of sexual pleasure, fear of intimate partner violence, and male partner disapproval of contraception use. At the institutional/organisation level, themes such as health providers’ negative attitudes, non-availability of preferred contraception, and lack of guidance and support from health workers were highlighted, and at the community level, we developed themes on the limited autonomy of women in making decisions and social expectations. Women’s choices and utilisation of family planning services are influenced by an interplay of multiple social-level factors. Interventions that address these influencing factors are needed to enhance the uptake of family planning services among women.

Keywords:

• Male partner
• modern contraception
• contraception side effects
• social-ecological model
• Family planning

1. Background information

Family planning and contraceptive programmes play a vital role in national and human development. They help regulate population growth that brings about socio-economic benefits such as decreased poverty levels, enhanced education opportunities, and reduced gender inequality (Boadu, 2022). Family planning services can offer an opportunity for improved maternal and child health by preventing unwanted pregnancies, and unsafe abortions (Heresa et al., 2018). Adera and colleagues have defined family planning as a conscious effort by a couple to limit or space the number of children they have using contraception methods (Adera et al., 2015). These include methods such as female sterilisation, male sterilisation, oral contraceptives such as pills, Intra-Uterine devices (IUD), injectables, implants, male condoms, female condoms, and withdrawal methods (Adera et al., 2015). Of all these, modern contraceptives such as injectables have emerged as effective methods of reducing the global population, especially in low-resource settings (Marquez et al., 2018).

Estimates of maternal mortality rates have risen exponentially in the last decade with geographical variations. According to the World Health Organization, in 2017 about 295,000 women died during pregnancy and childbirth (WHO, 2020). Most of these deaths (94%) occurred in low-resource settings with Sub-Saharan Africa accounting for roughly two-thirds (196,000) of global maternal deaths (Mutowo et al., 2014). Despite evidence suggesting the enormous benefits of family planning services and their effectiveness in reducing maternal deaths by 32% and child death by 10%, the rate and access to family planning services in the Sub-Saharan African region is still low (Wondim et al., 2020). Hence, global efforts are now channelled toward expanding access to contraception and ensuring that the need for family planning is satisfied, this is crucial in achieving universal access to reproductive health care as highlighted in the 2030 agenda for sustainable development (Kantorová et al., 2020).

Global consensus suggests that the proportion of women aged 15–49 reporting the use of a modern contraceptive method has risen minimally or plateaued between 2008 and 2015 (WHO, 2020). In Africa, it went from 23.6% to 28.5%, in Asia it has risen slightly from 60.9% to 61.8%, and in Latin America and the Caribbean, it has remained stable at 66.7% (Cahill et al., 2018). This slow increase in contraceptive use can be attributed to the fact that more than one in ten married or in-union women worldwide have an unmet need for family planning (Kld et al., 2021). This poses greater reproductive health challenges such as high rates of unplanned pregnancies, high rates of maternal mortality, teenage pregnancies, and a generalised HIV epidemic with young women being the most affected (Adeniyi et al., 2018; Jewkes & Morrell, 2022).

To this effect, multiple studies have linked the low uptake of contraceptives to a lack of awareness of the availability of family planning services (Lauria et al., 2014), a lack of information about various forms of family planning services and how they work (Bhattathiry & Ethirajan, 2014), and a lack of adequate counselling on the possible side effects of using contraceptives (Kabagenyi et al., 2014). Barriers to the utilisation of family planning services also exist at a structural level which includes long distances to healthcare facilities, unavailability of preferred methods, lack of policies facilitating the contraception provision, and undesirable provider attitudes (Silumbwe et al., 2022). Other barriers at the individual level include perception of risk and reactions to contraceptive use and insufficient knowledge needed to make informed choices (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019b).

The role of men in the utilisation of family planning services among women is increasingly being recognised globally. This is because male involvement in family planning services could help in increasing the uptake of contraceptives and enhance their effective use and continuation through spousal communication (Adera et al., 2015; Mulatu et al., 2022). However, women have been the primary beneficiaries of family planning services whilst men have often been considered silent partners (Prata et al., 2017). Also, socially constructed roles that favour men create gender inequalities leading to female disempowerment which influences women’s choice and utilisation of contraceptives (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019b; Prata et al., 2017). Fear of spousal retaliation due to disagreements about whether to use contraception could also lead to heightened gender violence in most relationships (Closson et al., 2021; Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019b). Undeniably, these socially constructed roles elevate men’s status over women thereby making men more economically empowered than women. Moreover, existing political and social-economic systems do reinforce male dominance in most societies through heightened gender inequalities that limit women’s access to financial independence and hence their ability to access and utilise family planning services (Cleland et al., 2014; Haider & Sharma, 2012; Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a; Ochako et al., 2015).

In the recent past, the Zambian government has invested heavily in family planning programmes aimed at reducing fertility rates by improving knowledge about birth control methods and access to contraceptives (Nduku & Simo-Kengne, 2022). As a result, family planning utilisation increased from 15% in 1992 to 50% in 2018 (Government Of The Republic Of Zambia, 2021–2026). Despite these gains, the Zambian Demographic Health Survey reports that only 48% of married women aged 15–49 use modern contraceptives (Government Of The Republic Of Zambia, 2021–2026). Also, Zambia’s fertility rate and unmet needs for family planning are still high, and Zambia is among the top 10 countries with high fertility rates (5.5 births /woman), with an estimated population of about 18.4 million, and a total fertility rate of 4.7 (Mutombo & Bakibinga, 2014). Many studies done on contraception use in Zambia have largely focused on the patterns, trends, and factors associated with contraceptive use (Chola et al., 2020; Mutombo & Bakibinga, 2014; Nduku & Simo-Kengne, 2022). However, there is a paucity of extant literature in Zambia that has addressed multilevel factors influencing women’s choices and utilisation of family planning services in the socio-ecological context despite theoretical validation for their investigation. Therefore, this study aimed at exploring multilevel factors that influence women’s choices and utilization of family planning services in Mufulira district, Zambia.

2. Conceptual framework

2.1. Social- ecological model

We employed the socio-ecological model (SEM) to understand the interplay of factors influencing women’s choices and utilization of family planning services in Mufulira district of Zambia. The SEM has nested layers of influencing factors at the individual, interpersonal, institutional, community, and structural levels (Baral et al., 2013; Kaufman, Cornish, Zimmerman, Johnson et al., 2014a; Khuzwayo & Taylor, 2018). The model posits that there are multiple interacting layers of environmental, community, and policy factors that influence health-seeking behaviour (Ezenwaka et al., 2022). At its very core is the individual whose behaviour is influenced by personal knowledge, beliefs, and attitudes. The second layer of the framework highlights interpersonal factors such as formal and informal social networks including social support. At the community level, are factors such as relationships between organisation and institutions. The fourth layer represents organizational systems, characteristics and norms, and rules and regulations that constrain individual behaviour, while the outermost layer signifies the local, state, and national policies, strategies, and guidelines (Chimphamba Gombachika et al., 2022). Although current research in reproductive and sexual health has emphasised the need for a multilevel approach to understanding health-seeking and utilization behaviour, its application has been low because multi-level interventions are diverse and often context-specific, and as such, it is not easy or even appropriate to replicate them (Kaufman, Cornish, Zimmerman, Johnson et al., 2014b), also, they do not easily support generalisation across contexts (Kaufman, Cornish, Zimmerman, Johnson et al., 2014b). However, it is a more explanatory and effective model in contextualising the factors that influence health-seeking behaviour.

3. Methods

3.1. Study design

We employed a qualitative explorative study design to explore the multilevel factors influencing women’s choices and utilisation of family planning services in Mufulira district, Zambia . The naturalistic inquiry of explorative design enabled rich data exploration and provided an in-depth understanding of the social phenomena within the participant’s natural settings.

3.2. Study setting

This study was carried out in Kawama East, a compound located in the eastern part of Mufulira district. Mufulira district is in the Copperbelt province of Zambia. It has 2 government hospitals and 1 private hospital. The district has 21 clinics of which 14 are urban. Kawama east has a total population of 8,498 (Mufulira (District, Zambia)—Population Statistics, Charts, Map and Location [Internet]. [cited, 2022]. It has a total number of 3,051 households. The nearest biggest health facility in this area is Twatasha Health Centre (1st level) and Ronald Ross General Hospital (2nd level). The main socio-economic activities in Kawama East include subsistence farming, charcoal burning, small-scale sand mining, and small business enterprises. Most are self-employed while a few others are government workers.

3.3. Study population and sampling

We targeted women of reproductive age 15–49 years (n = 50) single or married who were conveniently selected as they came to access family planning services at two health facilities in Mufulira district of Zambia. Two (2) focus group discussions of 10 women each (n = 20) and in-depth interviews involving 30 women were conducted at two health facilities in Mufulira district of Zambia.

3.4. Inclusion and exclusion criteria

The study included women aged between 15 and 49 who were present at the time of the study. Only those women who were present during the data collection period and consented to participate in the study were included in the study

3.5. Data collection

The focus group discussions (FGDs) and in-depth interview guides (IDIs) were used to explore the multilevel factors influencing women’s choices and utilisation of family planning services in Mufulira district of Zambia. In-depth interviews and focus group discussions were conducted between August and November 2021 at two health facilities in Mufulira district. The interviews and focus group discussions were held in audibly private areas, with notes taken during the interviews. To achieve prolonged engagement, we spent about three months at the two health facilities to understand the context and establish a rapport with the participants and healthcare providers. Interviews and focus group discussions were conducted in English and native Bemba. Consent was obtained from all participants of the study, and they were encouraged to openly discuss their opinions. The interviews and discussions were held in sessions of approximately 40 to 50 minutes and 40 to 60 minutes, respectively. Data collection in both FGDs and IDIs continued until the saturation point. We determined the saturation point when no new data emerged. Questions were asked in the language the participants were most comfortable with. No personal information in form of names or other identifying data was obtained.

3.6. Data analysis

The audio recordings from the IDIs and FGDs were transcribed verbatim in the English language. For focus group discussions and interviews which were conducted in Bemba, we engaged a qualified language translator who translated Bemba transcripts into English and back-translated them into Bemba to enhance translation accuracy. We employed content analysis through code classification and theme identification. All researchers had code books that were compared for similarities. The manuscripts were reread to note any similarities between and within participants’ accounts. We then imported the data into NVivo.x64 to help in the coding process, data management, and development of nodes. We manually developed categories and established themes and subthemes. We employed the steps recommended by Graneheim and Lundman (Graneheim & Lundman, 2004) on content analysis.

1. Transcribing the interviews verbatim and reading through the text several times to obtain a sense of the whole.

2. Dividing the text into condensed meaning units.

3. Abstracting the condensed meaning units and labelling them with codes.

4. Sorting codes into categories and subcategories based on comparing their similarities and differences; and

5. Formulating themes as the expression of the latent content of the text (Cleland et al., 2014).

3.7. Ethical considerations

Ethical clearance for the study was sought from the Tropical Diseases Research Centre (IRB: 00002911). Privacy and confidentiality were assured and maintained throughout the study. The information and recordings collected from the respondents involved were kept in a locked cabinet. Access to these documents was limited to the researchers only. No identifying information such as the name of the participant was captured in the recordings instead, codes were assigned to the participants to help in data collection. Written consent was obtained from the Mufulira district health office to conduct the study. Informed consent was sought from all participants of the study before they participated in the focus group discussions and in-depth interviews. In addition, written informed consent was obtained from the parent/guardian of each participant under 18 years of age.

3.8. Trustworthiness of the study

To enhance the trustworthiness of the study, we employed Guba and Lincoln’s criteria of credibility, dependability, transferability, and confirmability (Cypress, 2017). Credibility in the study was ensured through prolonged engagement with the participants. To achieve this, we spent about 3 months at the two health facilities engaging the participants and healthcare workers as we conducted focus group discussions and in-depth interviews. In this way, we were able to build trust and rapport with the participants. We conducted peer debriefing by having a qualitative research expert validate and critique our field notes. Data triangulation was achieved through focus group discussions and in-depth interviews. This was also necessary to enhance data richness. We achieved transferability through the thick description and robust data through accurate descriptions of the participants in their natural settings. This was achieved through continuous recruitment of participants and data collection until data saturation. In this regard, interviewing additional participants was critical in increasing the scope, adequacy, and appropriateness of the data (Cypress, 2017). Dependability was achieved by having the focus group and in-depth interview transcripts validated by 2 independent qualitative research experts in sexual and reproductive health. The experts reviewed the themes and the descriptors to note similarities. Confirmability was achieved through an audit trail. This was done by an independent qualitative research expert who examined the qualitative processes we had taken from data collection and transcription up to interpretation. This was also done by reviewing the documents and transcripts and all the interview notes that we had collected.

3.9. Study limitations

As is the case in qualitative studies, subjectivity during data collection and interpretation could not be avoided. However, we validated our findings through the engagement of experts in qualitative research and reproductive and sexual health. Also, sampling from two health facilities with geographic and social-economic variations, which offer sexual and reproductive health as well as maternal and child health services enabled in-depth and rich data exploration through participants’ perspectives in their natural settings.

4. Results

We had a total of 2 FGDs with 10 participants each and 30 IDIs. The majority of the participants were adolescents and youths aged 25–29 years old (28%), were married and living with their husbands (82%), had primary education 50%, were not working 74% and one to three children (72%). Almost half (48%) were Pentecostal while a third reported only having one pregnancy before. (Table 1)

Table 1. Demographic characteristics of the participants

	TOTAL	GROUP 1	GROUP 2		IN-DEPTH INTERVIEWS
AGE	n (%)	n (%)	n (%)		n (%)
15–19 years	12 (24)	2 (20)	3 (30)		7 (23)
20–24 years	7 (14)	2 (20)	2 (20)		3 (10)
25–29 years	14 (28)	4 (40)	3 (30)		7 (23)
30–34 years	6 (12)	1 (10)	1 (10)		4 (13)
35–39 years	8 (16)	1 (10)	1 (10)		6 (20)
40–44 years	2 (4)	0 (0)	0 (0)		2 (7)
45–49 years	1 (2)	0 (0)	0 (0)		1 (3)
MARITAL STATUS
Married and lives with husband	41 (82)	7 (70)	8 (80)		26 (87)
Married and do not live with their husband	1 (2)	0 (0)	0 (0)		1 (3)
Not married	5 (10)	1 (10)	2 (20)		2 (7)
Not married and lives with their boyfriend	3 (6)	2 (20)	0 (0)		1 (3)
LEVEL OF EDUCATION
Primary	25 (50)	4 (40)	6 (60)		15 (50)
Secondary	22 (44)	5 (50)	4 (40)		13 (43)
Tertiary	0 (0)	0 (0)	0 (0)		0 (0)
Never been to school	3 (6)	1 (10)	0 (0)		2 (7)
OCCUPATION
Informal employment	13 (26)	3 (30)	2 (20)		8 (27)
Does not work	37 (74)	7 (70)	8 (80)		22 (73)
RELIGION/CHURCH
Catholic	10 (20)	2 (20)	3 (30)		5 (17)
Pentecostal	24 (48)	4 (40)	6 (60)		14 (47)
United Church of Zambia	4 (8)	1 (10)	0 (0)		3 (10)
Jehovah’s witnesses	6 (12)	1 (10)	0 (0)		5 (17)
Seventh-day Adventist	6 (12)	2 (20)	1 (10)		3 (10)
NUMBER OF PREGNANCIES
1	17 (34)	5 (50)	4 (40)		8 (27)
2	13 (26)	3 (30)	3 (30)		7 (23)
3	6 (12)	2 (20)	1 (10)		3 (10)
4	3 (6)	0 (0)	2 (20)		1 (3)
5	4 (8)	0 (0)	0 (0)		4 (13)
6	3 (6)	0 (0)	0 (0)		3 (10)
7	2 (4)	0 (0)	0 (0)		2 (7)
8	1 (2)	0 (0)	0 (0)		1 (3)
9	0 (0)	0 (0)	0 (0)		0 (0)
10	1 (2)	0 (0)	0 (0)		1 (3)
NUMBER OF LIVE CHILDREN
1	17 (34)	5 (50)	4 (40)		8 (27)
2	14 (28)	3 (30)	3 (30)		8 (27)
3	5 (10)	2 (20)	1 (10)		2 (7)
4	5 (10)	0 (0)	2 (20)		3 (10)
5	6 (12)	0 (0)	0 (0)		6 (20)
6	1 (2)	0 (0)	0 (0)		1 (3)
7	1 (2)	0 (0)	0 (0)		1 (3)
8	1 (2)	0 (0)	0 (0)		1 (3)

4.1. Individual level factors

4.1.1. Theme 1: Knowledge about family planning

The majority of respondents knew what family planning was with only a few respondents indicating that they didn’t know much about it from FGD 1 and 2 respectively. However, some participants expressed a lack of understanding of what contraceptives were.

“It is when you don’t want your husband to be going to other women. You start it so that you will be spending time with your husband since when you have a child he will be going away.” (P2, Single, 23 yrs, FGD, G2)

4.1.2. Theme 2: Knowledge about the benefits of family planning

All participants were able to identify at least 1 benefit of FP. The most cited were the prevention of unplanned pregnancies and raising healthy children as depicted in the excerpts below. Some respondents cited the economic and physical benefits of using contraception as depicted below.

“Children are spaced out so it allows you to save money before having the next child.” (P4, Married, aged 25, FGD, G1)

Others cited the dual protective nature of condoms especially in preventing unwanted pregnancies and sexually transmitted infections (STIs)..

“I love that condoms can prevent both pregnancy and sexually transmitted diseases. Yes, I am married but you can never trust your partner to be completely faithful, especially in this ghetto area we live in. I find condoms to be good for us though they are frowned upon in marriage.” (P30, married, IDI)

4.1.3. Theme 3: Beliefs and perceived side effects of Contraception

Perceived side effects associated with contraceptive use contribute to low uptake of contraception. In our study, participants were able to cite several side effects ranging from prolonged menstruation, unwanted weight gain, weight loss, headaches, and loss of libido. Most participants could not continue taking hormonal contraception because of their perceived undesirable side effects.

“It causes headaches and it can deplete your blood levels because of continuous periods.”(P8, Single, 25 yrs, FGD, G2)

“When you start using contraceptives, you become less pleasant in bed and your husband can leave you.” (P3, Married, 32 yrs, FGD, G1)

“It causes you to gain weight carelessly.” (P1, Single, 27 yrs, FGD, G2)

4.1.4. Theme 4: Beliefs and perceived risk of infertility associated with contraceptive use

Most participants expressed fear of using certain contraceptives due to the perceived risk of infertility. This was associated with the delay in the resumption of menstruation after contraception discontinuation.

“I hear sub-dermal implants affect your fertility and can make you barren. I wouldn’t want that.” (P8, Married, 29 yrs, G

4.1.5. Theme 5: Distrust of hormonal contraception

Misconceptions about the use of family planning services were one of the factors which contributed to distrust of hormonal contraception. One participant had this to say.

“I prefer using soaked herbs. I don’t trust modern contraceptives.” (P1, Single, 27 yrs, FGD, G2)

4.2. Interpersonal level factors (Family and relationship factors)

Regarding the interpersonal level factors that influence women’s choices and utilisation of contraceptives and family planning services, themes from the in-depth interviews (n = 30) were mainly centred on male partner influence on women’s choices and utilisation of family planning services. From the categories and subcategories, six (6) themes emerged as follows:

4.2.1. Theme 1: Preference for a large family size by the male partner

Differences in discordant fertility desires between partners with men desiring to have more children and hence forcing their partners not to use family planning services and contraceptives were highlighted by most women as depicted below.

“He does not want me to use the sub-dermal implant for 5 years because 5 years is too long and can make me barren. He tells me they are very few in his family and wants me to bear him a lot of children.” (P27, Married, 27yrs, IDI)

“Injectables have a shorter duration and my husband wants more children. But I wanted the 5-year sub-dermal implant.” (P28, Married, IDI)

4.2.2. Theme 2: Perceived fear of side effects by a male partner

Perceived fear of contraception side effects and misinformation by male partners were cited to be one of the reasons male partners refused their partners to access and use family planning services .

“He doesn’t want me to gain weight because of it. He says it makes people fat. I am afraid of using it because I may lose my marriage and he may start seeing other women. He prefers I use natural methods, but it’s not effective, and I still end up getting pregnant.” (P18, Married, 26 yrs., IDI)

“My husband said says contraceptives can give me cancer. He heard of someone’s wife who got cancer and stopped bearing children because of contraceptives.” (P20, Married, 35yrs, IDI)

4.2.3. Theme 3: Fear of partner infidelity

One of the ways men could negatively influence women’s access and utilisation of family planning services was by accusing their female partners of being promiscuous or salacious behaviours when women seek to use contraception.

“He says I will be sleeping around when I start taking contraceptives because I won’t be able to get pregnant. He says contraceptives are for prostitutes.” (P10, Single, 24, IDI,)

“He says I can’t start taking contraceptives because they will make me look attractive to other men and I will start catching their attention and going out with them. Especially because I can’t get pregnant.” (P12, Single, 29yrs, IDI)

4.2.4. Theme 4: Disruption of sexual pleasure

Perceived decreased male sexual pleasure was associated with contraceptive use among women. Participants recounted how irregular and prolonged menstruation interrupted their sexual life. In this regard, libido and dryness of the vaginal canal were perceived to be caused by contraception.

“Contraceptives usually make me have irregular and prolonged periods. This disturbs my sex life because I can’t sleep with my husband as I normally do anymore. He may end up going to other women.” (P30, 37yrs, IDI)

“My sexual appetite gets low when I start using contraceptives and it affects my marriage. I also get really dry and unpleasant in bed. My husband hates it that it drives him away.” (P21, Married, 29yrs, IDI)

4.2.5. Theme 5: Fear of physical abuse/Intimate partner violence by the male partner

Participants mentioned instances where they feared being abused physically if their partner discovered that they were using contraceptives as depicted in the following excerpts.

’Yes, he doesn’t allow any method. He says they are bad and that makes me fear to come and get my injections because I fear his reaction in case he finds out.” (P15, Married, 25yrs IDI)

Related to physical abuse, some participants cited being coerced to stop using the contraceptives by their male partners.

“Yes, he forces me to stop using it. I just come here in secret.” (P25, Married, 26yrs.IDI)

“Yes, he doesn’t allow any method. He says they are bad and that makes me fear to come and get my injections because I fear his reaction in case he finds out.” (P17, Married, 23yrs. IDI)

4.2.6. Theme 6: Lack of male partner support

Many participants cited a lack of support from their male partners because most of them did not allow them to use contraception.

“He doesn’t want it at all, and I have never used it. This time I just decided that it was too much and decided to sneak out and start using it without his knowledge. If he finds out that I have started using it, I’ll be in trouble, so I leave my book with the sister here.” (P25, IDI)

Despite many studies pointing to the importance of male involvement in family planning services, A few participants recounted that they preferred the non-involvement of male partners in family planning services citing that it would enable them to be free in making choices that are best for them and their marriage without any coercion as shown in Table 2.

“No, because I am in charge of my body and he doesn’t bear the burden of childbearing.” (P4, Married, IDI)

“No, I would want him to let me be free to choose what is best for me. But he usually gets stories from his friends and is influenced to say no.” (P6, Married, IDI)

Table 2. Themes on interpersonal level factors

THEMES	EXAMPLE OF EXCERPTS
Preference for a large family size	“Injectables have a shorter duration and my husband wants more children. But I wanted the 5 years sub-dermal implant.”
Fearof partner infidelity	“He says I will be sleeping around when I start taking contraceptives because I won’t be able to get pregnant. He says contraceptives are for prostitutes.”
Disruption of sexual activity	“My sexual appetite gets low when I start using contraceptives and it affects my marriage. I also get dry and unpleasant in bed. My husband hates it that it drives him away.”
Fear of physical abuse	“Yes, he doesn’t allow any method. He says they are bad and that makes me fear to come and get my injections because I fear his reaction in case he finds out.”
Perceived fear of side effects by the male partner	“He doesn’t want me to gain weight because of it. He says it makes people fat. I am afraid of using it because I may lose my marriage and he may start seeing other women. He prefers I use natural methods, but it’s not effective, and I still end up getting pregnant

4.3. Community level factors

4.3.1. Theme 1: Limited autonomy in making decisions and social expectations

Community factors influencing women’s choices and utilisation of contraception bordered on gender and social norms. In our study, most respondents’ views were governed by strong cultural norms which empower male partners and disallowed women from making independent decisions. Most women narrated how their partners disapproved of their use of contraception as depicted below.

“My husband decides on whether to use contraception or not, he doesn’t like contraceptives, our culture allows this. But I have just come here in secrecy, and I fear how he will react when he discovers that I came here” (P18, Married, 26 yrs., IDI)

“Yes, he doesn’t allow any method. He says they are bad and that makes me fear to come and get my injections because I fear his reaction in case he finds out.” (P17, Married, 23yrs. IDI)

4.4. Institutional/organisation level factors

To gain insights into the barriers and factors influencing women’s choice and utilisation of FP services, we explored institutional and organisation factors influencing women’s uptake of contraception. Five (5) themes emerged as follows:

4.4.1. Theme 1: Unavailability of contraceptive and family planning services

The unavailability of family planning services and a variety of contraceptives in most health facilities were cited as one of the reasons influencing utilisation and choice of contraceptive use.

“Most contraceptives’ usually not available, I didn’t find what I wanted last time” (P 32, IDI, 25yrs)

“They’re usually not available, I didn’t find what I wanted last time.” (P8, Married, 29, FGD1)

“I usually only find injectables when I come. That’s why I use them.” (P3, Married, FGD2)

4.4.2. Theme 2: Insufficient information and guidance from healthcare workers

Lack of proper guidance from healthcare workers on contraceptive use contributed to contraceptive covert among women. Also, FP information was not provided accurately and appropriately as depicted in the following excerpt.

“People here are busy they just ask you what you want and don’t encourage much or ask how the method you are using is going for you.” (P35, IDI, 40yrs)

4.4.3. Theme 3: Health workers’ negative attitudes and

Most participants expressed concerns regarding health workers’ attitudes. Participants cited that health workers did not seem interested to engage women and explain to them how to use contraception.

“They take long to attend to us and are in a hurry it seems they are few workers, so they don’t have time to explain they don’t help much either when you ask questions.” (P4, FDG, 31 yrs.)

4.4.4. Theme 4: Convenience of contraceptives

Participants alluded to how convenient it was to use implants compared to oral pills. This influenced their choices of contraception. They cited that implants were given once-off while pills needed to be taken every so often as depicted in the following excerpt as shown in Table 3.

“If I take pills I may be forgetting to take them and I wouldn’t want to be coming here to collect them too frequently so I prefer the implant for 5 years.” (P35, IDI, 40yrs)

Table 3. Themes on institutional level factors

THEMES	EXAMPLE OF EXCERPTS
Perceived risk of Infertility	“I hear sub-dermal implants affect your fertility and can make you barren. I wouldn’t want that.”
Convenience	“If I take pills, I may be forgetting to take them, and I wouldn’t want to be coming here to collect them too frequently, so I prefer the implant for 5 years.”
Insufficient information and guidance from health workers	“People here are busy they just ask you what you want and don’t encourage much or ask how the method you are using is going for you.”
Unavailability of a variety of methods to use	“They’re usually not available, I didn’t find what I wanted last time.”

4.5. Structural level factors

We did not receive any insights from our participants on the structural-level factors influencing women’s choices and utilisation of family planning services.

5. Discussion

The study aimed at exploring the multilevel factors influencing women’s choices and utilisation of family planning services in Mufulira district, Zambia. Poor knowledge about the benefits of contraception, how to access FP services, how to use contraception correctly, and how to integrate knowledge into practice are major barriers to contraception use globally (Bailey et al., 2022). In exploring individual-level factors influencing contraception use, our study showed that most respondents were aware and knowledgeable about FP and could identify at least one method, benefit, and side effect of FP. Similar findings have been reported elsewhere (Prata et al., 2017). The most common method of contraception cited by participants was oral pills. Other methods cited include condoms, pills, injectables, and sub-dermal implants while others used herbs or nothing at all. Kassa and colleagues reported similar findings in their study which revealed that almost all (99.4%) participants’ wives (spouses) were using contraceptive methods mainly injections (53.2%; Kassa et al., 2014). The possible explanation could be that oral pills and injectables are the most available, cheaper, and tolerable forms of contraceptives in most settings in Africa (Truong et al., 2020). Factors such as the age of a woman, the social economic status, the education level, and the number of children can influence knowledge levels on contraception among women (Article, 2021). For instance, high education levels and high social economic status have been associated with an increase in contraception knowledge among women (Islam et al., 2016).

Contraceptive side effects can cause critical constraints to contraceptive use and often lead to the disapproval of contraceptives among women (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a). In the current findings, fear of side effects was one of the individual-level factors which influenced the contraceptive choice and use, this included fear of weight gaining, infertility, prolonged bleeding, decreased sexual pleasure, vaginal lubrication, or wetness. Most women expressed concerns about the delay of menstrual resumption after contraception discontinuation, which they perceived to be a sign of infertility. Similarly, a study by Aryeetey revealed that more than half (n = 64%) of all respondents reported at least one perceived side effect of using any modern method of contraception and the main side effects indicated were irregular periods and delay in menstrual resumption (n = 82 percent) and problems with the heart (n = 12 percent) (Aryeetey et al., 2010). Reasons for the non-use of contraception included the desire for more children, fear of side effects, religious beliefs, and the fact that reduction in family size hurts economic and food productivity (Akamike et al., 2022). Men’s desire for large families is regarded to be a social norm in most cultures particularly in Sub-Saharan Africa, particularly due to pressure from family members (Bailey et al., 2022). Given this, there should be a deliberately scheduled follow-up plan and clinical management of contraceptive side effects among women. Family planning programmes should address cultural and social dynamics that influence women’s contraception uptake (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a).

We explored factors at the interpersonal level that influence women’s choices and utilisation of family planning services and many themes bordered on male partner influence. This study confirms the existence of socially constructed norms that give rise to power differences in relationships and how they influence the choice and utilisation of family planning services among women (Ajah et al., 2022; Higgins & Smith, 2016; Ochako et al., 2015). Specifically, some cultural norms tend to elevate men’s status thereby making them more economically empowered than women (Jewkes & Morrell, 2022). Thus said, men tend to be the sole decision-makers thereby denying women of their reproductive and sexual health rights. Fear of spousal retaliation due to disagreements about whether to use contraception could also lead to heightened gender violence against women (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a). However, in the current study, less than half of the participants (n = 30%) cited male partner influence and disapproval regarding contraceptive use. Specifically, women recounted how male partners assumed ownership over their fertility. This can contribute to discordant fertility desires with male partners preferring large family sizes (Ackerson & Zielinski, 2017). With this, female partners are likely to be subjected to male partners’ demands and expectations for children (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a). Even more striking is the power imbalance regarding the decision and choice of contraceptive use and the inherent threat and fear of physical abuse by their male partners. Thus said, in many societies particularly in low and middle income countries (LMICs), women’s contraceptive beliefs augment various ways in which contraceptive use is conditional on gender roles and power dynamics (Alspaugh et al., 2020). In the current findings, participants expressed fear of being physically abused by their partners if they continued accessing contraceptives. Similar findings have been reported elsewhere where 21% of the female participants experienced physical abuse by their partners for accessing and using contraceptives (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a).

Despite a few citing disapprovals from their partners regarding contraceptive use, most of the respondents highlighted that their partners were supportive of their choice of contraceptives and family planning services. Similar findings have been reported elsewhere (Wondim et al., 2020). Arguably, this could indicate that cultural dynamics are changing and this lays strong support for family planning programmes aimed at engaging men as key stakeholders (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a; Msovela et al., 2022; Sarnak et al., 2021). However, misconceptions about family planning services which are largely driven by cultural beliefs are common and can influence the uptake of contraception among women(Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a; Truong et al., 2020). In the current study, most women cited various misconceptions about contraceptives which contributed to the low uptake of family planning services. Therefore, providing accurate and appropriate information during family planning counselling is essential in ensuring improved knowledge about contraception among women (Msovela et al., 2022; Sarnak et al., 2021).

Improving knowledge of contraception through the provision of accurate and appropriate family planning information by health workers is key to addressing many misconceptions associated with contraception use (Mulatu et al., 2022). In exploring institutional-level factors influencing contraceptive choice and utilisation, participants recounted undesirable attitudes by health workers and how they had received insufficient information and guidance on contraception use. Similar findings have been reported elsewhere (Ackerson & Zielinski, 2017; Dioubaté et al., 2021; Ouma et al., 2022; Truong et al., 2020). This can be due to healthcare providers’ lack of understanding of the reproductive health needs of women (Hlongwa et al., 2022), healthcare providers not well trained in family planning services (Ahanonu , 2014), and challenges in institutional staffing levels (Bailey et al., 2022). Our findings provide evidence of the need for a multilevel approach to addressing institutional barriers to contraception uptake among women. We posit that healthcare providers should be equipped with necessary family planning information through appropriate training, this is critical in improving their attitudes and understanding of family planning services (Msovela et al., 2022). Contraception use also depends upon their availability and accessibility, however, in most LMICs the scarcity of healthcare facilities and long distances to family planning clinics in rural areas influence women’s utilisation of family planning services (Bailey et al., 2022). Also, most clinics in LMICs may not offer contraception other than condoms, a situation that deprives women of their preferred choice of contraception (Ackerson & Zielinski, 2017). Although we did not receive insights from our participants on structural- level factors that influence contraception utilisation among women. Studies elsewhere have highlighted structural- level factors such as the age restriction on contraception use especially among young female adolescents (Bailey et al., 2022), and the cost of contraceptives in some areas where they are not provided for free (Blackstone et al., 2017), lack of access to employment and poverty (Ackerson & Zielinski, 2017).

Male partners who are knowledgeable about the role of contraceptives and possible side effects are more likely to approve of their partner’s choice of contraceptives (Nkwonta & Messias, 2019). This can be crucial in the elimination of community-related stigma regarding male involvement in family planning services (Kriel, Milford, Cordero, Suleman, Beksinska, Steyn, Smit et al., 2019a) because most men see contraception to be a woman’s responsibility (Bailey et al., 2022). In addition, male partner approval and disapproval of contraceptives reflect strong gender dynamics which are driven by societal norms and cultural values. These values form community-level barriers to the utilisation of contraception among women. In our study, most respondents’ views were governed by strong cultural norms which empower male partners and disallow women from making independent decisions. The interplay of these societal values produces gender disparities and inequalities that make women more vulnerable to their male partners in their sexual and reproductive health (Agyekum et al., 2022). Our findings suggest the need for family planning counselling that addresses various gender dynamics which influence contraception uptake. Also, family planning programmes should enhance linkages between health centres and communities and should engage men as key stakeholders (Dral et al., 2018).

6. Conclusion

A socio-ecological framework provides an ecological perspective to understanding an interplay of multilevel factors that influence women’s choices and utilisation of family planning services. Whilst most family planning interventions have focused on women’s individual factors that influence contraception use, factors such as health care providers attitudes, expectation of partners, peers, family, and wider society have significant influence on women’s choices and utilisation of contraception. Therefore, family planning interventions that focus on multiple social levels are needed to address these influencing factors.

Data availability

Data is available upon request.

Acknowledgements

We wish to acknowledge the invaluable support received from the Copperbelt University, School of Medicine. We would also like to extend our appreciation to the management at the two health facilities in Mufulira district, Zambia.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported that there is no funding associated with the work featured in this article.