“As a woman who watches how my family is… I take the difficult decisions”: a qualitative study on integrated family planning and childhood immunisation services in five African countries

Hoyt, Jenna; Krishnaratne, Shari; Hamon, Jessie K.; Boudarène, Lydia; Chantler, Tracey; Demissie, Shiferaw Dechasa; Landegger, Justine; Moseti, Easterlina; Marcus, Seth; Kambanje, Misozi; Pryor, Shannon; Spilotros, Nathaly; Gnintoungbe, Marius; Curry, Dora; Webster, Jayne

doi:10.1186/s12978-021-01091-1

Cited by 8 publications

(6 citation statements)

References 31 publications

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“…Evidence demonstrating fear of side effects and its role as a barrier to MCM uptake is common in the literature. Studies from India, Nepal, Nigeria, Uganda and the Philippines all show that fear of side effects can be a major barrier to MCM uptake 40–43. Studies that have assessed community myths about MCMs and how they lead to fears about side effects and resistance to MCMs have suggested that social norms play a large role in influencing individual-level choices about MCM use.…”

Section: Discussionmentioning

confidence: 99%

Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points

et al. 2022

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ObjectivesThis study sought to understand, during an intervention which integrated family planning (FP) and immunisation, (1) if and how prevailing contextual factors influenced acceptability and use of modern contraceptive methods (MCMs) in a pastoral community in Uganda, (2) what mechanisms were triggered by these contextual factors (3) if these contextual factors changed between two time points 2 years apart and (4) the impact of contextual changes on mechanisms triggered and acceptability and use outcomes.DesignQualitative realist evaluation over two time points.SettingGovernment health facilities in Moroto District, Karamoja, Uganda.Participants69 participants involved in the delivery and uptake of integrated FP and childhood immunisation services.InterventionIntegrated delivery of FP and childhood immunisation services offered to women accessing immunisation services in health facilities between January 2016 and December 2019.ResultsFour key themes were identified that encompassed context and mechanisms influencing acceptability of MCMs across both time points of the evaluation. These were: (1) fear of side effects of MCMs; (2) preference for natural FP methods; (3) pastoral lifestyles in the community and (4) food insecurity. The context of these themes changed over time leading to the triggering of mechanisms with an overall increase in acceptability of MCMs over time. Key mechanisms of acceptability triggered included: affective attitude, intervention coherence, self-efficacy, perceived effectiveness and opportunity cost, leading to the development of three context-acceptability theories.ConclusionsIn this study, social and cultural norms played a strong role in influencing acceptability of the intervention. The context combined with intervention components were found to trigger several mechanisms that mapped to constructs of diffusion of innovations and acted as catalysts for mechanisms of acceptability. The context in which the intervention was implemented changed leading to the triggering of mechanisms and an increase in the perceived value and acceptability of MCM use.

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Section: Discussionmentioning

confidence: 99%

Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points

et al. 2022

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“…These barriers have been widely described in the literature [ 2 , 32 ] and reflect the symptoms of patriarchal structures within which women make reproductive decisions [ 3 ]. In the context of SRH empowerment these external factors, combined with women’s internal motivations, shape fertility desires and ambitions [ 6 , 12 ]. Women engaged in CCU when they believed their fertility choices were not supported within their relationship.…”

Section: Discussionmentioning

confidence: 99%

“…Unequal gender-based power relations have emerged as a key constraint on woman’s reproductive health decision-making [ 3 ]. In particular, male reproductive preferences and disapproval of FP have been found to drive reproductive outcomes, including the use of modern contraceptive methods and family size [ 4 – 6 ]. To overcome these constraints, some women choose to engage in covert contraceptive use (CCU), that is contraceptive use without their husband’s knowledge.…”

Section: Introductionmentioning

confidence: 99%

“It was my own decision”: the transformational shift that influences a woman's decision to use contraceptives covertly

et al. 2022

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Background Family planning (FP) is an important element of sexual and reproductive health and rights, but socio-cultural barriers and unbalanced gender relations often limit women’s decision-making about contraceptive use. Covert contraceptive use (CCU) exemplifies the limits on women’s decision-making and represents a way in which some women overcome constraints to achieve their reproductive goals. This study explores the decision-making process through which women choose to use contraceptives covertly. Methods A qualitative synthesis was conducted using data from women, health providers, community members, health administrators, and intervention implementers (n = 400) to explore the decision-making process through which women choose to use contraceptives covertly. Interviews and focus group discussions were conducted at two time points as part of an evaluation of interventions integrating FP and childhood immunisation services at sites in Benin, Kenya, Malawi and Uganda. The sexual and reproductive health empowerment framework by Karp et al. (2020) was adapted and used to guide the analysis. Results Women recognised that although they suffered the negative consequences of frequent pregnancies and of raising large families, they lacked overt decision-making power over their fertility. Women were confident to engage in CCU because they believed their husbands did not understand these consequences nor acknowledged their suffering, which justified not informing them. CCU was a difficult choice however, women felt comfortable voicing their reproductive preferences in settings where health providers were supportive. Conclusions Women chose to use contraceptives covertly when they questioned the unfairness of their situation and recognised their own power to act in accordance with their reproductive preferences. This represented an important shift in a woman’s perception of who is entitled to make decisions about contraceptive use. Importantly, health providers can play a key role in supporting women’s autonomous decision making about contraceptive use and should be careful not to undermine women’s confidence.

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“…A few studies from Ethiopia also assessed FP integration with MCH services and reported on its effectiveness. Studies on the effect of FP integration with HIV care services reported improvement in FP uptake and declines in unmet need for FP among women of reproductive age group with HIV infection (13,14). A longitudinal study also demonstrated that FP counselling during postpartum and during child immunization period were associated with increased modern contraceptive uptake (15).…”

Section: Introductionmentioning

confidence: 98%

Family Planning Integration in Ethiopia’s Primary Health Care System: A qualitative study on opportunities, challenges and best practices

Titiyos,

Mehretie,

Alemayehu

et al. 2023

Preprint

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Background Family planning (FP) service integration into primary health care (PHC) is an effective approach to improve FP use, and maternal and child health outcomes. The Ethiopian government promotes integration of FP services into primary health care. However, there is paucity of evidence on the status of FP service integration. The aim of this study is to explore the state of FP integration into PHC services and identify facilitators and barriers to integration. Methods A qualitative study nested with a larger national study was conducted from July to October 2022. A total of 60 interviews were conducted with FP stakeholders including, government organizations, non-governmental organizations, donors, service providers, and clients. Interviews were audio recorded, transcribed, and coded using OpenCode 4.03. The coded data were analyzed using framework analysis approach, using the Primary Health Care Performance Initiative (PHCPI) framework. Direct quotes and results from the coding and categorization were used to develop the report. Results Family planning is largely provided in designated units by dedicated staff within PHC facilities. The provision of integrated FP service within each service unit is in its early stage. Successful examples of integration include integration of FP with postnatal care, abortion care, and youth-friendly service centers. Facilitators of integration include commitment of the government and partners, the presence of policies and guidelines, and positive attitude of service providers and clients. However, integration of FP also faces challenges that are largely related to challenges of the FP program even before integration. These include resource shortage, health workers shortage, health workers’ capacity/skill gaps, misconceptions about FP, religious and socio-cultural norms, and lack of awareness. Conclusions Integration of FP with PHC services in the Ethiopian public health facilities is viable. Pre-existing challenges of the FP program continued to be barriers to integration. Expanding the experiences of good practices in the integration of FP with post abortion care, post-natal care, and youth-friendly service centers to other components of PHC warrants attention. Addressing both supply- and demand-side challenges of the FP program is needed to facilitate the integration of FP with other PHC services.

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“As a woman who watches how my family is… I take the difficult decisions”: a qualitative study on integrated family planning and childhood immunisation services in five African countries

Cited by 8 publications

References 31 publications

Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points

Acceptability of family planning in a changing context in Uganda: a realist evaluation at two time points

“It was my own decision”: the transformational shift that influences a woman's decision to use contraceptives covertly

Family Planning Integration in Ethiopia’s Primary Health Care System: A qualitative study on opportunities, challenges and best practices

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