Prevalence and determinants of unmet family planning needs among women of childbearing age in The Gambia: analysis of nationally representative data

Introduction

Globally, data on unmet needs for family planning (FP) has become a useful tool for the measurement and prediction of contraceptive use, and the needs of a given population. Although, awareness and access to FP services has improved in recent years, unmet need for FP remains high, particularly in low-income countries¹. At the global level, 885 million women of reproductive age in developing nations do not want to be pregnant at a particular time, while 214 million of them have an unmet need for FP methods, which accounted for 84% of all unplanned pregnancies in 2017^2,3. This implies that they have no desire for pregnancy and no access to any FP methods². In developing countries, there are a high proportion of persons that want to use FP commodities but are not able due to lack of access to modern and up-to-date contraceptive methods^4,5. Sub-Saharan Africa (SSA) contributes enormously to the proportion of this FP need among women, with more than 24% in 2015 compared to the global average (25% to 40%)^1,6. Inaccessibility to FP services and low awareness levels contribute to high unmet needs for FP in SSA⁷. It is estimated that there are up to 21 million births which were not planned, 26 million abortions, and 7 million miscarriages not to mention 79,000 and 1.1 million maternal and child deaths respectively, which could be prevented if unmet needs for FP are attended to by FP programs⁴. Between 2017 and 2030, there is an expected surge in the frequency of FP utilization among women in parts of SSA, including West Africa, from 20% to 29%¹. Globally, SSA accounted for 65% of FP needs for spacing, whereas other continents such as Latin America accounted for only 42%⁸.

Regarding population growth, The Gambia is considered to be among the highest in the sub-region, which can be attributed mainly to low contraceptive utilization with attended high unmet need for FP, with the fertility rate that relatively remains unchanged from 1960 to 2015⁹. The Government of the Gambia aim to reduce the maternal mortality rate from 433/100,000 in 2013 to 315/100,000 and increase the contraceptive prevalence rate from 9% in 2013 to 25% by 2021¹⁰. Despite the extensive reproductive health programmes, the unmet need for FP in The Gambia is projected at 26.5%, with 6.2% of women not using contraception since they want to cease further childbearing (limiting childbearing) and 20.3% who want to postpone the next birth at least two more years (spacing childbearing) with demand for FP satisfied with modern methods at 33.9%¹¹. There is a high annual population growth rate of 3.3% and a maternal mortality ratio of 433 per 100,000 live births in the Gambia, compared to the 2016 global estimate of 385 deaths to 216 deaths per 100,000 live births^12,13. At the national level, the total fertility rate prior to the survey was 4.4: 5.8 in rural areas, and 3.8 in urban areas¹¹. The rural areas recorded higher age-specific fertility rates during their childbearing years. The general fertility rate for women aged 15–49 years is 140 births per 1,000, while the crude birth rate is 33 births per 1,000 population¹¹.

There is a close relationship between population growth and FP. The majority of countries use FP to balance population growth with economic growth. In order to reduce the rate of unmet needs among women of childbearing age in the West African sub-region, there is a need for a proper understanding of various factors associated with unmet needs. Considering the limited available literature on this phenomenon, some identified determinants were majorly focusing on factors operating at individual and household levels. These have systematically taken away attention from the community factors instead of an integrated approach for better outcomes.

However, the lack of empirical research evidence is required to explain the current unprecedented population-based reproductive health challenges. This phenomenon resulted in examining the predictors of unmet need among reproductive-age women in The Gambia. To date, little attention has been paid to understanding the nexus of unmet need for FP in the Gambia, especially among low-income urban residents⁵. However, there is limited research that has explored the undercurrents of unmet needs for the FP concentrating on community-level issues and the incorporation of individuals, households, and communities in The Gambia. Therefore, the paper attempts to examine the prevalence and determinants of unmet FP needs among reproductive-age women in The Gambia.

Methods

Results

Discussion

In this paper, we examined the prevalence and determinants of unmet FP needs in women who were within the age of reproduction in The Gambia. The prevalence of unmet FP needs was 17.6,% with 14.0% for spacing and 3.6% for limiting the number of live births. The results revealed that the age of women, region, ethnicity, number of living children, number of household members, ideal parity, and husband/partners’ desire for more children were significant determinants of unmet FP needs. The most significant reason given by the women who had unmet needs as the barrier to the use of contraceptive methods was breastfeeding. We observed very low unmet need among women who were within the age bracket of 15–24 years, with peak in women in their late 20s to early 30s, and a decline was observed among those in their 40s. This indicates that there is a lower likelihood of unmet need among the studied female population as their age increases. That may be due to the fact that older women must have been in a marriage for a longer period than the younger women and therefore, may have gained experience in contraceptive use. This may have been a contributory factor to the reduction in the unmet observed among Gambian women. This result is in accordance with published studies from Myanmar²⁰ and Bangladesh²¹.

However, the results are in contrast to the study conducted in Mumbai²² on the prevalence of unmet need for FP, which showed a rate of 40.6%, while in Nigeria, Okonofua²³ reported that the prevalence was less than 20%. Several studies such as The Gambia MICS report 2010²⁴ (22%), (18.7%) for South India²⁵, and (22.1%) in Nagpur²⁶ were found to be slightly higher than the reported prevalence for this study. However, the findings of this study were slightly lower than The Gambia DHS 2013 for overall unmet need for FP which was 24.9%. Furthermore, the unmet need prevalence as well as birth spacing and limiting as observed in this study were found to be slightly higher than that reported from an Ethiopia study in 2016. That study showed that the unmet need for FP prevalence was 16.2%, with 10.2% and 6.0% for child spacing and birth limiting unmet needs, respectively²⁷. These disparities could be attributed to cultural and religious variations, as well as the nature of the health systems in individual countries for the delivery of FP services. The fear of adverse effects, child sex preference and religious prohibitions were among the major deterrents for FP uptake in these studies.

The findings of this study show that urban women had a lower unmet need relative to those in the rural settings of The Gambia we attributed this to the availability of better healthcare services which supposedly is more available and accessible in urban settings than rural areas. Moreso, urban settings in the Gambia are assumed to have better facilities for health care services, and are more exposed in terms of access to information and education (in terms of adequate availability of various mass media services/programs), and the current trend in global health issues. Women from urban areas, as opposed to those from rural areas, could be more progressive and may have more autonomy to be independent in reproductive health decision making and utilization²⁸. Improved FP education and the systematic empowerment of rural women could lead to a reduction in the rate of unmet need in the rural parts of the Gambia.

The results of this study show that the educational status of the studied women is positively associated with a reduction in unmet need in The Gambia. Other studies have revealed a similar pattern of improved FP use and maternal health service utilization in better-educated women^28,29. Women with higher levels of education could enable them to better understand the need for FP in reducing fertility, related maternal and child morbidities, and mortalities. The sum of births or living children among the studied women is a predictor of the prevalence of contraception in The Gambia. This study revealed that the increase in the number of living children among the studied women brings about a decrease in unmet need for FP, which was also seen in studies conducted in Ghana³⁰, Uganda²⁸, and Burkina Faso³¹. Higher parity women may have gained more experience on the probable adverse effects of FP methods either by consulting service providers or reading different publications about the side effect of contraceptive methods which increased their consistent use.

The reported prevalence for unmet need for FP in this paper is slightly below 25%, as compared to DHS 2013 cumulative percentage^12,24,32 which could be due to slight variation in the estimation methods used (reproductive-age group versus married women)³³. Currently working and pregnant women had higher levels of unmet need for FP, which supported our initial postulation that unmet need for FP would be higher among women with a higher number of living children, and those that are unsure about their pregnancy status, as several studies^34–37 have revealed. As a result of the socio-cultural settings, these women lives in, they could not decide on their own to prevent further pregnancies^38,39. In this study, almost one in five women in the rural areas that were in a marriage experienced an unmet FP need. This further suggests that the issue of unmet needs is still a huge problem and therefore requires urgent action from all concerned agencies.

The study findings are reminiscent of the assumption that the multidimensional nature of unmet need may not have any association with the infrastructural variances across quarters and regions, rather it may be as a result variation in women age, regional differences, educational level, women working status, marital status and number of children living, number of household members, the ideal sum of children and partners’ desire for children across these settings. The authors have also acknowledged that the observed associations in unmet need and selected explanatory variables in this study may actually be dependent on the context and therefore may change when other outcome variables are manipulated. Since secondary data was used for this study, authors did not have control over them, there may be limitations to the intended analysis and therefore cannot change the original questions the researchers would want to answer. Another major limitation is reporting bias because most of the variables used are based on recall from the respondents.

Policy implications

Firstly, since uneducated women were found to be at higher risk of experiencing an unmet need for FP, there should be a continuous increase in the level of education which ultimately increases the chances of women using contraceptive methods. Therefore, the promotion of female education across primary, secondary, and tertiary levels should be institutionalized. Effective formulation of robust reproductive health policy with a clear strategy for its successful implementation among women (15–34 years) of age is highly required.

Secondly, the uptake of FP is very low among Mandinka and Wollof peoples, especially those from the rural areas of The Gambia. This could be as a result of fear of side effects, fertility preference, and partner desires for children. Therefore, the government together with development partners should provide adequate, timely, and reliable information to these women across the country. Thus, improving the skills and competence of service providers will enhance the consumption level of FP commodities in the Gambia.

Thirdly, spousal communication should be strengthened as both partners’ desire for children, the number of living children and the ideal number of children were found to be significant predictors of unmet need for FP in The Gambia. Advocacy for male involvement through raising their awareness of the benefits associated with various contraceptive methods should be prioritized and intensified.

Conclusion

The study revealed that about one in five women experiences an unmet FP needs in rural areas in The Gambia, largely due to selected adverse socio-demographic and related characteristics. The prevalence of unmet FP needs in The Gambia is still very high (17.6%) and there are more unmet spacing needs (14.0%) than limited (3.6%). Thus, some determinants of unmet FP need, such as women’s age, region, ethnicity, living children, number of household members, the ideal number of children and partner’s desire for children and effective community-based FP interventions, should be designed to reinforce the existing provision in order to spread to a larger amount of females^38,40. Breastfeeding was found to be the foremost cause of non-use of contraceptives across women with an unmet need for FP. The study findings suggest the need to expand FP programs and related strategic communications especially for younger women, including those in their late 20s and early 30s in order to improve their contraceptive prevalence. Improving women’s access to FP and the empowerment of women will help to lessen the current trend towards rising unmet need in The Gambia.

Data availability