Current Research in Public Health
Article | Open Access | 10.31586/crph.2022.299

Pooled prevalence and contextual determinants of contraceptive utilization among reproductive-age women in The Gambia: Evidence from 2013 – 2020 Demographic Health Surveys

Amadou Barrow1,*, Afape Ayobami2 and Erin M. Reynolds3
1
Department of Public & Environmental Health, School of Medicine & Allied Health Sciences, University of The Gambia, Kanifing, The Gambia
2
Kaduna State AIDS Control Agency, Ministry of Health and Human Services, Kaduna State, Nigeria
3
Health Services, University of Southern Indiana, Evansville, Indiana, USA

Abstract

Background: Family planning (FP) methods have been found as an efficient approach of reducing fertility and are therefore widely supported in order to decrease population growth, particularly in poor nations. Promoting contraception availability among women (15 – 49) age has also been shown to be an efficient public health strategy for improving maternal and newborn health outcomes. This paper aimed at exploring the pooled prevalence of contraceptive uptake and its contextual determinants among women of childbearing age in The Gambia. Methods: The Gambia Demographic and Health Survey (GDHS) in both 2013 and 2019-20 was used for this study. Data were obtained from a pooled 22,098 women aged 15-49 (10,233 for 2013 and 11,865 for 2019-20) through a stratified two-stage cluster sampling approach. Percentages and chi-square tests were used and variables with p-value <0.05 were included into the model. A multivariable logistic regression model was used to assess the predictors of contraceptive usage at 95% confidence interval (CIs) with computed adjusted odds ratios (aORs). All the study data were analyzed using Stata version 15. Results: The weighted pooled prevalence of modern contraceptive utilization in The Gambia was 10.1%. Younger age, compared with women aged 25-29; 30-34; 35-39; 40-44; primary education (aOR=1.25, 95% CI=1.05-1.49); secondary education (aOR=1.57, 95% CI= 1.32-1.85); Higher education (aOR=1.90, 95% CI=1.34-12.69); living in urban areas (aOR=1.49, 95% CI= 1.25-1.79); parity 2-4 (aOR=1.21, 95% CI= 1.01-1.47); told about FP at health facility (aOR=2.97, 95% CI= 2.61-3.38), and no desire for many children (aOR=1.96, 95% CI= 1.62-2.37) were more like to use modern contraceptives among Gambian women. Conclusion: The programme certainly needs to consider improvements in the quality of care being offered to acceptors. Government agencies should target these programs and campaigns on regional FP demands and provide suitable culturally sensitive and regionally adaptive services to the communities' contexts. The programme should intensify its efforts in rural and urban settings to improve accessibility to and availability of FP services.

1. Introduction

Family planning (FP) methods have been found as an efficient approach to reducing fertility and are therefore widely supported to decrease population growth, particularly in poor nations [1]. Promoting contraception availability among women of reproductive age has also been shown to be an effective public health strategy for improving maternal and newborn health outcomes [2]. Numerous studies demonstrate that increasing contraceptive use directly reduces maternal deaths by decreasing unexpected pregnancies, adolescent pregnancies, unsafe abortions, and high-risk pregnancies, as well as allowing for pregnancies to be spaced out [1, 2, 3]. The risks of morbidity and mortality associated with unsafe abortions are significant for women of all ages in most underdeveloped countries [4]. By preventing unplanned pregnancies, FP has numerous health benefits [5, 6, 7]. These benefits include decreased human immunodeficiency virus (HIV) transmission to newborns [8], decreased maternal mortality and morbidity [9], decreased neonatal, infant, and child mortality [10, 11], more significant employment and educational options for women (and men) who can postpone childbearing, and decreasing reliance on often dangerous abortion [9]. Certain contraceptives, such as condom use, have been hailed for their role in reducing sexually transmitted infections (STIs), including HIV/AIDS [1].

There are approximately 1.9 billion women of childbearing age (15-49 years) on the planet in 2019 [12]. 1.1 billion people worldwide require FP; 842 million of these utilize contraception now, whereas unmet contraceptive needs affect 270 million people [12, 13]. Globally, the current estimated amount of FP required to meet Sustainable Development Goal (SDG) indicator 3.7.1 was 75.7% in 2019 [12]. FP services are also critical to reaching SDG number five, which calls for gender equality as well as women and girl empowerment [12]. Nonetheless, fewer than half of the demand for FP in Africa's middle belt was supplied [12]. This demonstrates their inability to make the essential choices to avoid and prevent undesired pregnancies [14]. Unintended pregnancy is one of the outcomes of this unfulfilled demand [15]. In general, 39 per 1000 women aged 15-49 receive induced abortion out of the 73.3 million abortions performed each year [16]. Around three in ten pregnancies and six in ten unwanted pregnancies resulted in an induced abortion, whereas more than seven in ten are considered unsafe and happened in Africa [16]. As a result, Africa has the highest risk of dying from unsafe abortion [4].

Recently, The Gambia's National Indicators for FP satisfaction with modern contraception were 37.6% in 2017 [17] and 43.9% in 2019 [18], with rural areas reporting 40.3% satisfaction with FP and a cumulative marginal difference of 5.2% lower than urban areas [18]. At the Local Government Area (LGA) level, Basse (22.5%), Mansakonko (37.9%), and Kuntaur (39.9%) satisfied the least FP demands, which is slightly more than the 2015 and 2017 numbers []. Additionally, these LGAs have the lowest uptake of FP services in the country [20]. In The Gambia, rural women have a somewhat higher unmet demand for FP (25%) than urban women (24%) [18]. At the LGA level, Basse has the largest unmet requirement for FP (30%) while Janjanbureh has the lowest (18%) [18]. Regional variation in The Gambia may be explained by a variety of socioeconomic and cultural characteristics, including religion, ethnicity, cultural traditions, patriarchal cultures in nature, female education, and FP delivery modalities [20, 21]. The Gambia has a total fertility rate (TFR) of 4.8, a general fertility rate (GFR) of 149 per 1000 women between the ages 15-49, a maternal mortality ratio of 289 (confidence interval: 204-375), and a pregnancy-related mortality ratio of 320 (CI: 231-409) per 100,000 live births, with minor differences in rural regions [18]. Only 18.9% of married women use any method of contraception, compared to 17.1% who use modern techniques and 1.8% who utilize traditional methods [18]. Contraceptive use is still relatively infrequent in The Gambia [17, 18, 20, 21].

Generally, there have not been studies on prevalence and determinants of contraceptive use that focus on combining both 2013 and 2019/20 DHS surveys across women in The Gambia. Thus, this paper aimed at exploring the contextual determinants of pooled prevalence of modern contraceptive usage among women of reproductive age in The Gambia.

2. Methods

2.1. Data source

Data from the Gambia Demographic and Health Survey (GDHS) in 2013 and 2019-20 were used for the analysis, a stratified two-stage cluster sampling approach was used to create a population-based sample. Following the probability proportional to the size of the Enumerated Areas (EAs), 281 clusters/EAs were selected in the first stage of both surveys. The second stage involved a methodical selection of 25 households from each cluster/EA. In 2013 and 2019-20, from 281 households 11,279 and 12,481 women aged 15–49 were initially sampled, however, only 10,233 and 11,865 of them were interviewed successfully from 2013 and 2019-20 respectively. This resulted in 91% and 95% response rates which were taken into account for detailed analysis. Interviews with women aged 15 to 49 years old were used to collect data for the study. In The Gambia, through the USAID-funded MEASURE DHS programme, ICF International provided technical and financial assistance to the Ministry of Health in collaboration with the Gambia Bureau of Statistics (GBoS) who implemented the survey.

2.2. Variable selection and measurement

Outcome variables. The study outcome variable was contraceptive use among sexually active women (aged 15-49) excluding pregnant women. This variable was derived from the question “current contraceptive use by method type” in the dataset, the four responses were: “no method”, “folkloric method”, “traditional method”, “modern method”. Contraceptive use was recoded into “No contraception =0” for those who do not use any method, “Traditional =1” for those using folkloric and traditional methods and “Modern=2” for those using modern contraceptives.

Explanatory variables. Twenty independent variables were utilized in the study based on a thorough literature review and datasets availability; the variables are listed in Table 1.

2.3. Statistical analysis

The authors conducted a descriptive analysis by calculating the proportion of women using contraceptives (either traditional or modern). The datasets were combined and we calculated women’s use of contraceptives by type based on their socio-demographic characteristics. The chi-square test was used to identify the association of modern contraceptive uptake with independent variables. Study variables with p-value <0.05 were included into the model. Lastly, we used multivariable logistic regression model to assess the predictors of contraceptive usage at 95% confidence interval (CIs) with computed adjusted odds ratios (aORs). All the study data were analyzed using IBM SPSS version 25.

2.4. Ethical approval

The datasets used in this research were population-based datasets that are freely available in the public domain. For reasons of confidentiality, specific characteristics that could be used to identify participants in the study were excluded. As a secondary study, MEASURE DHS/ICF International granted the authors permission to use the datasets. Also, prior to the survey, the DHS project gained ethical approval from the Gambia's Research Ethics Committee.

3. Results

3.1. Socio-demographic characteristics of reproductive-age women in The Gambia

As shown in Table 2, the mean age (±SD) of women using contraceptives was 32.0 (±7.6). Two-thirds (65%) are married, 44% have no formal education, and half of the women reside in urban areas. More than 97% practice Islam. Just over half of the women (54%) had their sexual debut before 18 years of age and more than 60% have had at least one child. Only 20% were told about FP in the health facility and only 13% do not have a desire for more children. Half of the women claimed to have joint decisions with their partner on contraceptive usage and only 11% of the women used contraceptives.

3.2. Utilization of contraceptives among Gambian women (GDHS 2013-2019/20)

Over the years, overall contraceptive use increased from 7.3% in 2013 to 14.1% in 2019/20, as shown in Figure 1.

Figure 1: Showing contraceptive use & non-use among women of childbearing change in the Gambia (2013-2019/20)

As shown in Table 3, adolescents (15-19) and younger women (20-24) had lower contraceptive use of 1.3% & 7.8%, respectively, compared with women aged 30-34 and 35-39 with contraceptive use of 18.2% & 18.6%, respectively. Contraceptive use was 14.8% among married women, 13.0% among women with a higher level of education and 12.6% of these women live in urban areas. It was noted that 9.4% of them were in the middle wealth quintile. Contraceptive peaked among those at parity above 5 (19.3%) and those told about family planning at the health facility (31.6%). It was observed that 15.8% of those using contraceptives heard about family planning on the TV while 13.0% heard about family planning on the radio. Also, contraceptive use was high (22.7%) among women who don’t desire more children and 19.8% of those who used contraceptives are covered by health insurance.

3.3. Determinants of contraceptive uptake among Gambian reproductive-age women (GDHS 2013 -2019/20)

Predictors of modern contraceptive uptake on pooled data 2013-2019/20

Based on the result from pooled data as shown in Table 4, age was associated with modern contraceptive use, as women aged 25-29 (AOR=1.67, 95% CI= 1.14-2.45), 30-34 (aOR=2.12, 95% CI= 1.41-3.21), 35-39 (aOR=1.91, 95% CI= 1.23-2.94) and 40-44 (aOR=1.89, 95% CI= 1.18-3.05) had higher odds of using modern methods of contraception compared to women less than 24 years old. Furthermore, women living in the urban area had higher odds (aOR=1.49, 95% CI= 1.25-1.79) of using modern contraceptive methods than rural dwellers. Educated women had increased likelihood of using modern contraceptives method compared to women with no formal education. Those at parity two to four had increased odds of using modern contraceptives than those with less than two parities (aOR=1.21, 95% CI= 1.01-1.47). Those told about family planning at the health facility had a higher odds of using modern contraceptives (aOR=2.97, 95% CI= 2.61-3.38). Women who had no future plans for more children had increased likelihood of using modern contraceptives (aOR=1.96, 95% CI= 1.62-2.37) than women with plans for more children.

Predictors of modern contraceptive uptake for GDHS 2019/20 only

Table 4 shows the logistic regression results on the factors associated with modern contraceptives used among Gambia women. In the adjusted model, age was associated with modern contraceptive use, as women aged 30-34 had higher odds (aOR=1.84, 95% CI= 1.13-2.98) of using modern methods of contraception compared to women less than 29 years old. Furthermore, women with secondary education had increased odds (aOR=1.27, 95% CI= 1.04-1.56) of using modern contraceptive methods than those without education. Those told about family planning at the health facility had a higher odds of using modern contraceptives (aOR=2.31, 95% CI= 1.98-2.69). Women who are married or living with their partner had higher odds (aOR=1.23, 95% CI= 1.06-1.44) of using modern contraceptives than unmarried women. Women who had no future plans for more children had increased odds of using modern contraceptives (aOR=2.11, 95% CI= 1.68-2.66) compared to women with future plans for more children. Finally, women who delivered in government facilities had higher odds (aOR=1.31, 95% CI= 1.06-1.63).

4. Discussion

The paper explore the aggregated prevalence of modern contraception use in The Gambia from the 2013 GDHS to the 2019/20 GDHS, to ascertain the contextual determinants of its utilization in order to help in informing policies and intervention prioritization across the country. In the logistic regression analysis, women’s age, place of residence, education, parity, household wealth index, having been told about FP at health facilities, desire for more children, work status, and place of delivery were significant determinants of modern contraceptive utilization in The Gambia. This result will assist practitioners and authorities in designing successful ways to increase maternal health service utilization, including contraceptives, especially modern FP methods.

The pooled prevalence of modern contraceptive utilization in The Gambia was 10.1%. Our study showed lower contraceptive uptake which is smaller than previous studies done in The Gambia [20, 21]. The low uptake of modern contraceptives might be due to their health-seeking behavior, higher education status, an obvious source of information, less negative cultural influence towards FP services, and availability of health facilities including hospitals [22, 23]. In The Gambia, modern contraceptives were not widely used. One probable explanation is that cultural and behavioral factors are the primary impediments to contraceptive use among women [24].

The mean age of maternal women was similar to studies done in The Gambia [20, 25] and Nigeria [26, 27]. A more significant proportion of the women were in their prime reproductive years, and contraceptive utilization increased as their age advanced. It was also asserted that as a woman's age progresses, she would achieve the desired family size [28]. Thus, younger women are bound to experience a higher risk of overall unmet need for FP [29]. More than three-fourths of women had up to secondary education levels and are in contrast with a study done in Osun State, Nigeria on a lower side [30]. There are observed high parities across regions of The Gambia, which could be explained as a result of the Islamic faith being the predominant religion in The Gambia. In addition, rivalry and competition in most polygamous settings might also influence high parity seen as each woman would want to outnumber her counterpart regarding the number of living children she has, the woman’s ability to bear children is seen as a stabilizing influence on her marriage and in some Gambian culture, men have to prove their virility by the number of children they have. Male child preference for the families is also a significant determinant for high parity, although it is beyond the focus of this research. Some related studies in the Gambia looks into parental choice regarding son preference [20, 21] and Nigeria, where more women were married [27, 31].

The study revealed that urban settings utilized modern contraceptives more than rural dwellers. These could be attributed to cultural and religious variations as rural communities are culturally disinclined as compared to urban areas [21]. Furthermore, women having been told about FP by health workers at health facilities increases their tendencies toward utilizing modern contraceptives. As part these were shown in this paper, additional barriers such as fear of side effects, male son preference, and cost have been identified as barriers to the use of FP services for poor, rural women in previous studies [20, 21]. In other research, the most common reasons for not using contraceptives were the husband/partner's resistance and the fear of negative effects [21, 32, 33]. Male decision making on women’s uptake of contraceptives further justifies the significant role of male involvement and spousal communication, especially in rural settings, regarding the unmet need for FP. However, some studies in SSA have found that use of contraception increases if a woman has previously discussed contraception, been exposed to mass media about FP, or approves of FP [25, 34, 35]. However, this study also shows that the women desire not having many children increases their chances of using modern contraceptives. As a result, despite their wish to limit and space childbirths, women are likely to give birth to additional children since they do not use contraception. Thus, a society that encourages high investment levels per child is essential for receptivity to ideas about family size determination [36].

Strengths and limitations

We employed a nationally representative dataset, ensuring that the study's results can be generalized to Gambia's women of reproductive age. In addition, due to the large sample size, extensive reporting of modern contraception prevalence was possible. However, the studies used cross-sectional data, implying that no causal relationships were determined.

Conclusion

The utilization of modern contraceptives was very low across age groups, rural areas, low/no formal education, low parity, and those with a desire to have more children. The program must consider improvements in the quality of care provided to acceptors. Also, community leaders should be more actively involved in the MCH programme. Government agencies should target these programs and campaigns on regional FP demands and provide suitable culturally sensitive and regionally adaptive services to the communities' contexts. The programme should intensify its efforts in rural and urban settings to improve accessibility to and availability of FP services. Future studies should look into the healthcare systems and service-related factors that prevent women in the Gambia from using modern contraceptives.

Declarations

Acknowledgement

The authors thank the MEASURE DHS project for their support and for free access to the original data.

Funding

The authors have no support or funding to report.

Availability of data and materials

Data for this study were sourced from Demographic and Health surveys (DHS) and available here: https://www.dhsprogram.com/data/available-datasets.cfm

Authors’ contributions

AB & AA conceptualized the study and prepared the study design, reviewed literature, analysis of data and wrote the results. AB, AA & EMR critically reviewed the manuscript for its intellectual content. AB had final responsibility to submit for publication.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Ethics approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and ethical standards are available at: .

Consent for publication

No consent to publish was needed for this study as we did not use any details, images or videos related to individual participants. In addition, data used is available in the public domain.

Reference

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How to Cite

Barrow, A., Ayobami, A., & Reynolds, E. M. (2022). Pooled prevalence and contextual determinants of contraceptive utilization among reproductive-age women in The Gambia: Evidence from 2013 – 2020 Demographic Health Surveys. Current Research in Public Health, 2(1), 1–14. Retrieved from https://www.scipublications.com/journal/index.php/crph/article/view/299
  1. WHO (2019) Contraception: Evidence brief. 1–4
  2. Ahmed S, Li Q, Liu L, Tsui AO (2012) Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet 380:111–125[CrossRef]
  3. Beson P, Appiah R, Adomah-Afari A (2018) Modern contraceptive use among reproductive-aged women in Ghana: prevalence, predictors, and policy implications. BMC Womens Health 18:157[CrossRef] [PubMed]
  4. Ganatra B, Gerdts C, Rossier C, et al (2017) Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet 390:2372–2381[CrossRef]
  5. Cates W (2010) Family Planning: The essential link to achieving all eight Millennium Development Goals. Contraception 81:460–[CrossRef] [PubMed]
  6. Singh S, Darroch JE (2012) Adding It Up: Costs and Benefits of Contraceptive Services Estimates for 2012. Guttmacher Inst U N Popul Fund UNFPA 201 1–28
  7. Tsui AO, McDonald-Mosley R, Burke AE (2010) Family planning and the burden of unintended pregnancies. Epidemiol Rev 32:152–174[CrossRef] [PubMed]
  8. Reynolds HW, Janowitz B, Wilcher R, Cates W (2008) Contraception to prevent HIV-positive births: current contribution and potential cost savings in PEPFAR countries. Sex Transm Infect 84:49–53[CrossRef] [PubMed]
  9. Singh S, Darroch JE, Ashford LS, Vlassoff M (2009) Adding it Up: The Costs and Benefits of Investing in Family Planning and Maternal and Newborn Health. Guttmacher Inst U N Popul Fund UNFPA 6–31
  10. Rutstein SO (2005) Effects of preceding birth intervals on neonatal, infant and under-five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. Int J Gynaecol Obstet 89:7–24[CrossRef] [PubMed]
  11. Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A (2012) Contraception and health. Lancet 380:149–56[CrossRef]
  12. Kantorová V, Wheldon MC, Ueffing P, Dasgupta ANZ (2020) Estimating progress towards meeting women’s contraceptive needs in 185 countries: A Bayesian hierarchical modelling study. PLOS Med 17:e1003026[CrossRef] [PubMed]
  13. United Nations (2019) Family Planning and the 2030 Agenda for Sustainable Development Data Booklet.
  14. Malwenna LI, Jayawardana PL, Balasuriya A (2012) Effectiveness of a community based health educational intervention in reducing unmet for modern methods of family planning among ever married reproductive age women in the Kalutara district Siri Lanka. Int J Collab Res Intern Med Public Health 4:1097–1114
  15. World Health Organization (WHO) (2011) Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries: A Practical Guide. In: Dep. Reprod. Health Res. World Health Organ. pp 2–19
  16. Bearak J, Popinchalk A, Ganatra B, Moller A-B, Tunçalp Ö, Beavin C, Kwok L, Alkema L (2020) Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019. Lancet Glob Health 8:e1152–e1161[CrossRef]
  17. Gambia Bureau of Statistics (2019) The Gambia Multiple Indicator Cluster Survey 2018, Survey Findings Report. Banjul, The Gambia.
  18. Gambia Bureau of Statistics and ICF (2021) The Gambia Demographic and Health Survey 2019-20. Banjul, The Gambia and Rockville, Maryland, USA: GBoS and ICF.
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