THE EFFECTIVENESS OF FAMILY PLANNING METHODS USED AMONGST

COUPLES ATTENDING HARGEISA MCHs FAMILY PLANNING CLINICHARGEISA GROUP HOSPITAL

Scaling up family planning services is one of the most cost-effective interventions to
prevent maternal, infant, and child deaths globally. Family planning interventions aid
in lowering maternal, infant, and child mortality, contributing to the Millennium
Development Goals (MDGs) and the newly established Sustainable Development
Goals (SDGs). Through the reduction in the number of unintended pregnancies in a
country, it is estimated that one-quarter, to one-third, of all maternal deaths could be
prevented. Family planning is linked indirectly as a contributor to positive health
outcomes. For example, family planning interventions contribute to reducing poverty,
increasing gender equity, preventing the spread of HIV, reducing unwanted teenage
pregnancies, and lowering infant deaths (Carmma Campaign MOH, 2014)
additionally, each dollar spent on family planning initiatives on average results in a
$6.00 savings on health, housing, water, and other public (Performance Monitoring
and Accountability 2020.http://www.pma2020)
Lack of access to adolescent girls to family planning, including contraceptive
information, education, and services, is a major factor contributing to unwanted
teenage pregnancy and maternal death. In low and middle-income countries,
complications of pregnancy and childbirth are the leading causes of death amongst
adolescent girls ages 1519 (WHO, 2011)
Currently, more than 200 million women in developing countries desire to space or limit
pregnancies; however, they lack access to family planning options. Amongst women
of reproductive age in developing countries, 57 percent (867 million women) need
access to contraceptive methods because they are sexually active but do not want a
child in the next two years. Of these women, 645 million (74%) are using modern
methods of contraception; the remaining 222 million are not, resulting in the significant
unmet need for modern family planning methods (Darroch, and Lori Ashford, 2013).
The total fertility rate remains high for many of the countries in the region (4.6 in Kenya
and Rwanda, 5.4 for Tanzania, 6.2 for Uganda, and 6.4 for Somalia). Modern
contraceptive prevalence in the East African Region is generally low and with a wide
range of disparity (17.7% in Burundi to 45.1% in Rwanda).

The contraceptive prevalence rate is a product of many variables, including access to

information, education, and counselling; family planning commodity security; staff
availability; and skills and social and cultural factors. Efforts to improve access to
contraceptive information, particularly for adolescents and youth, and expand the
range of contraceptive choices need to be made.
Levels of unmet need for family planning are generally higher than contraceptive use
in most countries in Eastern Africa. In most Demographic and Health Survey (DHS)
reports, injectable and pills are the most popular methods, with low utilisation of
condoms, implants, and intrauterine devices (IUDs). Use of condoms and IUDs are
plagued by numerous myths and misconceptions both amongst health workers and
the general population. Major challenges with the provision of Family Planning services
in the region include an inadequate number of skilled providers and frequent stock-out
of contraceptive commodities within many facilities. (Eastern Africa Reproduction
Health Network Strategic, 2014)
Due to the countrys high fertility rate, Somaliland has one of the most youthful
populations in the world, with slightly more than half of its population under age 15. As
noted in the 2014 National Population Policy and Vision 2020, the high child
dependency ratio is a major barrier to social transformation and development in
Somaliland. A large average family size makes it difficult for families and the
government to make the requisite investments in education and health that are needed
to develop high-quality human capital and achieve a higher level of socioeconomic
development. (MDG, 2013) Family planning not only improves maternal and child
health and survival, but also increases the economic well-being of individuals, families,
communities, and nations and empowers women while promoting human rights for all
citizens. Strong national FP programmes also foster environmental sustainability
(UNFPA, 2014).

1.2 Statement Of The Problem

UNICEF remains the main organisation offering reproductive health services. The
policies and legislation of the Ugandan government have continued to promote family
planning services, including an action plan following the 2012 UN conference, a
reproductive health strategic plan for 2012-2015.
Despite these efforts, the indicators show little change in fertility rates or contraceptive
prevalence among the Somaliland population. The Unmet need in Somaliland is at
25.3%percent, with 21 percent in need of spacing and 14 percent in need of limiting.
This is a decrease from 41 percent in 2010. UBOS 2012 Poor access to quality family
planning services characterized by few skilled providers and inadequate commodities
that give the client little or no choice of methods of family planning and undermines the
ability of men and women to freely decide on the number and spacing of their children
contributes to high levels of unmet need in the country. It is from this background that
the researcher intends to examine the effectiveness of family planning methods used
among sexuality active couples through Hargeisa group hospital
1.3 Objectives Of The Study
1.3.1 General Objective
To examine the effectiveness of family planning methods used among sexually active
couples attending Family Planning Hargeisa Group Hospital.
1.3.2 Specific Objectives
i.

To examine the current family planning methods in Hargeisa hospital.

ii.

To find out the challenges affecting utilisation of family planning methods

iii.

To find out the factors for adoption of modern family planning

The study focused on establishing the effectiveness of family planning methods used
among sexually active men and women aged 15-49 years attending HGH Family
Planning Clinic-Hargeisa Group Hospital. The study established the current family
planning methods, and find out the level of effectiveness of family planning methods
and the recommendations to family planning methods.

2.1 Definition Of Family Planning

Family planning is the practice of spacing children that are born using both natural
(traditional) and modern (artificial) birth control methods. Birth spacing promotes the
health of the mother, children and the father (MOH, Mbonye et al 2011). Reproductive
health is the right of men and women to be informed and have access to safe, effective
affordable and acceptable method of FP of their choice. FP offers individuals and
couples the ability to anticipate and attain the desired number of children through
spacing and timing of their births. One of the guiding principles in the National
Population policy states that:
Recognition that all couples and individuals have the basic right to decide freely and
responsibly the number and the spacing of their children, and to have access to
information and education in order to make an informed choice and the means to do
so.
This is also in line with the Principle 8 which states that reproductive health-care
programmes should provide the widest range of services without any form of coercion.
All couples and individuals have the basic right to decide freely and responsibly the
number and spacing of their children and to have the information, education and
means to do so (Ministry of Finance, Planning, and Economic Development, 2013).
2.2 Current Family Planning Methods
The types of family planning can be broadly classified as natural and modern (artificial).
Modern family planning methods include the Hormonal contraception methods (oral
contraceptives, injectables and implants); the Intra-uterine device (IUD); barrier
methods (the male and female condom, spermicidal foam and jelly and foaming
tablets) and permanent methods (tubal litigation and vasectomy). The natural methods
include

standard

days

(Calendar

or

beads);

abstinence;

withdrawal;

and

LactationalAmenorrhoea (LAM). In order to ensure a method mix and to promote

informed choice, all FP methods are meant to be available throughout the country.

Some methods such as IUD, tubal litigation, vasectomy and implants require
authorization for use by a qualified health worker, while other methods such as pills,
injectables, condoms and counselling on periodic abstinence can be offered by trained
no skilled personnel (DHS, 2014)
An indication of the uptake levels for FP methods in Uganda is highlighted in the UDHS
(2015). All women who had ever heard of a method of family planning were asked
whether they had ever used that method. Men were only asked about ever use of male
methods, i.e., male sterilisation, male condom, rhythm method, and withdrawal. The
results show that just over half (52 percent) of currently married women have ever used
a contraceptive method, 42 percent have used a modern method, and 21 percent have
used a traditional method. The methods most commonly ever used by married women
are injectables (27 percent), male condoms (16 percent), pills (14 percent), and rhythm
(13 percent). Ever use of other methods does not exceed 10 percent. Ever use of any
method is highest among sexually active unmarried women, 75 percent of whom have
used a method at some time. Sexually active unmarried women are much more likely
(55 percent) to have used male condoms than either all women (18 percent) or
currently married women (16 percent).
Types Of Family Planning Pills & Their Uses:
There are two main types of pills; these are combined Oral Contraceptive Pills (COC's)
which contain oestrogen and progesterone, Progestin-only Pills (POPs) which contain
progesterone only. However, Emergency pills are another type of oral contraceptives
containing progesterone only.
Family Planning Pills has a number of medical benefits which include reduction of
menstrual cramps and ovulatory pain in the middle of the menstrual cycle since it
prevents ovulation. It also regulates the menstrual cycle and provides the woman's
body with normal amounts of oestrogen whose menstrual periods are irregular (too
often, too late, or not at all). FPP also reduces the amount and length of menstrual
bleeding hence reducing the risk of getting anaemia (Bertrand, and Monica Das Gupta.
2012)

Combined Oral Contraceptives (COCs)

These contain hormones progesterone and oestrogen. Examples include Femiplan,
pilplan, Microgynon, Femidom, Lofeminal, and Duofem. Their advantages include high
effectiveness when taken daily, decrease menstrual flow, reduce menstrual cramps,
may lead to more regular cycles, protects the woman from ovarian and endometrial
cancers, they do not require pelvic examinations prior to use, prevent ectopic
pregnancies. Common side effects include nausea and vomiting, breast tenderness,
headache, changes in body weight, changes in libido.
Progesterone Only Oral Contraceptives (POPs)
These contain a synthetic form of hormone progesterone only. Examples include
Ovrette, Microlute. They are in a pack of 21 and 28 pills. POPs are 87%-99% effective,
slightly less than regular COCs. They do not protect against reproductive tract
infections including HIV/AIDS (Advanced Family Planning, 2014)
The disadvantage of POPs include high risks of functional ovarian cysts, ectopic
pregnancies, they are also less effective more so when taken with other drugs. They
may cause irregular menstrual bleeding and require a prescription (AdemoleAdelekan,
Philomena Omoregie, and Elizabeth, 2011). They are contraindicated in women with
weight gain, those with liver diseases, gall bladder, heart disease, diabetes, and history
of depression. (WHO, USAID, Family Health International (FHI), 2010)
Emergency Contraceptive Pills (ECPs)
These pills contain progestin alone, or both progestin and oestrogen. They work by
disrupting the body hormone patterns needed for pregnancies to occur. ECPs are also
called ("morning after" pills or postcoital contraceptives). ECPs should be used in
cases of unplanned unprotected sex, rape, condom burst, or even slips off from the
penis during sexual intercourse and when a woman forgets to take her daily pills.ECPs
must be used in the first 72 hours after exposure to unprotected sexual intercourse.
Common side effects changes in bleeding patterns like slight irregular bleeding for 12 days after taking ECPs, monthly bleeding that starts earlier or later than expected.
There may be nausea, fatigue, headache, breast tenderness, dizziness and vomiting
in a week after using them.

2.3 The Level Of Effectiveness Of Family Planning Methods

The availability of a reliable supply of high-quality contraceptives is essential to
ensuring that family planning demand is met at all levels. Health facilities are often not
adequately stocked with family planning commodities due to challenges with
contraceptive security. This is particularly relevant for long-acting and permanent
methods (Uganda National Planning Authority, 2014). Availability of FP commodities
has increased in recent years. The availability of injectable contraceptives increased
from 69 percent in 2012 to 94 percent in 2013 (MOH, 2013). For oral pill contraceptives,
there was also an increase from 63 percent to 84 percent (MOH, 2012). Strengthening
the family planning commodity supply chain resulted in a substantial reduction in stockout reports, including no stock-outs of Depo-Provera in 2012/13 (OrachGarimoi
Christopher, Komakech Henry et al. 2013). The ICPD places the responsibility for
family planning equally on men and women instead of solely on women, thereby
emphasising the importance of educating men as a means of achieving gender equity,
especially with respect to family planning decisions and participation in method use.
Implementing this goal, however, remains a challenge to many programs that struggle
to find ways to increase male participation.
Uganda has an Essential Medicine and Health Supplies List (EMHSLU) that contains
all contraceptives classified by level of care. This document is revised to keep up with
new developments in technology and therapeutics and guides the national
procurement agencies to select the family planning commodities for use in Uganda.
The Quantification and Procurement Planning Unit within the Pharmacy Division of the
MOH serves as a single, centralised system for quantifying national requirements of
essential medicines and health supplies to ensure that appropriate products at
adequate quantities are supplied on a timely basis (Muwonge Moses et al. 2011).
Implementation of the Contraceptive Procurement Strategy, developed with support
from partners, has led to a dramatic reduction in the percentage of contraceptive stockouts (MOH, 2013). However, the current system for quantification, ordering, and
distribution from national to district levels, and from districts to facilities and end users,
faces challenges. Forecasting is not done in tandem with the budgeting cycles.

Quantification is also constrained by lack of programme data on distribution, demand,

and use. (RESPOND Project/ EngenderHealth.2011) there is limited involvement of
the private sector in RH supply chain management, especially during the forecasting
process, and this limits its ability to acquire the required intelligence to guide market
development efforts. (Zlatunich, Nichole, 2012)
A combined Family Planning/Reproductive Health Commodity Security Working
Group, led by the MOH, meets quarterly to coordinate partners and review stock levels
and shipments (UBOS, ICF International 2012). The working group has developed a
comprehensive supply plan and coordinates the distribution of commodities. In
addition, the Maternal and Child Health Working Group and Medicines Procurement
and Management Technical Working Group are Ministry of Health structures that bring
together Ministry of Health, development partners, the private sector and civil society
to, amongst others, discuss matters related to FP including contraceptive security and
reviewing commitments made.
National Medical Stores (NMS) is mandated to procure, store, and distribute
commodities to public health facilities. Joint Medical Stores (JMS), a channel of health
commodity access for the private sector, does not handle FP commodities because of
religious principles, leaving a gap in access to the private sector. To increase
availability, access to, and use of FP commodities, the Ministry of Health developed
the Alternative Distribution Channel Strategy to make available free public sector
commodities in the private not-for-profit (PNFP) sector and private for-profit (PFP)
sector (MOH, 2013). This has greatly increased the total commodities distributed from
the central warehouses. Institutionalisation of the Alternative Distribution Strategy is
still ongoing. In addition, a large segment of the population accesses FP commodities
through social marketing efforts, which are significantly subsidised by development
partners. The Ministry of Health, with partners, is piloting the Total Market Approach
(TMA) in the bid to increase access to FP services and commodities across all the FP
market segments (public, PNFP, PFP, and social marketing).

The MOH developed the Reverse Logistics Strategy to facilitate the redistribution of
contraceptives between health centres at the district level and the National Medical
Stores. (ICF International, 2014) In situations where a health unit experiences a stockout, additional supplies may be picked from a health unit with the surplus, thus enabling
those out of stock to restock from others in the district. Although the logistics strategy
is in place, challenges include weak capacity and poor linkages between reproductive
health commodities planning, procurement, and distribution with the budget cycles at
national and district levels (High-Impact Practices in Family Planning, 2014). There is
no centralised or coordinated system for the logistics management information system
(LMIS) reporting. (United States Census International Database 2014) Stock-outs are
reported to National Medical Stores, while other LMIS information is sent to the
Resource Centre at the MOH. The LMIS form (HMIS 018) lacks essential logistics data
(consumption data, losses, and adjustments); yet, this is the form used to collect RH
commodity data (London Summit on Family Planning, 2012). This is further
complicated by the lack of a dedicated budget for LMIS; there is no system for
sustaining the availability of logistics tools.
2.4 The Recommendations About Family Planning Methods.
One of ICPDs concerns about the quality of family planning services is how programs
can maintain a sufficient and continuous supply of contraceptive methods. For some
programs, funding for supplies is already insufficient to meet the existing need, and
this situation will only worsen as the demand for family planning grows. Experts
estimate that the gap between needed and available funds could reach as much as
$210 million by 2015 if funding remains at the 1999 level of $140 million (Bongaarts et
al, 2012). The gap could be narrowed by increasing reliance on the commercial sector
and by reducing the proportion of clients who receive free contraceptive supplies.
Nevertheless, stocks will still probably become depleted, and program needs are
unlikely to be completely met.

Integration of the Standard Days Method into programs could help close the funding
gap. The supplies required for the Standard Days Method are relatively inexpensive.
Recent figures indicate that the U.S. Agency for International Development pays 6.6
cents per condom, 22 cents per cycle of pills, 97 cents per injection of Depo-Provera
and $1.45 per IUD (Ministry of Finance, Planning and Economic Development. 2013).
In contrast, the one-time cost of a set of Cycle- Beads, which can be used for several
years, is about $1.50.
Once a woman has learned to use the Standard Days Method, she can rely on it
whenever supplies for other methods are unavailable. Hence, the method could be
introduced as a stopgap measure for returning clients during times of stock depletion.
In programs that are chronically out of stock, the Standard Days Method is both an
alternative option and a solution to an ongoing problem that can undermine program
efforts.
Accessible services are a hallmark of high-quality reproductive health programs. To
increase access, the ICPD Programme of Action recommends making family planning
information, education, communication, counselling and services available through
primary health care systems. This approach would make contraceptives available to
clients who need them and also offers a way of educating clients about new methods.
The successful introduction of a new method into a family planning program requires
more than simply announcing its availability. Programmatic concerns must be
addressed. The Standard Days Method can easily be incorporated into policy
development, service delivery, supervision of providers and program evaluation.
Experiences in Guatemala and Rwanda illustrate the feasibility of integrating the
method into public sector primary health care programs. In Guatemala, the Standard
Days Method was incorporated at the policy level, which is leading to its introduction
into services, the management information system and the supervision system.18 In
Rwanda, the method was initially introduced into a limited number of service delivery
points and is now being offered at an increasing number of centres. At the same time,
the Standard Days Method is being incorporated into the revised national reproductive
health program norms (Caroline Blair and Marie Mukabatsinda, 2014).

The Standard Days Method has also been incorporated into programs that previously
had not been involved in family planning and reproductive health. Kaanib, an
agricultural cooperative in the Philippines, introduced the Standard Days Method to its
members using trained couple and male providers.20 In addition, Project Concern
Internationals water and sanitation program in El Salvador incorporated the Standard
Days Method into its community development strategy. (Dosajh U, et al; 2013)
In both cases, providers were trained to ask clients about cycle length and discuss
couple issues related to method use, such as dealing with the fertile period, reducing
the risk of sexually transmitted infections, violence and alcohol abuse. Both
organisations trained their staff to make referrals to the public sector for other
contraceptive

methods.

The

advantages

of

using

these

community-based

organisations are that follow-up of clients can happen outside a structured clinic setting
and hours and that men are more readily involved. Primary health care systems and
non-health organisations usually use different outreach and service delivery strategies
to reach the public, but both have demonstrated their ability to increase access to the
Standard Days Method.
2.5 Factors Affecting Utilisation Of Modern Family Planning Methods
Family planning methods use is the expression of individuals desire to space or to limit
birth, individual demand for birth spacing and limitations are themselves shaped by the
surrounding social, psychological, economic and policy environment factors. It is
believed that information, education and communication about the importance of
modern FP methods use to play an important role in raising contraceptive prevalence
rate. But the fear of side effects, religious beliefs, partner disapproval and
misinformation can be a barrier to adoption or a reason for discontinuing modern family
planning methods. However different empirical evidence revealed that having
knowledge about modern FP methods alone could not guarantee utilisation of the
service. Thus, it can be summarised that modern FP methods use does not necessarily
depend on the knowledge of methods but there are other additional determinant factors
that influence the utilisation of the service. Among the various determinant factors
indicated by different studies conducted so far, few important factors indicated will be
reviewed below (Hailemariam A.et al.2006).

Knowledge & Information

In order to use modern FP methods, women must know about it, regarding its use as
beneficial and effectiveness of the methods, and its necessary to obtain the information
related the MFPM before and during the utilisation of contraception. The crosssectional community-based study involved among married women residing in rural and
urban areas of Bareilly district in India 2012, shows that the most common reasons for
not using any modern FP was a lack of awareness and deficient of information relating
the benefits of MFP methods (Khan S.et al.2012). A cross-sectional community-based
study conducted March 2011 the Mekelle town of Tigray region in Ethiopia, reveals
that the mothers who had high knowledge were 8 times more likely to use MFP as
compared with those who had low knowledge AOR = 7.9, 95% CI: 3.1 to 18.3
(Alemayehu et al.2012).
Another community-based cross-sectional study done at Mojo town in Ethiopia 2011,
indicated that the lack of knowledge and low awareness towards the sources of MFPM
were important factors for non-utilization of modern FP methods (Gizaw.A.et al 2011).
In Ethiopia, currently married men and women and sexually active unmarried of age
15-49, who know any FP method, by specific type and knowledge of at least one
method of contraception is nearly universal among both women and men, regardless
of marital status and sexual experience. Men and women are almost equally likely to
have heard of MFP methods 98 and 97% respectively. Both women and men are more
familiar with modern methods of FP than with traditional methods (ECSA 2014).
Education
Education is a key determinant of the lifestyle and status an individual enjoy a society.
It affects many aspects of life, including demographic and heath behaviour. Education
is one of the most important factors for acceptance and utilisation of MFP. Usually, the
educated women have more awareness and opportunities to know the importance of
MFP in respect birth control. The educated women are more likely to marry late and
the first pregnancy to leave more time between births and have few children in total
(BDHS,2008).

As many studies conducted in different regions at different times suggest the

educational status in both individual and community is one of the major determinants
the utilisation of MFP. Increasing partners education might help in a discussion on
MFP and increases the knowledge about MFP and hence, improves predisposition to
their intention and use of different MFP. A cross-sectional study among a
representative of married women from both urban and rural localities in Khartoum State
in Sudan 2007, shows that the education level had a statistically significant influence
on the odds of the respondents using MFP. Compared those with education to those
with no schooling; those with education were significantly more likely to use MFP
(P=0.003) (A.H. Ibnouf.2007).
Another cross-sectional study complemented by qualitative method conducted 2012 in
Adigrat town in Ethiopia shows that the partners education was one of the most
important factors positively related to intention to use the long-acting and permanent
methods of MFP (Gebremariam.et.al.2014). Similarly, education was positively
associated with MFP utilisation among married women as revealed a communitybased study done 2011 in Butajira district south central Ethiopia (Mekonnen W.et al
2011). Also, cross-sectional study conducted in 2006 on urban and rural youth in
Ethiopia indicated that contraceptive use was 4.9% in those with no education, 13.1%
in those with low education and 82% of higher education (Tesfaye G.et al.2006).
Religion & Cultures
The roles of religion and culture as fertility determinants have been a subject of
considerable discussion in fertility literature. Every social group has a characteristic
culture, complex of beliefs, attitudes, values and social controls. The cultural and
religious background of a given community has the powerful effect on health seeking
behaviour in general, and modern FP uses in particular. Globally, the strongest
opposition was from the Catholic Church, which prohibits utilisation of MFP in the
1930s and Muslim religion followed it (Ketende.C, 2009). Male involvement in MFPM
has negatively affected contraceptive use as revealed this study; A cross-sectional
qualitative study was conducted using focus group discussions with women aged 15
49 and men aged 15 54 in 2012 at Bugiri and Mpigi districts in Uganda,

This study found that many participants perceive men to be obstacles to womens
utilization of MFP, and largely uninvolved despite the fact that men are often
responsible for decisions which affect the household. This was attributed to mens
reluctance to support the use of FP for their spouses or themselves based on fears of
harmful side effects and spousal infidelity, as well as preferences for large-sized
families. Mens fertility preferences and attitudes towards FP seem to influence their
wives attitudes towards the use of MFP (Kabagenyi et. al.2012).
A study conducted in Bangladesh revealed that the percentage of current users of MFP
among Muslims was significantly lower than their non-Muslim counterparts 30.2% and
36.3% respectively (Shahid Ullah.etal.1993). According to the 2011 EDHS report, the
significantly high proportion of females reported that in most cases religious leaders
oppose the use of modern FP and ethnicity and religion were the determinant factors
to the use of MFPM (CSA 2011). A study was done in 2007 in Sudan, an Islamic
country in the developing world shows that very few women reported the use of MFPM
as if it was against their religion and their cultural beliefs (Ibnouf H.et al 2007). The
descriptive cross-sectional study was carried out in the rural communities of Osun
state, Nigeria 2011, explain the significant association between religion and ever used
MFP, shows that Christians having a higher uptake of MFP methods than the Muslims
community in that study (Olugbenga-Bello AI.et.al.2011)
Type Of Family Setting & Modern Family Planning Methods Use:
The type of family setting is another factor for determinants of utilisation of MFPM as
many studies revealed. The cross-sectional study done in the rural communities of
Osun state, Nigeria 2011, shows that there was a significant relationship between
family setting and ever used MFP with more women in monogamous family settings
using MFP method as compared to those from polygamous family settings. This may
be a reflection of the insecurity that exists among women in polygamous family settings
with the women trying to out with each other in the number of children in other to secure
their positions in the family and in the will when the husband dies (Olugbenga-Bello
AI.et.al.2011).

Husbands Approval & Effect On Family Planning Use:

A community-based cross-sectional study on contextual influences on modern FP
methods use among reproductive married women conducted in some of the SubSaharan African countries 2007, shows that partner approval was more likely to be
associated with of use of MFP in all the six African countries that included Kenya,
Malawi, Tanzania, Ivory Coast, Burkina Faso, and Ghana. For example partner
approval was 4 times more likely to be associated with MFP methods use in Malawi
(OR =3.59: 95% CI 2.93-4.39) and in Kenya (OR =3.49: 95% CI 2.73-4.46) (Rob et.al
2007).
Health Service Delivery & Effect Of Modern FP Methods Use:
In a community based cross-sectional study of MFP use and incidence of pregnancy
done in Ivory Coast among 546 married women followed up for 2 years after delivery
and given free modern FP and counseling results showed high proportions of women
using MFPM varying from 52 to 65% and low pregnancy incidence (calculated as the
number of pregnancies for 100 women-years at risk) of AOR=5.70 (95% CI: 4.17-7.23).
Findings in this study indicated that FP counselling and regular follow-up was
accompanied by a high rate of MFP use and a low pregnancy incidence among married
women after delivery (Brou et al. 2009). In Ethiopia MFPM including primarily: pills,
injection, male/female condoms, emergency contraception and counselling services
are provided for clients at the lower level health facilities. Services like IUDs, Norplant
and tubal ligation are provided at the higher centres like hospitals. There are no
specialised FP workers in Ethiopia (FMoH 2009).

Supply & Demand Factors & Modern Family Planning Use:

Studies have indicated that supply and demand factors have a profound influence in
the utilisation of MFP services which includes the use of modern FPM the overarching
strategy of successful supply-side FP programs is to ensure that contraceptive
methods are as readily accessible to clients as possible. This includes ensuring that a
wide range of affordable contraceptive methods is offered, making services widely
accessible through multiple service-delivery channels, ensuring that potential clients
know about services, following evidence-based technical guidelines that promote
access and quality and providing client-centered services. These types of supply-side
interventions ensure that women and couples are able to use methods of FP services
effectively (Mwaikambo L.et al. 2011).
A study conducted in Ethiopia 2011 shows that problem of availability and accessibility
influenced the use of MFPM (Gizaw.A.et al, 2011). The study in Bangladesh indicated
that the main reasons for women not visiting MCH clinics were non-availability of
commodities, but the behaviour of service providers and long waiting times (Zainab B
2011).This was also evident in Iranian studies where women using MFP were
dissatisfied with the monthly provision of FP and these led to seeking services from
private outlets (Mackenzie.H.et.al.2012). Thus, it is evident from different studies that
use of MFPM and uptake of contraception is a multifactor. Socio-economic status,
cultural beliefs and value attached to children, educational level of a mother play an
important role. Perceptions of risks and benefits attached to MFP have influence in the
use of methods. Furthermore, the studies have shown that spousal acceptance and
communication contributes to acceptance of MFP (Gizaw.A.et al, 2011).

Healthcare Workers Factors & Modern Family Planning Methods Use:

A major goal of FP programs is to help couples to achieve their reproductive intentions.
To assist clients to achieve these goals, FP services should be tailored to meet clients
needs. Effective delivery and uptake of MFP depend a lot on the competency and
attitudes of the providers particularly for the long-acting and permanent methods.
Some of the constraints in MFP include lack of trained staff, transfer of trained and
motivated staff resulting in a decrease of commitment of the staff. Also, there is poor
information provision ranging from the poor display of IEC materials to limited
disclosure of methods and counselling especially the long term and permanent ones
(Kasedde 2000).
A community-based cross-sectional study done at Daami district in Hargeisa found out
that only about 18% of mothers attending ANC clinics received messages regarding
MFP services and yet 71% intended to use FP in the future (Abdisalan. 20014). A
descriptive cross-sectional survey conducted among the health care service providers
working in eastern Ethiopia in 2010, shows that nearly one-third (30%) of HCWs had
negative attitudes toward providing RH services to unmarried adolescents. Close to
half (46.5%) of the respondents had unfavourable responses toward providing modern
FP methods particularly unmarried adolescents (Tilahun et al. 2012).
Overall, the rate of modern FP methods use is associated with wealth, education and
ethnicity, place of residence, family size, culture, religious beliefs, health service
availability and strength of national MFP service programs within countries (Mackenzie
H.et al 2012).

DESCRIPTION OF THE CONCEPTUAL FRAMEWORK

Socio-Demographic Factor
The elements in this theme include; Age, Sex, Education level, No. & Sex of Children,
Infant mortality, Support from partner, Residence and Income/economic status.
Health Facility/System
This theme is consisted of; Physical access, No & availability of skilled staff, Availability
of contraceptive services, Staff attitudes & practices, Cost of contraceptives,
Supportive policies, Infrastructures and Quality of FP services.
Community Factors
The factors in this theme include; Social organisation, Social networks, Religious
beliefs, Family/Societal pressure for births, Household/kinship structures and Cultural
values/norms regarding fertility.
Individual Factors
The individual factors to family planning include; Personal preference, Contraceptive
Knowledge and Attitudes towards contraceptives.
Medical Factors
The medical factors include; Side effects, Contradictions and Formulation.

THE CONCEPTUAL FRAME WORK

Socio-Demographic factor

Health facility/ system

Age
Sex
Education level.
No. & Sex of Children
Infant mortality
Support from partner
Residence.
Income/economic status

Physical access
No & availability of skilled staff
Availability of contraceptive services
Staff attitudes & practices
Cost of contraceptives
Supportive policies
Infrastructures
Quality of FP services

REPRODUCTIVE INTENTIONS

Contraceptive
use

Childbearing

AND
CONTRACEPTIVE UPTAKE AMONGCLIENTS

Community factors

Social organization
Social networks
Religious beliefs
Family/Societal pressure for
births
House hold/kinship structures
Cultural values/norms regarding
fertility.

Individual

Personal preference
Contraceptive
Knowledge
Attitudes towards
contraceptives.

Medical Factors

Side effects
Contradictions
Formulation

References
Advance Family Planning. 2011. Taking injectable contraceptives to villages.
Retrieved on 5 November 2014.
Bongaarts, John, John C. Cleland, John Townsend, Jane T. Bertrand, and Monica Das
Gupta. 2012. Family Planning Programmes for the 21st Century: Rationale and
Design.
Ministry of Health, 2012.Essential Medical and Health Supply List for Somaliland.
(EMHSLU).
Ministry of Health. 2013. Annual Health Sector Performance Report FY 2012/13.
Ministry of Health. 2013. Committing to Child Survival: A Promise Renewed, 2013.
Hargeisa Somaliland.
World Health Organization, USAID, and Family Health International (FHI). 2010.
Community-Based Health Workers Can Safely and Effectively Administer Injectable
Contraceptives: Conclusions from a Technical Consultation, Research Triangle Park
(NC): FHI.140
By Mohamed Shucayb Ahmed (Marty)