Background
In 2014, an estimated 225 million women in developing regions had an unmet need for modern contraception.1 Singh and Darroch reported an estimated 222 million reproductive- aged (15–49) women in the developing world having an unmet need for modern contraception, out of which sub-Saharan Africa [SSA] accounted for approximately 24% of this number.2 In much of SSA, 55 million reproductive aged women (15–49) have an unmet need for modern contraceptive methods.1 Sub-Saharan Africa refers to all African countries that are fully or partially located south of the Sahara Desert.3 Most women, predominantly in the developing world, are unable to practice contraception.1,2,4,5 This discrepancy is known as the unmet need for contraception.5 Furthermore, a woman of reproductive age has this unmet need if she is married or unmarried but is sexually active, is not using any method of contraception, is fecund, and does not want to have a child in the next two years or at all.4 Meeting the contraceptive needs of women in developing countries is estimated to prevent 54 million unintended pregnancies, 21 million unplanned births and 26 million abortions.2 Met contraceptive needs would lead to reductions in maternal and infant deaths.6-7 Modern contraception is a product or medical procedure that interferes with reproduction from acts of sexual intercourse as defined by Hubacher and Trussel.8
Globally, enabling women to meet their pregnancy preferences has become a priority on the development agenda. Access to and utilization of modern contraception by women especially those who want to delay or stop childbearing has been the focus of most international family planning programs.4,9,10 Family planning is the practice by individuals and couples to attain the desired number, spacing and timing of their children through the use of modern or traditional contraceptive methods.11 To successfully meet women's modern contraceptive needs, governments and stakeholders must address a number of factors. These include socio-demographic factors, policies, laws, service provision systems and other societal factors that impede access and use of contraceptive services.2,12,13 Evidence from studies indicate that infrequent sex, concerns about health and other side effects of methods are the most common reasons women give for non-use or discontinuation of contraceptives.4,10,14,15 Addressing religious beliefs and practices opposed to modern contraception, women's low decision making power in the family, spousal non-communication, and differences in fertility preferences between partners can result in improved contraceptive uptake.2,5,16,17
Several studies have articulated the concern over side effects or health risks, infrequent or no sex, social or familial opposition, breastfeeding and lack of knowledge as the range of reasons responsible for a woman's inability to act on her childbearing preferences in SSA.4,5,10,18 Bongaart and Bruce, Sedgh et.al., Westoff and Bankole, and Sedgh et al. have also examined trends in reasons for non-use among regions and countries.4,5,10,18 The reasons for non-use among married and unmarried sexually active reproductive aged women were consistent with the findings of these researchers.4,5,10,18 Bongaart and Bruce, Sedgh et al., Westoff and Bankole, and Sedgh et al. used quantitative data to conduct their analyses of the obstacles to contraception use in the developing world.4,5,10,18 Many qualitative studies examining obstacles to contraceptive use in SSA have been undertaken, although limited in geographical scope and number compared to quantitative ones.19-21 These qualitative studies have largely uncovered the general deterrents to contraceptive use identified by the large scale quantitative surveys but with more indepth detailed explanations.19-21 A review of qualitative studies by Williamson et al. uncovered fear of infertility, side effects and health risks, social disapproval with regards to seeking services, and lack of access to information as some of the underlying themes among young unmarried women in SSA.22 Generally, most drivers of contraceptive use identified in the literature are the direct opposite of the barriers or deterrents.23-26 Religious approval of contraception, male approval and support, participation in choice of husband, and engaging in premarital sex are some of the driver themes enumerated in qualitative studies in the sub region.24-25 Understanding the facilitators and barriers of modern contraceptive use among women remains critical to formulating effective policies and programs for combating high unmet needs in the sub region.
There have been five previous reviews on reasons for non-use of modern contraception by women with unmet needs in developing countries.4,5,10,22,27 Four of these used Demographic and Health Surveys (DHS) data and were quantitative in nature.4,5,10,27 Only Williamson et al. conducted a qualitative review on limits to contraceptive use among young women in the developing World.22 Bongaart and Bruce reported lack of knowledge, social and familial disapproval, and fear of side effects as principal reasons for non-use.5 Sedgh et al. grouped reasons for non-use into three broad categories.10 These were: reasons that indicate the woman perceives she is at low risk of getting pregnant (exposure-related); reasons relating to the availability of contraceptive supplies and services, including women's knowledge of family planning, their access to contraceptives or their concerns about the health or side effects of contraception (supply of methods and services); and opposition to family planning, including opposition on religious grounds (demand-side).10 Sedgh and Hussain also identified infrequent sex and concerns regarding health risk as the most widespread reasons for nonuse.27 Sedgh et al. noticed that there is no single predominant reason for contraceptive non-use but rather several key common ones across countries and regions.4 Among these included postpartum amenorrhea, opposition to family planning, infrequent sex and fear of side effects.4
It is worth emphasizing that all five reviews covered developing countries. None of them focussed on SSA only. Also, the only qualitative review by Williamson et al. included studies between 1970 and 2006.22 It is also noteworthy that Williamson et al. conducted a review focusing on young women (11–24 years) in developing countries.22 Furthermore, due to family norms that promote large family size, the most recent ideal family size in SSA is still high. It has a median of 4.6 children per woman, compared to the rest of the world.28-29 More so, owing to the fact that SSA still has a high unmet need than the rest of the other regions of the world, a qualitative review that focuses on SSA will undoubtedly offer an indepth exploration of identified themes.30-32 This understanding will lead to programs and services responding effectively to address women's unmet need for modern contraception in SSA.
In a quest to address these gaps, this qualitative systematic review would include studies conducted in SSA only. This review aims to identify facilitators and barriers to the use of modern contraception among reproductive-aged (15–49 years) women living in SSA. It will ascertain any differences in key facilitators and barriers to contraceptive use among married and unmarried reproductive-aged women. It would also determine whether there are differences by age and over time of these barriers or key facilitators contributing to uptake or otherwise of modern contraceptive methods. The analysis of emerging themes would lead to further understanding of the actual mechanisms by which contraceptive use is affected by marital status, age and time. Understanding these themes and mechanisms will assist in the design and development of effective interventions to combat high unmet needs. The beneficiaries of this review would include public health practitioners, researchers and policy makers working in SSA. A search for systematic reviews from the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, the Campbell Collaboration Library and PubMed identified no reviews relating to the above topic.
Inclusion criteria
Types of participants
The review will consider studies that include both married and unmarried reproductive-aged women (15–49 years).
Phenomena of interest
The review will consider studies that report on the experiences related to the drivers and deterrents of modern contraception use among reproductive-aged women.
Context
The review will consider qualitative studies reporting on the experiences of reproductive-aged women living in SSA.
Types of studies
The review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Studies containing mixed methods research both qualitative and quantitative relating to this topic will also be considered. In such cases, qualitative data from such studies will be extracted and included in this review.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE using PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English and from 1994 will be considered for inclusion in this review. The date range is to endeavor to capture facilitators and barriers of modern contraception since the 1994 International Conference on Population and Development (ICPD). This conference established a 20-year goal of achieving sexual and reproductive health and rights for all. Also, this range would cover facilitators and barriers over three decades in order to determine any changes over the period and at the same time document the most current themes.
The databases to be searched include: PubMed, CINAHL, POPLINE, Web of Science, ProQuest Social Services Abstracts and Scopus.
The search for unpublished studies will include: World Bank website, World Health Organization website, UNICEF website, ProQuest Sociological Abstracts and Dissertations and MedNar.
Initial keywords to be used will be: unmet need, use, non-use, modern contraception, contraceptives, family planning, birth control, reproductive-aged women, barriers, facilitators, drivers, deterrents, factors, determinants, limits, SSA, Africa.
Assessment of methodological quality
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).33 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data extraction
Qualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI SUMARI.33 The data extracted will include specific details about the phenomenon, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-SUMARI.33 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorizing these findings on the basis of similarity in meaning (Level 2 findings). These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings (Level 3 findings) that can be used as a basis for evidence-based practice.
Acknowledgements
We acknowledge support from the Kintampo Health Research Centre: a Joanna Briggs Centre of Excellence, Kintampo, Ghana.
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