Modern contraceptives use among women in Terekeka County, Central Equatoria State, South Sudan

Author(s): Imba Alex David [1], Ambayo Peter Otte [2], Mawa Ratib [3] and Lou Eluzai Loponi [4]

Authors Affiliations: 

1. Uganda Christian University, Uganda.

2. Liverpool School of Tropical Medicine, UK.

3. Victoria University, Kampala, Uganda.

4. Texila American University, Guyana, Central America.

Correspondence: Imba Alex David [email protected] 

Submitted: May 2024 Accepted: August 2024 Published: November 2024

Citation: David et al, Modern contraceptives use among women of reproductive age in Terekeka County, Central Equatoria State, South Sudan, South Sudan Medical Journal, 2024;17(4):159-166 © 2024 The Author (s) License: This is an open access article under CC BY-NC  DOI: https://dx.doi.org/10.4314/ssmj.v17i4.2 

Abstract

Introduction: The South Sudan health sector strategic plan indicates that only 1.2% of women aged 15-49 years have their need for family planning met, and the contraceptive prevalence rate of 6% is lower than the rate of 17% in the whole of sub-Saharan Africa. The use of modern contraceptives contributes to women’s health and reduces maternal mortality related to pregnancy and childbirth complications globally. The study investigated the utilization of modern contraceptives among women of reproductive age (WRA) in Terekeka County of South Sudan.

Method: We employed cross-sectional, qualitative, and quantitative research involving in-depth interviews with key informants. Respondents were selected purposively and through a multistage random sampling technique. Data were analysed using thematic content analysis. 

Results: There were 384 respondents. The results indicate that 21.4% of the women use modern contraceptives. Demographic factors such as education, religion, marital status, knowledge, access to contraceptive information, and partner support are positively associated with the use of modern contraceptives in Terekeka County. 

Conclusion: We conclude that if all WRA had access to education and family planning information, many would use modern contraceptives. The study recommends more studies to explore the use of modern contraceptives in the whole country. 

Keywords: Modern contraceptives, contraceptive use, women of reproductive age, family planning, South Sudan

Introduction

To measure progress towards Sustainable Development Goals (SDG 3.7), we need to know the extent of both modern contraceptive use and the unmet need for family planning: “By 2030, ensure universal access to sexual and reproductive healthcare services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs.” [1] According to the World Health Organization,[2] globally, only 842 million women of reproductive age used contraceptives, but 270 million had an unmet need for contraception, and 1.1 billion needed family planning compared to the 1.9 billion population.[2]

The prevalence of modern contraceptive use among married women of reproductive age (MWRA) has increased worldwide between 2000 and 2019 by 2.1 percentage points from 55.0% to 57.1%, but this is below the SDG target of 75.7%.[3]

The prevalence of modern contraceptive use ranges from 7% in the Gambia to 29% in Uganda, and aspects of the issues vary substantially across countries.[4] A study conducted in Uganda revealed that most women (99%) had knowledge of contraceptive use compared to about 40% uptake.[5]

According to a 2017 report in Warap State, South Sudan, only 1.2% of WRA were using family planning methods.[6] According to the South Sudan FP2030 indicator summary sheet for modern contraceptive use, modern contraceptive use was 3.4% in 2018, 3.6% in 2019, and 3.7% in 2020.[7] South Sudan has some of the worst social indicators globally, particularly for women and girls; for example, the maternal mortality ratio is estimated at 1,150 per 100,000 live births. Most of these deaths are preventable through the provision of essential maternal health commodities, such as contraceptives and essential medicines.[8] However, Terekeka County has limited information on modern contraceptive utilization. Therefore, this study aimed to bridge the knowledge gap to provide better family planning services. 

Method

This was a descriptive cross-sectional study that employed both quantitative and qualitative data collection methods to determine modern contraceptive utilization among WRA (15-49 years) in Terekeka County. The data were collected from August to September 2021.

The study used multistage systematic random selection – where selection started at County, Payam, Boma, village, and finally, household levels, respectively, for quantitative data. The data were collected from 384 women of reproductive age at their homes in rural and semi-urban areas using a structured questionnaire. Purposive sampling was used to collect qualitative data through ten focused group discussions with women who did not participate in the structured questionnaire interviews and six key informant interviews with the health facility and the midwife in charge. Cochrane’s formula was used to calculate the sample of 384 for a large population and an unknown proportion using modern contraception.

To ensure the quality of the data, competent research assistants and supervisors were recruited and trained, and study tools were translated into the local Bari language and tested before data collection. Focused group discussions were tape-recorded, and the research team was under daily supervision, in addition to the researcher’s collection and storage of completed tools.

Prior approval of the study was obtained from the Research Ethics Committee (REC) of Uganda Christian University (UCU) and the Ministry of Health Research Ethics Review Board (MOH-RERB), South Sudan. Informed consent was sought from the respondents before administering the study tools. 

Data analysis was done using IBM SPSS Statistics version 23.0. Chi-squared tests and logistic regression were used to analyse the quantitative data, while thematic content analysis was used for qualitative data. The significance level was set to 95%.

Results

The socio-demographic characteristics of the sample, and use of modern contraceptives are shown in table 1. Overall, 21.4% of respondents used modern contraception (CI 17.5 - 25.7).

Table 1. Socio-demographic characteristics of sample and modern contraceptive use (N=384)

 

 

Percentage

n (%)

User

n (%)

Non-user

n (%)

 

p-value

 

Women Age (years)

15 - 24

125 (32.6)

26 (20.8)

99 (79.2)

 

0.120

25 - 30

133 (34.6)

27 (20.3)

106 (79.7)

31 - 35

51 (13.3)

17 (33.3)

34 (66.7)

36 - 49

75 (19.5)

12 (16.0)

63 (84.0)

 

 

Partners Age (Years)

20-29

41 (13.1)

11 (26.8)

30 (73.2)

 

 

0.018

30 -34

64 (20.5)

14 (21.9)

50 (78.1)

35 - 39

70 (22.4)

12 (17.1)

58 (82.9)

40 - 44

65 (21.0)

22 (33.8)

43 (66.2)

45 - 62

72 (23.1)

08 (11.1)

64 (88.9)

Marital status

Single

83 (21.6)

19 (22.9)

64 (77.1)

0.700

 

 

Married

301 (78.4)

63 (20.9)

238 (79.1)

Woman’s education

None

232 (60.4)

23 (09.9)

209 (90.1)

 

<0.001

Primary

80 (20.8)

25 (31.3)

55 (68.8)

Secondary

or above

72 (18.8)

34 (47.2)

38 (52.8)

 

Partner’s education

None

190 (60.9)

18 (09.5)

172 (90.5)

 

 

<0.001

Primary

45 (14.4)

08 (17.8)

37 (82.2)

Secondary

or above

77 (24.7)

41 (53.2)

36 (46.8)

 

Woman’s occupation

Peasant/small scale business

351 (91.4)

65 (18.5)

286 (81.5)

 

<0.001

Formal employment

33 (8.6)

17 (51.5)

16 (48.5)

Partner’s occupation

Peasant/small scale business

248 (79.5)

34 (13.7)

214 (86.3)

 

<0.001

Formal employment

64 (20.5)

33 (51.6)

31 (48.4)

 

Family income (SSP)

0 – 2500

126 (32.8)

18 (14.3)

108 (85.7)

 

0.090

2501 – 5000

75 (19.5)

17 (22.7)

58 (77.3)

5001 – 10,000

54 (14.1)

12 (22.2)

42 (77.8)

10001 & above

129 (33.6)

35 (27.1)

94 (72.9)

 

Religion

Catholic

268 (69.8)

50 (18.7)

218 (81.3)

 

0.020

Protestant

98 (25.5)

24 (24.5)

74 (75.5)

Muslim

18 (4.7)

08 (44.4)

10 (55.6)

Ethnicity

Mundari

347 (90.4)

72 (20.7)

275 (79.3)

0.340

Others

37 (9.6)

10 (27.0)

27 (73.0)

 

Number of children alive

0

78 (20.3)

14 (17.9)

64 (82.1)

 

0.660

1 – 5

210 (54.7)

48 (22.9)

162 (77.1)

6 – 12

96 (25.0)

20 (20.8)

76 (79.2)

Total

 

384 (100)

82 (21.4)

302 (78.6)

 

Seventy-two respondents did not answer partners' age, education, and occupation questions.

Chi-squared tests showed that the factors associated with modern contraceptive utilization were the age of the partner (p-value=0.018), education level of women (p-value <0.001) and partner’s education level (p-value <0.001), occupation of women (p-value <0.001), partners occupation (p-value <0.001) and religion of women (p-value=0.02).

Table 2 shows the results of unadjusted and adjusted logistic regression analysis. The adjusted analysis showed that only women’s education was a significant factor. Women who had either primary (AOR 2.86, CI 1.32 – 6.22) or secondary/college/university (AOR= 8.68, CI: 3.22-23.42) education had higher odds of using modern contraception.

Table 2: Logistic regression exploring the relationship between socio-demographic characteristics and use of modern contraceptives.

 

 

COR (95% CI)

AOR (95% CI)

 

Age of women (years)

15 – 24

1.00

1.00

25 – 30

0.97 (0.53 – 1.78)

0.56 (0.23 – 1.40)

31 – 35

1.90 (0.92 – 3.93)

1,26 (0.40 – 3.92)

36 – 49

0.72 (0.34 – 1.54)

0.47 (0.14 – 3.33)

Marital status

Single/divorced/widow

1.00

1.00

Married

0.89 (0.50 – 1.60)

0.68 (0.09 – 2.95)

Education Level of woman

None

1.00

1.00

Primary

4.13 (2.18 – 7.83)

2.86 (1.32 – 6.22) *

Secondary/College/University

8.13 (4.32 – 15.29)

8.68 (3.22 – 23.42) *

Occupation of woman

Peasant/small scale business

1.00

1.00

Formal employment

4.68 (2.24 – 9.74)

1.85 (0.65 – 5.22)

Family income (SSP)

0 – 2500

1.00

1.00

2501 – 5000

1.76 (0.84 – 3.67)

2.05 (0.79 – 5.30)

5001 – 10000

1.71 (0.76 – 3.86)

1.20 (0.43 – 3.35)

10001 & above

2.23 (1.19 – 4.20)

1.60 (0.68 – 3.73)

Religion

Catholic

1.00

1.00

Protestant

1.41 (0.81 – 2.46)

1.12 (0.55 – 2.26)

Muslim

3.49 (1.31 – 9.29)

2.48 (0.63 – 9.72)

Number of live children

0

1.00

1.00

1 – 5

1.35 (0.69 – 2.63)

4.55 (0.72 – 28.81) *

6 – 12

1.20 (0.56 – 2.57)

5.36 (0.66 – 43.79) *

However, some key informants had a different perception, for example: 

“... In this community, the age of the partner of the women influences the utilization of modern contraceptive” (In-charge of the Primary Health Centre).

Knowledge of, access to, and use of modern contraceptives amongst the sample are shown in Table 3.

Table 3. Knowledge of, access to, and use of modern contraceptives (N=384)

 

 

Percentage

n (%)

User

n (%)

Non-user

n (%)

 

p-value

Heard about modern contraceptives

Yes

256 (66.7)

71 (27.7)

185 (72.3)

 

<0.001

No

128 (33.3)

0 (0.0)

128 (100.0)

Sources of information

Health facility

199 (77.7)

52 (26.1)

147 (73.9)

 

0.440

Friends/Relatives/

Radio/TV/News papers

57 (22.3)

12 (21.1)

45 (78.9)

Why are modern contraceptives good?

Healthy children

113 (49.1)

38 (33.6)

75 (66.4)

 

0.810

Healthy mothers

65 (28.3)

20 (30.8)

45 (69.2)

Saves Family incomes

52 (22.6)

15 (28.8)

37 (71.2)

Health facilities with modern contraceptives

Yes

259 (67.4)

71 (27.4)

188 (72.6)

 

<0.001

No

125 (32.6)

11 (8.8)

114 (91.2)

Type of health facilities

Public PHCCs/PHUs

296 (92.5)

70 (23.6)

226 (76.4)

 

0.004

Private health facilities

24 (7.5)

12 (50.0)

12 (50.0)

Cost of modern contraceptives (South Sudanese Pound)?

No payment

285 (74.2)

63 (22.1)

222 (77.9)

 

<0.001

500 or less

81 (21.1)

8 (9.9)

73 (90.1)

Above 500

18 (4.7)

11 (61.1)

7 (38.9)

Cost affects modern contraceptives use

Yes

87 (22.7)

18 (20.7)

69 (78.3)

 

0.860

No

297 (77.3)

64 (21.5)

233 (78.5)

Distance to health facility (Km)

3 & above

60 (16.7)

13 (21.7)

47 (78.3)

 

0.860

1 - 2

177 (49.2)

40 (22.6)

137 (77.4)

Less than 1

123 (34.1)

25 (20.3)

98 (79.7)

Distance affects modern contraceptives use

Yes

126 (32.8)

24 (19.0)

102 (81.0)

 

0.440

No

258 (67.2)

58 (22.5)

200 (77.5)

Safe to travel to health facilities

Safe

240 (62.5)

68 (28.3)

172 (71.7)

<0.001

Unsafe

144 (37.5)

14 (9.7)

130 (90.3)

Waiting time for modern contraceptives

1 hour & above

164 (42.7)

18 (11.0)

146 (89.0)

 

<0.001

30 minutes to 1 hour

121 (31.5)

31 (25.6)

90 (74.4)

Less than 30 minutes

99 (25.8)

33 (33.3)

66 (66.7)

Waiting time at health facilities fair

Yes

150 (39.1)

50 (33.3)

100 (66.7)

<0.001

No

234 (60.9)

32 (13.7)

202 (86.3)

Husband support use of modern contraceptives

Yes

136 (43.6)

45 (33.1)

91 (66.9)

 

<0.001

No

176 (56.4)

22 (12.5)

154 (87.5)

Type of support

Escort wife to FP clinic

26 (19.1)

8 (30.80)

18 (69.20)

 

 

<0.001

Approve/Decide use of Modern Contraceptives

39 (28.7)

22 (56.40)

17 (43.60)

Financial support

71 (52.2)

15 (21.10)

56 (78.90)

Total

 

384 (100)

82 (21.4)

302 (78.6)

 

Not all questions were relevant to all respondents: 128 respondents did not answer source of information, 154 did not answer why modern contraceptives good, 64 did not answer types of health facilities, 24 did not answer distance to health facilities, 72 did not answer husband’s support, and 248 did not answer type of husband’s support.

Attendees at private health facilities were more likely to use modern contraception (p-value= 0.004). Other significant factors were the cost of modern contraceptives (p-value <0.001), safety on the road (p-value <0.001), waiting time at health facilities (p-value <0.001), waiting time fair (p-value <0.001), husband support for modern contraceptives (p-value <0.001) and type of support provided by husband (p-value <0.001).

Table 4 shows the results of unadjusted and adjusted logistic regression analysis. Women who felt safe/secure on the road were more likely to use modern contraception (AOR=2.76, CI: 1.10-6.98), as were women who waited for less than 30 minutes at health facility (AOR=6.80, CI: 2.41-19.15) and those who waited nearly an hour (AOR=5.31, CI: 2.14-13.17).

Table 4: Logistic regression exploring the relationship between health services factors and use of modern contraceptives.

 

 

COR (95% CI)

AOR (95% CI)

Heard about modern contraceptives

No

1.00

1.00

Yes

4.08 (2.08 – 8.02)

3.70 (1.43 – 9.61) *

Health facility with modern contraceptives

No

1.00

1.00

Yes

3.91 (1.99 – 7.69)

2.86 (1.11 – 7.39) *

Payment for modern contraceptives

Yes

1.00

1.00

No

1.19 (0.67 – 2.12)

0.68 (0.28 – 1.66)

Distance to health facility (Km)

3 & above

1.00

1.00

1 – 2

1.15 (0.61 – 2.18)

0.47 (0.19 – 1.21)

Less than 1

1.01 (0.50 – 2.01)

0.22 (0.07 – 0.66)

Safety on road to health facilities

Unsafe

1.00

1.00

Safe

3.67 (1.98 – 6.82)

2.76 (1.10 – 6.98) *

Waiting time for modern contraceptives (hours)

1 hour & above

1.00

1.00

30 minutes > 1 hr

2.79 (1.47 -5.28)

5.31 (2.14 – 13.17) *

Less than 30 minutes

4.05 (2.13 – 7.72)

6.80 (2.41 – 19.15) *

* Statistically significant results.

Comments from the qualitative analysis included:

...Some women and men in this community believe that implants can move to other parts of the body. As a result, the woman will not get pregnant anymore, and it is being witch/wizard when you use modern contraceptives’’ (Midwife Primary Health Care Centre). 

“... The modern contraceptives we provide include injectables, pills, implants, and condoms’’ (In-charge Primary Health Care Centre). 

“...Modern contraceptives help in child spacing or prevent unwanted pregnancy and me as the mother of the child will be healthy’’ (Woman Tali Payam Focused group discussion).

“...My husband does not want me to use modern contraceptives; he said I will not get pregnant again when I use modern contraceptives, and I must respect him to avoid fighting at home’’ (Woman Muni Payam Focused group discussion).

Discussion

The age of the partner was associated with modern contraceptive utilization, and this is because older men can make informed decisions, though this finding is not in line with a study in Ethiopia[9] where the age of the partner never had a positive relationship with modern contraceptive utilization. The study also revealed that couples who are educated are more likely to use modern contraceptives because they know their importance, and this study agrees with the study in Juba City.[10] A study in Ethiopia[9] revealed that the occupation of women and their partners was associated with modern contraceptive utilization. In Nigeria, socioeconomic status has a significant influence on modern contraceptive utilization.[11] Another study in Nigeria also revealed that being Muslim (religion) was statistically significant to the utilization of modern contraceptives, and the authors stated that it was because women who are Muslim have fewer misconceptions about modern contraceptives.[12]  A further study in Nigeria indicates that women with many children were more likely to use modern contraceptives.[13]

In Nepal, only 21% of women were using modern contraceptives due to a lack of media exposure.[14] Again, a study conducted in Nigeria revealed that the effect of awareness of family planning methods on the increased use of modern contraceptives was significant.[11] Likewise, in Indonesia, a study indicated that access to health services and free services had a positive relationship with modern contraceptive utilization.[15]

Conclusion

The study concluded that level of education, occupation, religion (Muslim) and having many children, knowledge about modern contraceptives, access, and partner’s support were positively associated with modern contraceptive utilization while age, marital status, and traditional healers were not. Finally, modern contraceptive utilization was higher than the national prevalence.

We  recommend increasing awareness of  contraception, encouraging partners’ support, and researching why Terekeka County has a higher prevalence of modern contraceptives.

References

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  2. World Health Organization. 2019. Contraceptive use by method. https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception 
  3. Vladimíra K, Mark C W, Philipp U, Aisha N Z: Estimating progress towards meeting women›s contraceptive needs in 185 countries: A Bayesian hierarchical modelling study. 2020 https://pubmed.ncbi.nlm.nih.gov/32069289/#:~:text=Save,eCollection%202020%20Feb 
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  10. Justin Geno Obwoya, J. K. 2018. Factors influencing contraceptives among women in Juba city of South Sudan. https://doi.org/10.1155/2018/6381842 
  11. Alo OD, Daini BO, Omisile OK, et al. Factors influencing the use of modern contraceptive in Nigeria: a multilevel logistic analysis using linked data from performance monitoring and accountability. BMC Women›s Health 2020; 20:191. https://doi.org/10.1186/s12905-020-01059-6 
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  13. Ndriyas M, Eshete A, Mekonnen E, Misganaw T, Shiferaw M, Ayele S. Contraceptive utilization and associated factors among women of reproductive age group in Southern Nations Nationalities and Peoples› Region, Ethiopia: cross-sectional survey, mixed methods. Contracept Reprod Med. 2017 Feb 2; 2:10. https://doi.org/10.1186/s40834-016-0036-z 
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  15. Maharani A, Sujarwoto S, Ekoriano M. Health insurance and contraceptive use, Indonesian Family Planning Census 2021. Bull World Health Organ. 2023 Aug 1;101(8):513-521. Epub 2023 Jun 15 https://doi.org/10.2471/BLT.22.289438