Behaviour change and contraceptive use in low- and middle-income countries

By Gayatri Koshy, Head of mHealth

When you think of family planning initiatives in low- and middle-income countries (LMICs), it’s hard not to think about the forced sterilisation drives in India in the late 1970s and the one-child policy of China. The primary objective of these policies was population control — a response to the growing alarm in the 1960s that population growth was outstripping food supply.

These policies had disturbing long-term consequences. For example, in India, the trauma of forced sterilisation of men made it difficult for family planning to be on the agenda for any subsequent government. As a result, India’s family planning programme did not move beyond sterilisation for decades.

Family planning today

The world has since moved away from seeing family planning as a population control measure. It’s now a crucial aspect of women’s reproductive rights as well as global health and development. Achieving universal reproductive healthcare is one of the goals of the 2030 Agenda for Sustainable Development. Expanding access to contraception and ensuring that demand for family planning is met using effective contraceptive methods are essential aspects of this goal.

Today, 270 million women worldwide have an unmet need for contraception (WHO 2020). These are women in the reproductive age group (15 to 49) who are not using contraception despite wanting to wait at least two years to get pregnant or not wanting to get pregnant at all.

More than 80 per cent of unintended pregnancies occur in LMICs (Phiri et al. 2015). Unsafe abortion is highly prevalent and contributes to high maternal mortality rates in LMICs (Cleland et al. 2006).

If contraceptive use increased among those who need it, each year it would avert:

  • 76 million unintended pregnancies
  • 21 million unplanned births
  • 26 million unsafe abortions

There would also be 186,000 fewer maternal deaths each year (Sully et al. 2020).

Slow growth in modern contraceptive use

Globally, the proportion of married women aged 15 to 49 using modern contraceptive methods has risen by just 2 per cent between 2000 and 2019, from 55 per cent to 57 per cent (WHO 2020).

Why is this?

Reasons for this slow increase include:

  • limited availability of services
  • limited choice of methods
  • inequities in access to services, particularly among young, poor and unmarried people

Where services exist, many do not access them because of, for example, the fear or experience of side-effects with certain methods. This is made worse by poor quality of counselling. Many face cultural or religious opposition to the use of contraceptives. There are also barriers to women leaving home to access services (WHO 2020).

In many marriages, men’s opposition to contraceptive use suggests an imbalance in power relations and contraceptive decision-making. Empowering women with better negotiation skills with their partners is crucial (Adanakin et al. 2019).

There‘s a lack of knowledge about when to use modern contraceptives. For example, many women who have just given birth believe that their fertility returns only with the return of their period. They wait until their period returns before they start using any contraception. This makes them vulnerable to unplanned pregnancies (Sedgh et al. 2016).

The stigma associated with sexual activity among young or unmarried women also prevents them from accessing modern contraceptives (Cohen et al. 2020; Yarrow 2014).

What works?

Bringing the service to the people: Community-based interventions to increase contraceptive use have been implemented in LMICs and have proved useful in reaching rural, hard to reach populations with limited access to health services (Cleland et al. 2006; Mwaikambo et al. 2011). Family planning interventions that include home visits have more of an impact on contraceptive use (Belaid et al. 2016; Phiri et al. 2015).

Male partner involvement: There’s overwhelming evidence to suggest that involving male partners in making decisions about contraception helps to improve uptake (Aung et al. 2020, Phiri et al. 2015). Many of these studies have also shown that male involvement in family planning decisions improves attitudes towards using contraception. This has long-term benefits for women (Aung et al. 2020, Tao et al. 2015). Studies have also shown that involving family members during counselling can be effective (Belaid et al. 2016).

Mobile phone outreach: Mobile phones provide a unique opportunity to reach underserved communities. Their wide availability, portability and potential for privacy makes them an efficient means of sending family planning messages to those whose needs are not being met by existing services. For example, a text messaging service called m4RH, targeting young people in Kenya and Tanzania, led to an increase in contraceptive knowledge (Johnson et al. 2017).

‘Push’ approach using motivational messaging and interactive communication: A review of digital interventions aimed at increasing contraceptive uptake found that those that were effective had the following commonalities:

  • they used a ‘push’ approach to deliver information that was tailored to the recipient
  • they allowed interactive communication
  • they provided motivational messages (Aung et al. 2020).

There’s also some evidence to suggest that using financial incentives like cash transfers and vouchers can help nudge people into accessing family planning services (Belaid et al. 2016). Leading organisations have also recommended piggybacking on other services such as vaccinations to provide family planning counselling. This would especially work with women who are reluctant to attend family planning sessions due to social pressures.

What next?

We’ve come a long way since the days of the draconian population control policies of China and India. Family planning is now accepted as an essential part of human development and social progress. However, it’s not just a case of making a wide range of contraceptive methods available to all. It’s also about shifting social norms and attitudes, and empowering women to take control of their bodies. The United Nations Population Fund (UNFPA) and other organisations, for example, are working with religious leaders in such places as Nigeria and Chad to change attitudes.

There’s also a need to look beyond married couples or adult women. Adolescent girls are significantly less likely to use contraceptives than adult women (Zhihui et al. 2020). A quarter of sexually active adolescent girls are not using contraception. Unplanned pregnancies in this group can upend the hopes and dreams of young people (UNFPA 2016).

There’s also a tendency to focus on cisgender women when we think of sexual and reproductive rights. This excludes a diverse group of transgender and non-binary people who have sexual and reproductive health needs and experiences that might be different from cisgender women.

We need age-appropriate targeted behaviour change programmes to help increase uptake of contraceptives among all marginalised groups. We also need creative solutions and behaviour change communication strategies to change attitudes and social norms.

Gayatri is the Head of mHealth at Thrive. With a Master of Public Health (MPH) degree, she has extensive experience working in global health projects as well as national level programmes such as India’s National AIDS Control Programme.

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Adanakin AI et al. (2019) Power relations and negotiations in contraceptive decision-making when husbands oppose family planning: analysis of ethnographic vignette couple data in Southwest Nigeria. Cult Health Sex. 21(12):1439-1451. doi: 10.1080/13691058.2019.1568576.

Aung B et al. (2020) Effectiveness of mHealth Interventions for Improving Contraceptive Use in Low- and Middle-Income Countries: A Systematic Review. Global Health: Science and Practice December 2020, 8(4):813-826;

Belaid L et al. (2016) Effectiveness of demand generation interventions on use of modern contraceptives in low- and middle-income countries. Trop Med Int Health . 2016 Oct;21(10):1240-1254. doi: 10.1111/tmi.12758. Epub 2016 Aug 17.

Cleland et al. (2006) Family planning: the unfinished agenda. Lancet. 2006 Nov 18; 368(9549):1810-27.

Cohen N et al. (2020) Behavioral barriers to the use of modern methods of contraception among unmarried youth and adolescents in eastern Senegal: a qualitative study. BMC Public Health, 20(1025).

Ir P et al. (2010) Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia. BMC Pregnancy Childbirth 2010: 10: 1–11.

Johnson D et al. (2017) A randomized controlled trial of the impact of a family planning mHealth service on knowledge and use of contraception. Contraception 95(1): 90-97.

Mwaikambo L et al. (2011) What works in family planning interventions: a systematic review. Stud Fam Plann. 2011 Jun; 42(2):67-82.

Phiri M et al. (2015) Behaviour change techniques and contraceptive use in low and middle income countries: a review. Reprod Health. 2015; 12: 100. doi: 10.1186/s12978-015-0091-y

Sedgh G, LS Ashford and R Hussain (2016) Unmet Need for Contraception in Developing Countries: Examining Women’s Reasons for Not Using a Method. Report. Guttmacher Institute

Sully EA et al. (2020) Adding It Up: Investing in Sexual and Reproductive Health 2019, New York: Gutt­macher Institute.

Tao AR, et al. (2015) Providers’ perspectives on male involvement in family planning in the context of a cluster-randomized controlled trial evaluating integrating family planning into HIV care in Nyanza Province, Kenya. AIDS Care. 27(1):31–37. doi:10.1080/09540121.2014.954982. pmid:25329436

UNFPA (2016) Facing the facts: Adolescent girls and contraception.

Van de Poel E, et al. (2014). Can vouchers deliver? An evaluation of subsidies for maternal health care in Cambodia. Bull World Health Organ: 92: 331–339.

WHO (2020) Family planning/contraception methods.

Yarrow E. (2014) Over-protected and under-served: a multi-country study on legal barriers to young people’s access to sexual and reproductive health services.

Zhihui L et al. (2020) Contraceptive Use in Adolescent Girls and Adult Women in Low- and Middle-Income Countries. JAMA Netw Open. 5;3(2):e1921437. doi: 10.1001/jamanetworkopen.2019.21437.

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