Barriers to modern contraceptive use in rural areas in DRC

Abstract

Recent research in the Democratic Republic of Congo (DRC) has shown that over a quarter of women have an unmet need for family planning and that modern contraceptive use is three times higher among urban than rural women. This study focuses on the reasons behind the choices of married men and women to use contraception or not. What are the barriers that have led to low levels of modern contraceptive use among women and men in DRC rural areas? The research team conducted 24 focus groups among women (non-users of any method, users of traditional methods and users of modern methods) and husbands (of non-users or users of traditional methods) in six health zones of three geographically dispersed provinces. The key barriers that emerged were poor spousal communication, sociocultural norms (especially the husband’s role as primary decision-maker and the desire for a large family), fear of side-effects and a lack of knowledge. Despite these barriers, many women in the study indicated that they were open to adopting a modern family planning method in the future. These findings imply that programming must address mutual comprehension and decision-making among rural men and women alike in order to trigger positive changes in behaviour and perceptions relating to contraceptive use.

Résumé

De récents travaux de recherche conduits en République Démocratique du Congo (RDC) montrent que plus d’un quart des femmes ont des besoins non satisfaits en matière de planification familiale et que le recours aux contraceptifs modernes est trois fois plus élevé chez les femmes vivant dans des zones urbaines que chez celles vivant dans des zones rurales. Cette étude s’est penchée sur les motivations dans le choix des hommes et des femmes mariés d’utiliser ou non la contraception. Quels sont les obstacles qui ont eu pour conséquence de faibles niveaux d’utilisation des contraceptifs modernes par les femmes et les hommes des zones rurales de la RDC ? L’équipe de recherche a conduit 24 groupes de discussion thématique parmi des femmes (non-utilisatrices d’une quelconque méthode, utilisatrices des méthodes traditionnelles et utilisatrices des méthodes modernes) et des époux (de non-utilisatrices ou d’utilisatrices des méthodes traditionnelles) dans des zones de santé géographiquement dispersées. Les obstacles clés révélés par l’étude sont la mauvaise communication entre époux, les normes socioculturelles (en particulier le rôle du mari en tant que principal décideur et le désir de fonder une grande famille), la crainte des effets indésirables et le manque de connaissances. Malgré ces obstacles, nombreuses sont les participantes de l’étude à avoir déclaré qu’elles étaient ouvertes à l’idée d’adopter une méthode moderne de planification familiale à l’avenir. Ces résultats impliquent que toute planification doit prendre en compte, de la même manière pour les hommes et pour les femmes des zones rurales, les questions de compréhension mutuelle et de prise de décision, afin de susciter des changements des attitudes et des perceptions vis-à-vis de l’usage des méthodes contraceptives.

Resumen

En un estudio reciente realizado en la República Democrática del Congo (RDC) se ha demostrado que más de una cuarta parte de las mujeres no disponen de suficientes medios de planificación familiar y que el uso de anticonceptivos modernos es tres veces superior entre mujeres de áreas urbanas que entre mujeres de áreas rurales. En este estudio nos centramos en qué motivos llevan a mujeres y hombres casados a usar anticonceptivos o no. ¿Qué obstáculos han llevado a que el nivel del uso de anticonceptivos modernos en mujeres y hombres de la RDC de áreas rurales sea tan bajo? El equipo de investigación llevó a cabo 24 charlas en grupo con mujeres (que no utilizaban ningún método, métodos tradicionales o métodos modernos) y maridos (de mujeres que utilizaban métodos tradicionales o ningún método) en seis zonas de salud de tres provincias geográficamente dispersas. Surgieron diferentes obstáculos clave: una falta de comunicación entre los esposos, normas socio-culturales (especialmente el papel del marido como la persona principal que toma las decisiones y el deseo de formar una familia grande), el temor de los efectos secundarios y la falta de conocimiento. Pese a estos obstáculos, muchas mujeres en el estudio manifestaron que en el futuro estarían abiertas a adoptar un método moderno de planificación familiar. Estos resultados implican que en los programas deben incluirse temas como la comprensión mutua y la toma de decisiones de los hombres y las mujeres de áreas rurales por igual a fin de generar cambios en la conducta y las percepciones sobre el uso de anticonceptivos.

Keywords:

• Democratic Republic of Congo
• family planning
• barriers
• cultural norms
• family size

Introduction

The Democratic Republic of Congo (DRC) is the second largest country in land mass in sub-Saharan Africa and the third most populous, home to an estimated 77 million people in 2012 (UN 2015). The country is experiencing high population growth that is increasing at an annual rate of 3.1%, which if unchecked will lead to a doubling of the population every 22 years. The DRC is also characterised by the young age structure of its population, with roughly 61% of the total population under 20 years of age and with 52% under 15 years (DHS 2014).

At a national level, the unmet need for family planning is 28%, with more women having an unmet need for spacing births (21%) than for limiting births (7%). As of 2013–14, only 7.8% of women married or in union of reproductive age used modern contraception and the average fertility rate remains high at 6.6 children (an increase from 6.3 in 2007) (DHS 2014). Fertility is lower in urban areas (mean of 5.4 children per woman) than in rural areas (mean of 7.3 children). Consistent with this finding, modern contraceptive prevalence is higher in urban (15%) than rural (5%) areas (DHS (Demographic Health Surveys) 2014).

Modern contraceptive prevalence is influenced both by ‘supply’ of services and ‘demand’ on the part of the population to use these services and in turn adopt contraceptive methods. This article focuses specifically on demand. Given the low levels of modern contraceptive use in rural populations of the DRC, what are the barriers to use among women and men in these rural populations?

This study was conducted in conjunction with the UK Department for International Development funded Accès aux Soins de Santé Primaires (ASSP) project, a large scale integrated health service project operating in 52 rural health zones (of the 516 total in the DRC). The study aimed to provide insights to programme managers that might inform the family planning interventions in these health zones, given that family planning is a priority within the project. Data from a baseline survey conducted in project health zones in 2014 showed low levels of education (less than 5% of women had completed high school) and high levels of fertility (by age 45–49 women had an average of 5.0 children). Unmet need in these areas was high (21.2%), though primarily for spacing (17.9%) rather than limiting (3.3%) (Bertrand et al. 2016). The reasons given in a 2014 quantitative baseline survey for non-use of contraception among married women wishing to delay birth for two or more years were infrequent or no sexual relations (42.2%), breastfeeding (40.8%), lack of menstruation since last birth (28.0%), lack of knowledge (18.6%), their own or partner’s opposition to use (13.1%) and side-effects or health concerns (3.8%) (Hotchkiss et al. 2016). This study sought to gain more nuanced insights into these reasons through the use of qualitative methods.

Methodology

The ASSP project operates in selected health zones of six provinces (of 26 total provinces in the country). This study collected data in three of these six provinces (which are geographically dispersed in different regions of this vast country): Maniema, Kasai and Nord Ubangi. One ‘high’ and one ‘low’ performing health zone were purposely selected in each of these three provinces, based on family planning performance as measured by couple-years of protection (Stover, Bertrand, and Shelton 2000; USAID 2011). The selected zones, shown in Figure 1, included:

(1)	Maniema: Alunguli (high performance) and Kampene (low performance)
(2)	Kasai: Mutoto (high performance) and Mweka (low performance)
(3)	Nord Ubangi: Bili (high performance) and Bosobolo (low performance)

Figure 1. Map of the health zones in the DRC, showing the six included in this study.

This study included a total of 24 focus-group discussions among married men and women living in communities supported by the project. Men were recruited separately from women and were not the husbands of female participants. The age criteria (women 20–30 and men 25–34 years) were intended to produce fairly age-homogenous groups. The age ranges were selected to include married women during their peak reproductive period and husbands whose wives might likely (though not necessarily) be in this same peak reproductive period. Men were also more likely to be married at a later age, which led to the purposeful selection of older men rather than those who were the same age as female participants (Hotchkiss et al. 2016). In addition, participants were selected based on contraceptive use (by either the wife or husband). In sum, in each of the three provinces, focus groups were conducted in one ‘high’ and one ‘low’ performing health zone among the following four groups:

•	married women who were using a modern method
•	married women who were not using a modern method (i.e., were using a traditional or no method)
•	married men whose wives were using a modern method
•	married men who were in a non-user union.

Focus-group discussions covered several themes: (1) community norms and communication regarding family size, (2) knowledge of modern contraceptives and where to obtain them, (3) reasons for use or non-use of modern contraceptives and (4) intentions to use family planning in the future.

All focus-groups were conducted in the local language and audio recorded; complementary hand written notes were taken. These audio recordings were then transcribed into French and analysed to identify main themes as well as areas of agreement and divergence with respect to the questions contained in the discussion guide.

Ethical approval for the study was obtained from the Institutional Review Boards of Tulane University (reference # 717117) and Kinshasa School of Public Health (reference # ESP/CE/0901/2015) before the start of data collection. Oral informed consent was obtained from all participants prior to their participation in the study.

Findings

Community norms regarding family size

Both men and women described their aspirations to have a large family, even those who were using contraceptives. According to participants, people in their communities favoured having many children (as low as 4, as high as 8–10) for several reasons. Parents viewed children as a gift from God. They intended to have many in the hope that at least one would survive, be able to go to school and help them financially in the future:

People want to have more children so that there is at least one child who has the means to help parents because not all the children will be schooled for lack of funds. (Female/modern method user, Mweka)

In our culture as Africans, children are ‘riches’ for us. One must produce many children because you do not know which one will help you. By contrast, if you have two children and they die, there will be no one to care for you. (Husband of a modern method user, Mutoto)

In the territory of Mweka, there are many diseases and many deaths. People give birth to many children because death will take more children. (Husband of a modern method user, Mweka)

Children are wealth to Africans. Each family must have many children because these children are able to help work in the fields. (Female, non-user/Mutoto)

Spousal communication regarding the number of children desired

Both men and women agreed that decisions on family size fall largely on the husband. Participants agreed that husbands and wives do not explicitly discuss the number of children that would be best for their family. Men consider themselves as the head of the household who support their wife and children financially and are therefore responsible for deciding on all matters relating to reproduction:

For me it is the man who wants to have more children and who decides the number of children because he is the head of the family, the one that feeds the children and women. (Husband of a modern method user, Bili)

Here in Kampene, the man and woman don’t come to an agreement, because the man wants to have children until the woman can no longer give birth, couples want to have many children. (Husband of a modern method user, Kampene)

No, we don’t need to discuss the number of children; it is the man who makes the decision, he is the head of the family and it is he who pays the dowry. (Husband in a non-user union, Bosobolo)

Among the Ngbaka, it is the man who decides the number of children. People here think that if they have many children, living conditions will improve because the children will help their parents and they live with this hope. A woman is also happy to have many children because she thinks that with many children, her husband cannot divorce her. (Female/non-user, Bosobolo)

Another husband stated that it would be futile to discuss number of children in a marriage because God was the one who ultimately decides:

No, we never talked about the number of children with my wife at home because we know that it is God that gives children and he is [determining] the number of children. (Husband of a non-user, Bili)

Even if a couple could agree on their desired family size, they might find themselves needing to amend this later on, for example if the women begins to experience health problems or if they end up with more children than they hoped for, due to non-use of contraceptives:

Initially we had agreed with my husband on the number of children to have, but we did not use Family Planning (FP); now we have a large number of children, which is not what we had wanted. (Female/modern method user, Bili)

One participant also explained:

It is the man who decides on the number of children. The man wants the woman to have many children so she can grow old quickly so that no man might still love her after he dies. But if she has only 2 or 3 children, another man might still marry her. (Female/non-user, Mweka)

And a minority of husbands were in favour of limiting the number of children:

We agreed with my wife to have only two children. We set this number because we do not have the means, we think that [having children] beyond that number will bring poverty, misfortune. (Husband of a modern method user, Alunguli)

Husband-wife differences in desired family size

Whereas both men and women aspired to have large families, participants indicated that men were likely to want more children than women. Children are expected to help their parents financially and are a free source of labour. They are seen as a way to help assure a family’s status and longevity in the long run:

It is the man who wants to have more children so that these children can help when he is no longer able to cultivate the fields and do other farm work. (Female/modern method user, Mweka)

It is the husband who decides because he is the head of the family, he is the one who takes care of the wife and children. It is he who educates, nurtures and pays for clothes for everyone including his wife. And in the future, these children will be able to help him. (Female/non-user, Mutoto)

By contrast, women are more likely to want some means of planning their births because they are aware that pregnancy is often difficult and carries life-threatening risks:

Men want to have more children because they are not experiencing labour pains; but we women feel that pain during childbirth and we want to limit the number of children. (Female/modern method user, Alunguli)

At first my husband and I didn’t talk about the number of children we wanted, but now I have health problems and I always give birth by cesarean section, so we decided to limit the number of children. This is why I use family planning. (Female/modern method user, Kampene)

The husband’s support for family planning use was a decisive factor in a couple’s decision. Female participants explained how their husband’s judgement took precedence over any other family member or friend’s approval or disapproval:

My husband and I decided to use this method. When my sister-in-law learned that I was going to use these methods, she was against me and we bickered about it. But as my husband was for family planning, I use contraception without problems. (Female/modern method user, Bosobolo)

Outside influences on family size

Peers may try to influence couples to have a large family, but the primary pressure came from the husband’s family. Many older family members held traditional ideas about childbirth, family size and fertility and they were prone to intercede when they saw that a couple did not yet have a lot of children. Apart from the common belief that children are ‘riches’ and the desire of elders for grandchildren, participants explained how family members on the husband’s side often believe that they deserve children in return for having paid a dowry:

My mother-in-law told me one day that she had wanted to have a lot of children but was unable to. [She said] the children I wanted to have – it’s now up to you to have them. (Female/modern method user, Mweka)

It is the man’s parents influencing their child to have many children. They say it is not for nothing that we gave you money to pay the dowry. (Husband in a non-user union Mutoto)

The grandmother influences the number of children in the household. She comes to tell her son that he must have many children because among them there will be doctors, nurses, judges etcetera. (Female/non-user, Mweka)

Women also expressed the fear that they might be replaced by a second wife if they failed to please their husband’s family by having children.

It is the family members of the man who influence a couple to have children in order to enlarge the family. If their brother does not have many children with this wife, they will encourage him to take another wife. (Female/modern method user, Mweka)

If you do not produce many children, your husband’s family can come and chase you out of his home. (Female/non-user, Bili)

Community attitudes towards family planning

Most participants believed that their communities were unfavourable toward family planning for a variety of reasons, cultural and religious reasons in particular. People identified as being the most against family planning were religious leaders and grandparents (or ‘the older generation’):

Churches are against these methods that don’t conform to the word of God, which says to ‘multiply and replenish the earth’. (Husband in a non-user union, Kampene)

People say that these methods are good for those who have many children, but those who have few children should not use family planning. After you have three children you can use family planning. (Husband of a modern method user, Bili)

Negative attitudes towards family planning were based on several factors, including the belief that the use of contraceptives encourages prostitution, hinders families from having a lot of children if they so desire and causes sterility or bleeding. Even women who used contraceptives themselves felt that the practice was regarded unfavourably by their communities:

Men say that these methods will cause diseases, others say that these methods will burn our organs. For now we put all these comments into the hands of God, who is our only refuge. (Female/modern method user, Kampene)

Some members of our community say it’s not good to use family planning methods because they make the woman sterile. (Husband in a non-user union, Mutoto)

Our culture is not favourable to family planning. People here think that family planning encourages prostitution. (Husband in a non-user union, Kampene)

Suggesting a possible change in norms, a few participants mentioned that some community members were becoming more open to contraceptive use over time but did not indicate why this was so.

Knowledge of modern contraceptives and where to obtain them

The vast majority of women had some knowledge of contraceptive methods. Those who were not using a modern method were still able to name a few, including the contraceptive pill, the implant and Depo Provera. They also knew that they were available at health facilities that were easily accessible to them. On the other hand, husbands in a non-user union were less likely to know about modern contraceptive methods. A few had heard of condoms, the contraceptive implant and Depo Provera, others mentioned recent educational campaigns in their communities aimed at explaining modern contraceptives.

Reasons for use of modern contraceptives

Women who were using contraceptives indicated that they had overcome community disapproval to become contraceptive users. These women chose to do so for a number of reasons, including the difficulty of their living conditions, problems of health for themselves and their children, and their belief in the benefits of child spacing or child limiting. Husbands of these women also tended to know more about contraceptives than their peers and were aware that contraceptive methods were easily accessible at their local health facility:

What prompted me to use family planning was that my four children were sick. They had anaemia and were dehydrated. So I told my husband about family planning. We went to see the nurse at the health centre who advised us to use family planning to space births, as there was a risk of losing them. (Female/user, Bosobolo)

I already have six children. We must feed them, send them to school, and cover all their needs. My husband and I decided to stop having children. (Female/user, Kampene)

This prompted us to use family planning, because our children were malnourished, they were always sick. The nurses advised us to use family planning methods to space births. (Husband of a modern method user, Mutoto)

Both female and male participants reported that in general they had favourable interactions with the healthcare providers at their facilities:

A provider who received me at the health centre was very happy. It was the same nurse who had given a group talk in the community. When she saw me, she had me sit down and I got the method I wanted. (Female/modern method user, Mweka)

When I got to the health centre, I found a nurse. I told her I wanted to have a modern method, she then explained the advantages and disadvantages. She said that these methods were free. (Female/modern method user, Kampene)

My wife was well received by the nurses. They explained to her the advantages and disadvantages of the methods. The nurse told her if she had any side-effects, she could come back to the health centre. (Husband of a modern method user, Bosololo)

Reasons for the non-use of modern contraceptives

Many of the men and women had a strong fear of side-effects. Others mentioned that they were not provided with any counselling on the methods and thus felt unsure about them. Low community awareness on the facts surrounding family planning is a significant deterrent to its use, leading couples to decide to take their chances rather than suffer any potential consequences caused by contraceptive use:

Women who have used family planning methods in the past make these types of comments: ‘I used family planning but I stopped. I wanted to have a child and I could not get pregnant.’ When our friends hear that, they do not go to the health centre to use these methods. (Female/modern method user, Mutoto)

Others refuse because these methods disrupt the monthly cycle. For example, I’ve used the implant and I had constant spotting. When I told that to other women, they were reluctant to go to the health centre. (Female/modern method user, Bili)

We want to use these methods but we do not have enough information to reassure us. There is no counselling and it surprises us when we are told to go to the health centre to take these methods. (Female/non-user, Bosobolo)

Religious concerns also played a role in decision-making:

God is against these products. Take for example the condom, the Scriptures forbid man to throw away his seed, whereas the condom collects the seed. (Husband in a non-user union, Bosobolo)

Male participants expressed doubts about the utility and safety of contraceptives:

People are afraid to use these methods because some women who have used them talk about the side-effects. There was a woman who said to her friends ‘I used those methods and I got cancer and I had to go to Goma to get treated.’ (Husband in a non-user union, Alunguli)

I do not know about these methods, I do not see how I will use them. (Husband in a non-user union, Bosobolo)

I have my doubts because these methods cause disease. (Husband in a non-user union, Alunguli)

Intentions to use family planning in the future

A number of female participants not currently using a family planning method suggested that they would be open to the idea of using one in the future. Most shared the view that they had limited opportunities to receive counselling or in-depth information from healthcare providers and were therefore unsure about the use or benefits of modern contraceptives. The primary concern of these women was addressing their fear of side-effects and gaining more information about how to manage these before making a decision:

We want to use these methods, but I want to first have information on the disadvantages of these methods. (Female/non-user, Bili)

We ask the nurses to do outreach to all mothers so that they have the opportunity to know the advantages and disadvantages of these methods and especially tell us where we can find these methods. (Female/non-user, Kampene)

We must involve community leaders, churches, political and administrative authorities and commit all to give us information on these methods, then we will use them. (Female/non-user, Mutoto)

A number of men whose wives were not using a family planning method also revealed that they were open to changing their minds and using a method in the future:

Yes, we will use these methods because if we follow our traditional ways, we will have children who will not study and that will not be healthy because of malnutrition. (Husband in a non-user union, Bili)

I’m going to use family planning in the future because in my family, I have a child every year and a half, and that is creating a lot of problems. (Husband in a non-user union, Bosobolo)

It was important for couples to feel that they would be using family planning methods to space births, not limit them:

I agree to these methods for birth spacing. If children are too close, they will have health problems and we will not be able to feed them because we do not have the means. (Husband in a non-user union, Mutoto)

For certain couples, future use was predicated on the husband’s agreement:

My wife and I can use these modern methods in the future, provided I give my consent. (Husband in a non-user union, Kampene)

Only one male participant was categorically opposed to ever using modern contraception because of his religious convictions:

I will not use these methods because they are against the word of God. If there are other methods besides modern methods, I can use those in the future. (Husband in a non-user union, Mweka)

Discussion

The objective of this study was to identify the key barriers that have led to low levels of modern contraceptive use among women and men in rural areas of the DRC. It specifically focused on attitudes that would affect the uptake of contraceptive methods. The findings from the 24 focus-group discussions held among these married men and women reflected a strong adherence to cultural norms favouring large families. The majority of couples who did use family planning methods did so to space the births of their children for financial or health reasons while still expressing their desire for a large family. This desire grew out of the shared belief that not all of one’s children will survive to adulthood; that having many offspring increases the odds that at least one would become successful; that children are a gift from God; and that large families are an important part of ‘African’ culture. Influence exerted from extended family members and peers had a strong effect on family size, with women feeling pressured to live up to the expectations of their husband’s family and prove their worth.

This study had several limitations. As with most qualitative research, the findings are not generalisable to other populations. The purposeful selection of ‘high’ and ‘low’ performing health zones vis-a-vis family planning does not ensure that these populations were in fact representative of all rural health zones in the DRC or even those covered by the ASSP project.

This study contributes however to a growing body of research on barriers to contraceptive use in rural populations of sub-Saharan Africa. A quantitative baseline survey conducted in 2013–14 in the DRC showed that the majority of married women (54.2%) who did not currently use contraceptives had no intention of doing so in the future; this number dropped from 68.6% if the woman had no children, to 49.4% if she had two, and to 56.3% if she had at least four (DHS 2014). The qualitative findings from this study show that a number of married non-user women would be open to using contraceptives in the future. While a key finding, this openness does not necessarily indicate intent, as suggested by the results of this and several other qualitative studies that highlight the husband’s significant role in contraceptive use, as his approval is often the deciding factor.

In this study and in others undertaken in rural areas, women pointed out that their male partner’s resistance to family planning was a major barrier to use, even in the rare cases of joint decision-making (Bogale et al. 2011). Although men play the role of decision-maker, they are often detached from and lack interest in reproductive health issues, particularly in rural patriarchal communities (Kabagenyi et al. 2014). A study in rural Ghana noted that despite the fact that a majority of women considered family planning acceptable, an even higher percentage of women expressed that they would require the permission of their partners before they actually adopted a modern method. Consistent with the results of this study, this finding suggests that a woman’s personal conviction is insufficient to ensure actual uptake of modern contraceptive methods. The Ghanaian study also showed, however, that men and women had similar levels of acceptance of family planning, which could point to inadequate spousal communication leading to an inaccurate perception of male partners’ opinions in some instances (Eliason et al. 2013).

Qualitative research undertaken in other sub-Saharan African countries also supports the suggestion that male involvement in family planning can increase uptake and continuation of contraceptive use by improving spousal communication (Kabageny et al. 2014; Okwor and Olaseha 2010; Vouking, Evina, and Tadenfok 2014). In situations where men were unanimous in their belief that using contraceptives gave room for infidelity on the part of the woman, a large number also believed that joint decision-making and truthfulness could help limit some of these suspicions and fears leading to non-use (Okwor and Olaseha 2010). However, some researchers have called for more work to be done on the perspective of male partners on contraceptive choice (Izale et al. 2014).

In addition to communication issues and differing spousal perspectives, cultural norms that support large families were revealed as a major barrier in a qualitative study conducted in Kinshasa with similar objectives. Although cultural norms were identified as contributing to non-use in this study undertaken in DRC rural areas, some women revealed that if their husband supported the use of a modern family planning method, they felt justified in using one, even if their family or friends criticised this decision (Muanda et al. 2016). This finding differs from the common impression backed up by other studies that report that deep-rooted cultural beliefs about gender norms help explain non-use in rural areas (Farmer et al. 2015). At the same time, the understanding of the husband’s role as the primary decision-maker in this study undertaken in DRC rural areas could also be explained or affected by the greater economic dependence and lower education level of rural women (Bogale et al. 2011).

Unlike the above-cited qualitative study recently undertaken in Kinshasa, the men and women interviewed in this rural study did not indicate that cost or availability were barriers to modern contraceptive use (Muanda et al. 2016). The majority of female users and non-users simply explained that they knew contraceptives were available and where to find them. Unlike costs and availability, additional barriers named by the men and women in this study were fear of side-effects and infertility, cultural norms, lack of knowledge about modern family planning methods and the association of contraceptives with promiscuity. These barriers are supported by findings from other qualitative research in rural sub-Saharan Africa that emphasise limited knowledge as a major deterrent to use (Bogale et al. 2011; Center et al. 2016; Jammeh et al. 2014; Kabageny et al. 2014).

These findings have a number of programmatic implications. Many of the women in this study who were non-users and open to adopting a family planning method in the future wished to do so as a way to limit births after they had already reached their desired number of children. However, participants also cited inadequate spousal communication, limited knowledge and fear of side-effects and cultural norms as additional factors in their decision as to whether or not to eventually adopt a modern contraceptive method, even after reaching their ideal family size. These concerns need to be addressed.

Poor spousal communication regarding the adoption of a modern contraceptive method was the primary deterrent to use for women open to adopting a family planning method. As the heads of household, men held the power in decision-making, including family size and contraceptive use. It was not common for husbands and wives to communicate openly and share this decision. In the minority of cases when a husband and wife discussed and agreed on their desired number of children, it was out of respect for the women’s health or the financial strain of adequately feeding, clothing and educating their children. Couples who had decided to use a modern contraceptive method understood it to be a response to difficult economic times as well as a strategy to protect the health of the mother and give their children an opportunity for a better life. Even women who were not using modern contraceptives generally knew about them and where to find them, while their husbands were less likely to be familiar with these methods or be aware of their accessibility. In a patriarchal culture where men are ultimately in charge of reproductive health decisions, it is crucial that awareness campaigns target husbands as well as their wives. Family planning efforts must involve men equally and they should be the focus of community-level awareness activities or educational talks on the benefits of these programmes alongside their partners. Programmes should rely on the understanding that spousal communication is important as a practical tool to increase the likelihood of modern contraceptive use, and should promote the idea that parenting is a duty; a larger family may not be financially feasible and it is important for parents to ensure the health, safety and education of those children they already have.

After husband disapproval, the main reason for non-use among women who were open to adopting a family planning method was a fear of side-effects, including sterility. This fear persisted even among women who were knowledgeable about contraceptives in their communities. Although challenging, it is paramount to mitigate the spread of false rumours and misinformation, as fears of long-term health effects such as sterility or disease undermine reproductive health programmes for at-risk communities, particularly in rural areas. Family planning programming needs to be based on clear and present information that is easy to understand and made readily available to provide couples with the factual information that they need to make a decision together. It is critical that healthcare providers dispel rumours and provide appropriate education, including on the proper management of potential side-effects.

Cultural norms supporting large family sizes are difficult to address and can take a long time to change. Male and female participants alike perceived the older generation as less accepting of family planning, but the changing population demographics in the country suggest that there is a strong potential to change attitudes among a growing younger population. Recognising this, programmes should stress expanded access to both information and services as well as greater depth of education and understanding for young men and women even before marriage, when they begin to feel a great deal of cultural pressure from pro-natalist family members and communities alike. If possible a reproductive health course should be introduced into secondary school education curriculum and easy-to-read information should be made available at health clinics.

The results of this study suggest that simply ensuring that couples are aware of family planning methods and their availability is not enough to trigger widespread changes in behaviour or perceptions. It is critical to address these persistent challenges with rural men and women alike to promote mutual comprehension, awareness and decision-making in regards to the use of modern contraceptives.

Disclosure statement

No potential conflict of interest was reported by the authors.

Funding

This work was supported by UK Government Department for International Development [grant number IMA-DFID/ASSP102012-1/].

Acknowledgements

This study was funded by the UK Government’s Department for International Development as part of a Prime Award to the Interchurch Medical Assistance, Inc., entitled Access aux Soins De Santé Primaires (ASSP) in DRC. The views expressed do not necessarily reflect the UK government’s official policies. We wish to thank Daniel Carter and Gemma Garent for management oversight of this award; Mavula Kusungu Baudoin and José Masanga Ndungi for their assistance with data collection and analysis of transcriptions; Julie Hernandez for creating the map included in this article; and Janna Wisniewski for assistance with data from the ASSP baseline survey.