Decision-making power among women of reproductive age towards family planning use and its associated factors: A cross-sectional study in Simiyu region, Tanzania

doi:10.21203/rs.3.rs-2230843/v2

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Decision-making power among women of reproductive age towards family planning use and its associated factors: A cross-sectional study in Simiyu region, Tanzania

https://doi.org/10.21203/rs.3.rs-2230843/v2

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Background: One of the Sustainable Development Goals (SDGs) to be achieved by 2030 is to empower women in decision-making. It is universally agreeable that women's decision-making power influences their use of family planning. However, due to disparities in social and cultural norms and beliefs, the percentage of women with decision-making power varies across societies. Furthermore, unintended pregnancies and unsafe abortions have remained a public health concern, with serious consequences such as death, physical and mental complications, as well as social and economic problems for a woman and her family

Objective: To assess women’s decision-making power towards contraceptive use and its associated factors in Simiyu region.

Methodology: The study utilizes data from a cross-sectional study conducted by Amref Health Africa among women of reproductive age in the Simiyu region. An interviewer-administered questionnaire was used for data collection. Stata 15 was used for data analysis. Categorical variables were summarized using frequency and percentage. The Chi-square test was used to compare the proportion of women’s decision-making power across independent variables. To identify factors associated with women's decision-making power regarding contraceptive use, a multinomial logistic regression model was used.

Results: A total of 917 women were investigated. Of these, 304 (33.1%) reported making their own decision on contraceptive use, 421 (45.9%) made a joint decision with their spouse, and 192 (20.9%) had their decision made by another person. Age, marital status, previous use of contraceptives, husbands using force for sex, and family planning being considered as women's health issues were all associated with women's decision-making power.

Conclusion; The findings of this study underscores that one in every five women has no decision on contraceptive use. It is high time for early women empowerment interventions, particularly among young women, to strengthen, promote, and encourage their decision-making on general health issues, particularly contraceptive use. This study calls for a qualitative study to get an in-depth understanding of the socio-cultural issues behind this power dynamic among women.

Contraceptive

decision making

family planning

women empowerment

One of the Sustainable Development Goals (SDGs) to be accomplished by 2030 is the empowerment of women in decision-making (1). A fundamental human right is a freedom of choice for women regarding the number, spacing, and timing of their pregnancies which is also regarded as the cornerstone of women's rights to reproductive health and contributes to their quality of life (2, 3).

Globally unintended pregnancies have been increasing and remained a public health concern. Unwanted pregnancies are associated with serious consequences such as death, physical and mental complications as well as social and economic problems for a woman, families and communities thus effective use of family planning prevents unwanted pregnancies (5, 6) Globally, approximately 1.1 billion women of reproductive age (15–49 years) have a need for family planning, of these 270 million have an unmet need for contraceptives (7). In sub-Saharan Africa (SSA) about 25% of women reported to have unmet need for modern contraceptive (8). Unmet need for family planning among married women of reproductive age in Tanzania is approximately 22% and contraceptive use amongst married women is 38% (6) Simiyu region is amongst the region with low prevalence rate of family planning use, only 17% of women of reproductive age used contraceptive (6).

Effort to improve women access to maternal and child health care together with reproductive health services have been implemented in the country. Despite the effort, the rate of modern contraceptive uses in the country is 32% in 2016 and very low in Simiyu region 17% (6). Studies show that, family planning decreases pregnancy-related risks that can be caused by a lack of birth spacing (9). Infant mortality is reported to be 40% higher when birth spacing is less than two years compared to when the birth spacing are two to three years apart (10). In addition, a short inter-pregnancy interval is reported to increase the risk of pre-pregnancy obesity, gestational diabetes and postpartum hemorrhage, and to women with a previous cesarean delivery increase the risk of uterine rupture (11, 12). Beside, family planning is important in economic growth since it offers benefits like extended education and empowerment of women and control overpopulation growth (7).

Women decision making power has been reported to influence family planning use (13). However, the percentage of women with decision-making power varies across societies due to difference in social cultural norms and beliefs (24, 25). Among other factors includes women’s age, young women aged below 20 are less likely to participate in decision making towards contraceptive. However, other studies shows that older women aged above 35years have less odds of decision making. Furthermore, occupation, level of education, religion, believes towards contraceptive methods, husbands use force for sex and prior experience on contraceptive influence decision making (14–18). Evidence shows that, 92.2% of women in India whether jointly with their partners or by themselves have the power in decision making towards contraceptive use (19). In Africa, a range from 67.4–70% of women who jointly with their partner make decisions toward contraceptive use (15, 16). Moreover, Studies have shown that, effective communication between partners can increase family planning uptake and continuation (20–22). However, little is known about the factors that influence women’s decision-making power on use of contraceptives in the country. Therefore, this study aimed at assessing women’s decision-making power towards contraceptive use and its associated factors in Simiyu region.

Study design and setting

This was a cross-sectional study that used secondary data collected by Amref Health Africa in Tanzania in Simiyu region from May 20^th to June 3rd, 2021. Simiyu is among the 33 regions in Tanzania located in the lake zone. The region has a total population of 1,747,997 people with 22% of the population being women of reproductive age (15-49 years). (23). Moreover, according to the National trends, the region has reported worse child and maternal health indicators as compared to other regions in the country, with family planning being at only 17% (6).

Study population and sampling

The study population were women of reproductive age (WRA) 15 – 49 years living in Simiyu region interviewed in an end line survey of UZAZI UZIMA II project. The project aimed to improve reproductive, maternal, newborn and child health in the region. A multistage sampling technique was used to select the study participants and an interviewer administered questionnaire was used for data collection. The data set consist of information on maternal and newborn care, family planning, and decision making aspects.

From the data base a total of 2020 women were interviewed, we excluded 1086 women who missed information on the outcome variable (decision making on contraceptive use). Out of the 934 remaining women, we further excluded 17 women who missed information on age. Therefore, a total of 917 women were included in the final analysis (Figure 1).

Study variable

The dependent variable was women decision making power towards contraceptive use categorized into three groups; women reported self-decision on contraceptive use, women reported jointly with her partner decides on uses of contraceptive and those whose decision was made by her partner or any other person.

The independent variable included age (<20, 20-29, 30-39, 40-49), marital status (unmarried, married cohabiting), education level (no formal education, primary , secondary), district of residence (Bariadi, Busega, Itilima, Maswa, Meatu), employment status (not employed, employed), religion (Christian, Muslim, other religion), a decision on utilization of other health services, believes that family planning is women issue, husband use force for sex and previous uses of contraceptive.

Data analysis plan

For data cleaning and analysis, STATA software version 15 was used. Frequencies and percentages were used to summarize categorical variables. The type of modern contraceptive used by women was summarized using a bar graph. To compare differences in proportion between groups of independent variables, cross tabulation of contraceptive use decisions against each independent factor along with a chi-square test was used. To identify factors independently associated with decision making power, a multinomial logistic regression model was done. The variables that were statistically significant in the bivariate analysis were included as potential confounders in the multivariable analysis. All significance tests were two-sided, and differences were considered significant at p-value less than or equal 0.05.

Socio-demographic characteristics of study participants

Among 917 women with the mean age of 29.8 (± 8.7), 374 (40.8%) were aged between 20 to29 years. Among them, 567 (62%) were married, more than half 589 (64.2%) had primary education, 505 (55.1%) were employed. In addition, 580 (63%) were Christians, and 31 (3.4%) were Muslims. (Table 1).

Table 1

Demographic characteristics of the study participants
Variable	n	%
Age
Mean (± SD)	29.8 (± 8.7)
< 20	122	13.3
20–29	374	40.8
30–39	269	29.3
40–49	152	16.6
District of residence
Bariadi	194	21.2
Busega	150	16.4
Itilima	182	19.9
Maswa	261	28.5
Meatu	130	14.2
Marital status
Single	270	39.7
Married	567	62.3
Cohabiting	73	8.0
Education level
No formal education	199	21.7
Primary education	589	64.2
Secondary education	127	14.1
Employment status
Employed	505	55.1
Not employed	412	44.9
Religion
Other religions	306	33.4
Christian	580	63.3
Muslim	31	3.4

Contraceptive Use By Age And Type

The finding revealed that, out of 917 women of reproductive age, only 83 (9%) said they had ever used contraceptives, and among them 66 (7%) were found to use contraceptive by the time of study. Looking at the age distribution among those ever used contraceptive, 44 (11.8%) were aged 20–29 years and 27 (10%) were aged 30–39 years.

Out of those found using contraceptives, 50 women were using modern contraceptive methods; whereas 22 (46%) used injections and 13 women used diaphragm. (Fig. 2)

Decision On Contraceptive Use By Characteristics Of Study Participants

Among 917 women analyzed, 304 (33.1%) reported to make self-decision on contraceptive use, while those who made joint decision with their spouse were 421 (45.9%) and 192 (20.9%) women had their decision made by another person.

Among women aged 20 to 29, 118 (50.3%) made a joint decision with their spouse. Furthermore, 46 (63.0%) of cohabiting women made a joint decision with their spouse, and 68 (48.6%) of women with the ability to make decisions about other health services utilization had a joint decision with their partner. Among women who had ever used contraception, 41 (49.4%) made self-decision, whereas 305 (50.3%) women whose husbands do not use force for sex reported making a joint decision. (Table 2).

Table 2

Decision on contraceptive use by characteristics of study participants (n = 917)
Variable	Decision on contraceptive use
	Self-decision	Jointly with spouse	Another person	P Value
Age				< 0.001
15–19	36 (29.5)	35 (28.7)	51 (41.8)
20–29	118 (31.6)	118 (50.3)	68 (18.2)
30 − 29	92 (34.2)	128 (47.6)	49 (18.2)
40–49	58 (38.2)	70 (46.1)	24 (15.8)
Employment status				0.225
Employed	167 (33.1)	242 (47.9)	96(19.0)
Not employed	137 (33.3)	179 (43.5)	96(23.3)
Marital status				< 0.001
Single	160 (59.3)	48 (17.8)	62(23.0)
Married	131 (23.1)	320 (56.4)	116(20.5)
Cohabiting	13 (17.8)	46 (63.0)	14(19.2)
Education level				0.556
No formal education	65 (32.7)	98 (49.3)	36(18.1)
Primary education	192 (32.6)	271 (46.0)	126(21.4)
Secondary education	47 (36.4)	52 (40.3)	30(23.3)
Religion				0.357
Other religions	104 (33.9)	134 (43.8)	68(22.2)
Christian	185 (31.9)	275 (47.4)	120(20.7)
Muslim	15 (48.4)	12 (38.7)	4(12.9)
District				0.273
Bariadi	68 (35.1)	82 (42.3)	44(22.7)
Busega	38 (25.3)	76 (50.7)	36(24.0)
Itilima	63 (34.6)	88 (48.4)	31(17.0)
Maswa	92 (35.3)	110 (42.2)	56(22.6)
Meatu	43 (33.1)	65 (50.0)	22(16.9)
Decision to use other health services				0.007
Yes	247 (33.9)	336 (46.2)	145(19.9)
No	31 (22.1)	68 (48.6)	41(29.3)
Ever used contraceptive				0.001
Yes	41 (49.4)	36 (43.4)	6 (7.23)
No	263 (31.5)	385 (46.2)	186 (22.3)
Husband uses force for sex
Yes	113 (36.5)	116 (37.4)	81 (26.1)	0.001
No	191 (31.5)	305 (50.3)	111 (18.3)
Family planning is women’s issue
Yes	93 (44.3)	80 (38.1)	37 (17.6)	< 0.001
No	177 (29.7)	306 (51.3)	113 (19.0)
Don’t know	17 (26.2)	19(29.2)	29 (29.2)

Factors Associated With Ability Of Women’s Decision-making Power Towards Contraceptive Use

Women aged 20 to 29 were 66% less likely to have their decision made by another person than jointly with their husband compared to those aged 15 to 19 (AOR = 0.344, 95% CI = 0.193–0.612).In addition, when we compared women who had never used contraceptives, those who had ever used contraceptives had more than 3 times higher odds to make self-decision rather than making a joint decision with their spouses (AOR = 3.405; 95% CI = 1.868–6.208).

When compared to unmarried women, married (69.8%) and cohabiting women (36%) were both less likely to have their decision made by another person than a joint (AOR = 0.088 95%CI = 0.054–0.145 and AOR = 0.052795%CI = 0.024–0.117). Furthermore, women who reported that family planning is solely a female issue had twice higher odds to make decisions on their own rather than jointly with their spouse compared to those who believed that family planning is not solely a female issue (AOR = 2.442; 95%CI = 1.571–3.797). And women whose husbands use force for sex were 70.5% more likely to have their decision made by another person than jointly with their spouse compared to women whose husbands do not force them to have sex (AOR = 1.705 95%CI = 1.109–2.621) (Table 3)

Table 3

Factors associated with ability of women’s decision-making power towards contraceptive use (n = 917)
Variables	Self-decision-making Vs jointly		Other person making decision Vs jointly
	AOR (95% CI)	P- Value	AOR (95% CI)	P- Value
Age
< 20	1		1
20–29	0.919 (0.488–1.728)	0.794	0.344 (0.193–0.612)	< 0.001
30 − 29	1.152 (0.601–2.208)	0.669	0.398 (0.216–0.736)	0.003
40–49	1.223 (0.606–2.467)	0.574	0.283 (0.138–0.578)	0.001
Marital status
single	1		1
married	0.088 (0.054–0.145)	< 0.001	0.302 (0.180–0.507)	< 0.001
cohabiting	0.0527 (0.024–0.117)	< 0.001	0.636 (0.123–0.591)	0.001
District
Bariadi	1		1
Busega	0.642(0.340–1.211)	0.171	0.887 (0.471–1.669)	0.709
Itilima	0.870 (0.503–1.504)	0.618	0.636 (0.339–1.192)	0.158
Maswa	0.946 (0.570–1.571)	0.831	1.036 (0.603–1.781)	0.897
Meatu	1.084 (0.585–2.008)	0.797	0.920 (0.469–1.803)	0.807
Decision to use other health services
No	1		1
yes	1.665(0.992–2.796)	0.440	0.861 (0.508–1.344)	0.442
Ever used contraceptive
No	1		1
Yes	3.405 (1.868–6.208)	< 0.001	0.522 (0.212–1.28)	0.157
Husband use force for sex
No	1		1
Yes	1.184(0.786–1.783)	0.247	1.705 (1.109–2.621)	0.015
Family planning is women’s issue
No	1		1
Yes	2.442 (1.571–3.797)	< 0.001	1.155 (0.696–1.917)	0.578
Don’t know	1.479 (0.653–3.350)	0.348	2.743 (1.361–5.529)	0.005

*AOR= adjusted odds ratio

This study aimed to assess women’s decision-making power towards contraceptive use and its associated factors in Simiyu region, Tanzania.We found that, 33.1% of WRA had a self-decision -making power in family planning use, while 45.9% made a jointly decision with the husband. The proportion of women making self-decision in Simiyu Tanzania is higher compared to 22% in South Africa. There was no significant difference in joint decision making which was found to be 45.9% in Simiyu Tanzania and 45% in South Africa (17). However, a higher proportion of women making joint decision was observed in Ethiopia (15). The observed variation might be due to differences in settings, and or culture of women across these countries.

This study also examined factors associated with women’s decision-making power on family planning. Our findings indicated that age, marital status, previous use of contraceptives, husbands using force for sex, and family planning being considered as women's health issues were significantly associated with women’s decision-making power to contraceptive use. Accordingly, women aged less than 20 years were less likely to make decisions on their own or with their partners/husbands than women aged above 20 years. This finding clearly communicate that the adolescents rely on other people to decide for them. Hence, empowering women at a young age and emphasizing their ability to make decisions about various aspects, most notably family planning, will improve their participation in decision making. This finding is consistent with the findings of a study conducted in Ethiopia, which found that young women have less decision-making power when it comes to contraceptive use (15). However, the finding is inconsistent with the results from a study conducted in the Gedeo zone and Ethiopia, where young women were more likely to participate in decision-making regarding contraceptive use than older women (24). The observed variation could be explained by differences in settings and time duration of women exposure to contraceptives.

This study has also revealed that being married or cohabiting influence decision making in family planning. However, these women were more likely to make a joint decision on family planning use than unmarried women. Because of the African community's deep-rooted masculine culture, women in a union tend to rely more on their male partners for decision making, particularly on reproductive health issues. (25, 26). Therefore, developing a method of promoting family planning that reaches men will assist women in making free and inclusive decisions on contraceptive use without interference from their partner/husband. The finding is also similar to what was reported in other African countries which showed that majority of married or cohabiting women makes a joint decision on contraceptive use (17, 24).

In this study, a comparison was made between women who ever used contraceptive versus those never used in relation to decision on contraceptive use. Findings revealed that women who reported to have ever used contraceptive were more likely to make self-decision compared to those who never used. This demonstrates that women with contraceptive experience are more informed on contraceptive methods and are more likely to make choice on contraceptive use. Unlike other study conducted in Ethiopia which looked at knowledge on contraceptive and its association on decision making, which found that women with knowledge on contraceptive are more likely to make self-decision. (24). Therefore, we advocate for increasing women's knowledge that will change their attitudes toward family planning through health education.

Furthermore, women whose husbands use force for sex were more likely to have their decision made by other people than those whose husbands did not force for sex. This could be due to the fact that use of force for sex in a relationship may lead to reduced self-esteem of women thus compromising control over their reproductive lives. This implies that men continue to show dominance in sexual matters, necessitating a deliberate effort to engage the male gender in campaigns and innervations aimed at improving knowledge and contraceptive use. However this finding is in contrary with findings from a study conducted in South Africa whereas a joint decision on contraceptive was made among women whose partners use force for sex (17).

Study Strengths And Limitation

Since the study involved sampled women from all districts of Simiyu region therefore the findings can be generalized to all women in the region. However, the study faced some limitations such as unmeasured confounding factors like knowledge of women on contraceptives, spousal communication/ relation. Also, because the study used cross-sectional survey data, only an association between the outcome variable and exposures, but not a causal relationship, could be established.

To conclude, the study found women's contraceptive decision-making power were influenced by several factors including; age, marriage, prior contraception experience, husband force for sex, perception that contraceptive is women’s issue. This calls for programmers, policymakers, and other stakeholders to develop interventions that focus on early women empowerment, especially among young women, in order to strengthen and promote their decision-making on a variety of issues, including contraceptive use. Women should be taught about contraception from an early age and encourage them on personal decision making regarding general health issues including the use of contraceptives.

RMNCAH: Reproductive, maternal, newborn, child, and adolescent health;

SDGs: Sustainable Development Goal;

TDHS: Tanzania Demographic and Health Survey

TDHS-MIS: Tanzania Demographic and Health Survey-Malaria Indicator Survey;

WHO: World Health Organization.

WRA women of reproductive age;

Ethical considerations

For this study a permission was sought and granted from Amref the organization owning the database where we extracted secondary data. However, the primary study (survey of UZAZI UZIMA II project) that generated the data received ethical clearance from Muhas Reserch Ethics Committee (REC) with the reference number MUHAS-REC-09-2021-840. During data collection, all study participants were provided and signed an informed consent. For the minor participants 15-17 years, permission was provided by parent or guardian before she/he was introduced to the assent form. All procedures were performed in accordance with relevant guidelines and regulations. Unique identification numbers were used in the identification of study participants to maintain confidentiality.

Consent for publication

Not applicable

Authors’ contributions

LJS contributed to the study design, data analysis and drafted the Manuscript. FNN, S.M, GM contributed to data collection, manuscript development and review. SEM revised the manuscript. All authors read, commented on, and approved the final manuscript.

Competing interest

All authors declare that they have no competing interests.

Acknowledgements

We thank the Uzazi Uzima Amref term for project design and data collection, as well as the Monitoring and evaluation team for assisting with data retrieval for this study.

Funding

The study received financial support from the Government of Canada through Global Affairs Canada (GAC). The funding source had no any influence in the study's design, manuscript development, data collection, analysis, or interpretation of the findings.

Availability of data and materials

The dataset for the Uzazi Uzima project is available at Amref Health Africa in Tanzania. The dataset used for the current study's analysis is available on reasonable request from the corresponding author.

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No competing interests reported.

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Decision-making power among women of reproductive age towards family planning use and its associated factors: A cross-sectional study in Simiyu region, Tanzania

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Abstract

Figures

Background

Methods

Results

Socio-demographic characteristics of study participants

Contraceptive Use By Age And Type

Decision On Contraceptive Use By Characteristics Of Study Participants

Factors Associated With Ability Of Women’s Decision-making Power Towards Contraceptive Use

Discussion

Study Strengths And Limitation

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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Version 2