This study found that half of the women accessing RCH services had an age between 21-30 years and the majority were married similar to the study which was done in Oman which showed that about 54% of the women had an age within the same range28. Contrary, a study was done in Congo, and a review from Sub Sahara Africa showed that the majority of women accessing modern contraceptive methods had aged above 30 and between 35-39 years24,29. Also, the majority of the participants in this study were married similar to the study done in other countries, Ethiopia (64%), Rwanda (70%), Talensi Ghana (73%), Congo (60%), Nigeria (81.5%) 12,27,29–31. Furthermore, half of the women in this study were not employed (housewives) similar to the others studies which revealed that almost 78% and 74% of participants22,27 were not employed. Contrarily, the study done in Oman and Pakistan showed that the majority 54%, and 65% of the participants were employed22,28.
The demographic characteristics of age, religion, employment status, and marital status of the participants in this study as in most studies done in Muslim communities22,32,33 can be explained by the demographic nature of Zanzibar where concerning religion and culture, the majority of women get married earlier and most of the residents are Muslim. In Zanzibar, it is taboo practicing sex or discuss or access modern contraceptive-related services if you are not married34. In addition, most of the women in this study like in most of the Muslim communities, were housewives since they perceive that women are queens, they have to stay home and take care of their husbands and families while men are breadwinners. However, in some Muslim communities, they have different practices and women have a good education, are employed, and are supported as breadwinners for the family35.
Furthermore, in this study, the majority of the women have heard about modern contraceptive methods and the main source of information was health facilities. A different study done in Rwanda reported that only 47% have heard about modern contraceptives26. Other studies reported different results where about 85% and 57% of the participants had information from radio25,36. More studies also showed that friends/peers and family were the main source of information37–39. The findings in the current study may be explained by the measures that have been in place and future targets by the government through the Ministry of Health ensuring that modern contraceptive services are provided to all levels of facility40.
Interestingly, although most women have heard about modern contraceptives, the majority of them were currently not using any. This is similar to studies from Pakistan, Saudia, and Ajman which showed that about 75%, 55%, and 61% respectively never used any modern contraceptive methods 41,38,39. Additionally, another study reported that compared to Christians, Muslims were 65% less likely to uptake modern contraceptives although they were informed and knew where to access the services42. Contrary, a study which was done in Oman showed that 54% of women used modern contraceptives28. These differences may be influenced by how families believe and practice their culture and religion. Those who find contraceptives contradicting with religion and culture give birth to children as God gives33.
Moreover, among the users of modern contraceptives, injectables and implants were the common methods similar to a previous study where users preferred the same methods24. Other different methods were reported in previous studies where about 78% and 31% of the participants used condoms as a common method 38,43. A study which was done in Saudia revealed that pills were the common method among users 71%44. The findings in the present study may be because injectables may be more convenient and friendly in terms of privacy since some women do not want their husbands to know if they use modern contraceptive45.
The present study also identified several cultural factors as barriers to modern contraceptive uptake where the majority reported that its use is against religious values and norms, associated with community stigmatization, the lack of power to decide to use, the need for more children, and lack of support from husband. Studies done in Oman, Ethiopia, and Pakistan also reported similar factors; need for more children 43% and 38%, 50% spouse opposition respectively 28,30,41. More studies reported similar information where about 90% of the participants experienced opposition from their husbands, community stigma 55%31,46, need for more children by husband47, and influence of religion22,39. Contrary, two previous studies reported that about 91% and 68% of the women respectively had full support from their husbands on the use of modern contraceptives and support in buying and transportation28,48,49. As for this study and those done in countries with similar cultures and religious beliefs, men have the priority and power to decide on issues related to the health of the family, if they are not ready most women will respect them because doing otherwise is perceived a disrespect50,51 and may lead to serious consequences including divorce.
It was interesting to find that women with college/university education were 2 times more likely to uptake modern contraceptives than those with primary or not attended school similar to findings in other previous studies7,24,26–28. In addition, the present study revealed that employed women were 2 times more likely to uptake modern contraceptives compared to unemployed/housewives similar to other previous studies22,27,29. The findings in the present study may be because reproductive health education and modern contraceptive information have now extended and it’s provided in schools, colleges, universities, health facilities, and media. In addition, most educated women are either employed or self-employed hence they may prefer modern contraceptive use so that they can have enough time to participate in different productive activities.
Moreover, in this study, modern contraceptive use was reported to have different community perceptions. The majority of the participants reported users of modern contraceptives were perceived as modernized and also in the future this practice will lead to a reduction of manpower different from a previous study where users were considered to have bad behavior and informed consent to use from the husband was mandatory 75%44. More studies reported different social views on modern contraceptives such as; men having the final say on health matters 94%27, God’s plans that marriage should be fruitful and the church does not support modern contraceptive use43. These perceptions may be due to awareness, cultural background, and religious beliefs that can affect modern contraceptive uptake.
In the present study, the majority of participants had different suggestions to improve the uptake of modern contraceptives including; Male involvement, community engagement for awareness, and public campaigns. Community and male partner involvement were also recommended in the previous study due to the influence they can have on women's decision to use MC, including to use or discontinuation 50. The suggestions raised by the participants could be because women feel that they have not been addressed as other problems like availability, accessibility, distribution for free, and training of experts have been prioritized and interventions are in place but still, MC uptake is low10.
Limitations of the study
This study used a stratified random sampling technique to obtain the participants; selecting participants randomly from the strata might result in selection bias but we recruited a large sample considering different participants’ characteristics to get representativeness.