A total of 53 IDIs/KIIs and 8 FGDs (Table 1) were carried out to achieve the required result. The first part presents the results from the CFIR and GYSI frameworks and the second part, presents the findings of the GYSI framework.
Facilitators and Barriers for PP/PA FP Integration
The enablers and barriers for PP/PA FP integration were identified in line with the domains of the CFIR framework i.e., individual characteristics and involvements, inner setting and context, intervention characteristics, outer setting and the implementation process. The facilitators and barriers identified using CFIR framework under different domains are further checked to see which component of the GYSI framework (i.e., asset and resources; practice, roles and participation; knowledge, belief, and perception; and legal rights and status) fit in for the integrated results (Table 2).
Table 2
Facilitators and barriers to PP/PA FP integration, Formative Assessment analysis based on CFIR and GYSI components
CFIR Domains
|
GYSI Components
|
Asset and Resources
|
Practice, roles and participation
|
Knowledge, belief and perception
|
Legal rights and status
|
Individual characteristics and involvements
|
Facilitators
|
|
|
|
|
Health facilities (HF) always open and provide PPPAFP service, HW are respectful, HF & MCH administration and HW committed to provide FP services, all types of FP methods available
|
√
|
|
|
|
Majority of the community accepts women to use FP service, have good perception/belief/attitude towards FP
|
|
|
√
|
|
Use of religious leaders are the best option to overcome the misbeliefs and misperception of FP services
|
|
√
|
|
|
Most of the clients are knowledgeable about FP and they are ready to use the services, FP is good for Mother and infant
|
|
|
√
|
|
HW give information, health education, counseling (at OPD, delivery, house to house counseling…), heard from TV a lot of advertisement regarding FP use and benefits, Good knowledge and right to get health information
|
|
|
√
|
|
Health education, Awareness creation can improve the acceptability of PPPAFP and remove barriers of FP
|
|
√
|
√
|
|
Barriers
|
|
|
|
|
Some community members belief/perceive PF not good lead to infertility and cancer, religiously forbidden and its disobey of ALLAH, especially for young unmarried girls
|
|
x
|
x
|
|
lack of information about legality of FP use for recently delivered/aborted mothers
|
|
|
|
x
|
Some husband not allow to use PF
|
|
x
|
|
|
Some people hate and discourage PPPAFP
|
|
x
|
x
|
|
Low community awareness about FP in general and PP/PAFP in recently delivered/aborted mothers in particular
|
|
x
|
|
|
Decision of FP and income by different people
|
|
x
|
|
|
Some people don’t know where FP can be accessed and types as well
|
x
|
|
x
|
|
desire to have more children in early marriage and by husband
|
|
|
x
|
|
Table 2
Inner setting and context
|
|
|
|
|
Facilitators
|
|
|
|
|
Health centers and hospitals Provide FP, all types of PF methods are available, FP are equally available for all social groups and status, Ambulance service available, IEC material available, FP supplies available, PF service free of charge
|
√
|
|
|
|
Health workers are respect clients and committed, HW give information, HE, awareness creation and counseling regarding FP, home visit provide health information including FP, and conduct house to house counseling
|
|
√
|
√
|
|
HF not far from the community and always open
|
√
|
|
|
|
No restriction of mobility
|
|
√
|
|
|
Heard FP is allowed for recently delivered/aborted mothers
|
|
|
|
√
|
Awareness creation improve access to FP services
|
√
|
√
|
|
|
Age of marriage don’t affect FP use
|
|
√
|
|
|
Barriers
|
|
|
|
|
FP not equally available for all people, only for married women
|
x
|
|
|
|
Shortage of budget allocated for FP
|
x
|
|
|
|
Shortage of separate rooms for FP and counseling service
|
x
|
|
|
|
there is an information gap for where FP is available, it is use and benefits of FP in the community, especially; those who live in remote areas
|
|
|
x
|
|
Fear of divorce, stigma and discrimination
|
|
x
|
x
|
|
Most of the rural community marry at early age 15–18 years due to failure of study, parents influence, peer pressure, family problem, desire to have birth to many children
|
|
x
|
|
|
Intervention characteristics
|
|
|
|
|
Facilitators
|
|
|
|
|
Distric Health Office decide the budget utilization
|
√
|
√
|
|
|
Community support recently delivered/aborted mothers to get FP
|
|
|
√
|
√
|
Community has good knowledge that they have a right to get proper health information including FP
|
|
|
√
|
√
|
Table 2 continued
community have good perception, beliefs, behaviors/accepts for women to use FP
|
|
|
√
|
|
Community beliefs FP is good for both mother and infant
|
|
|
√
|
|
Women participation of all program will enhance FP utilization
|
|
√
|
|
|
Use of religious leaders, community/clan leaders, kebele heads will increase the uptake of FP and will clear the misconception
|
|
√
|
√
|
|
PF/MCH services are free of charge
|
√
|
√
|
|
|
Women had god role in the community and they can influence the use of FP
|
|
√
|
|
|
Women assumes leadership at different level of the government and NGO
|
|
√
|
|
|
Barriers
|
|
|
|
|
Shortage and costly transportation for remote community,
|
x
|
|
|
|
Some community members not support and beliefs FP lead infertility and forbidden by religion
|
|
|
x
|
x
|
there is an information gap for where FP is available, it is use and benefits of FP in the community, especially; those who live in remote areas
|
x
|
|
x
|
x
|
Fear of divorce, stigma and discrimination
|
|
x
|
|
|
Most of the rural community marry at early age 15–18 years due to failure of study, parents influence, peer pressure, family problem, desire to have birth to many children
|
|
x
|
x
|
|
Husband is the decision makers for FP use
|
|
x
|
|
|
Outer-setting
|
|
|
|
|
Facilitators
|
|
|
|
|
Community have good attitude, beliefs and perception of FP use
|
|
|
√
|
|
heard recently delivered/aborted mothers are legally allowed FP use
|
|
|
|
√
|
Community support and encourage women to use FP
|
|
√
|
√
|
√
|
Community have good knowledge to get proper health information including FP services
|
|
|
√
|
|
Clients knew the importance and benefit of FP
|
|
√
|
√
|
|
Table 2 continued
Clients are satisfied with service providers
|
√
|
|
√
|
|
Clients choice the FP method they prefer
|
√
|
√
|
|
|
Awareness creation improve FP acceptability
|
|
√
|
√
|
|
FP/MCH service are free of charge
|
√
|
|
|
|
Female assume leadership
|
|
√
|
|
|
Good client knowledge of FP services
|
|
|
√
|
|
Spouse decide FP use
|
|
√
|
|
|
Use of UMUL GARGAAR" community organization
|
|
√
|
√
|
|
Barriers
|
|
|
|
|
Heard only from TV recently delivered/aborted mothers are legally allowed FP use
|
|
|
|
x
|
Never heard legal mechanism to assure health care including FP services
|
|
|
|
x
|
Some community members perceive FP lead to side effect, infertility, stigma, discrimination, FP is culturally/religiously forbidden especially for young unmarried girl.
|
|
x
|
x
|
|
Breastfeeding is enough for child spacing and not FP
|
|
|
x
|
|
Husband do not allow to use FP services
|
|
x
|
|
x
|
Shortage and cost of transportation for remote areas people
|
x
|
|
|
|
Low awareness of FP use and benefits
|
|
|
x
|
|
Preferred more children and no need of FP
|
|
x
|
x
|
|
Fear of divorce, stigma, discrimination etc
|
|
x
|
x
|
|
Process
|
|
|
|
|
Facilitators
|
|
|
|
|
Provide FP service equally to all needed people
|
√
|
|
|
|
Use influential people (Religious leaders, community leader, kebele leaders etc) to enhance FP service
|
|
√
|
√
|
|
Awareness creation to improve FP uptake
|
|
√
|
√
|
|
Do house to house counseling
|
|
√
|
|
|
Proper documentation and monitoring and evaluation
|
√
|
√
|
|
|
Increase TBA linkage with health facilities
|
√
|
|
|
|
Table 2 continued
Advocate and use leaders and role models
|
|
√
|
√
|
√
|
Women empowerment and use of them for FP service
|
|
√
|
|
|
Proper plan preparation and follow up
|
√
|
√
|
|
|
Barriers
|
|
|
|
|
Religious leaders, community leaders and couples should be involved in project to be successful
|
|
x
|
x
|
x
|
Key: √ = facilitators x = Barriers
Source: Field Survey, 2022
|
GYSI framework analysis
Four main components of the framework namely assets and resources; practices, roles, and participation; knowledge, beliefs, and perceptions; and legal rights and status examined at individual, community, and institution/system/policy levels and presented as follows;
Assets and resources
Individual level
In relation to resources, the study identified that the decision and control over family resources falls under the men, particularly, the elderly were found playing significant role on the decision making and control over important assets and resources.
Unlike unmarried female, married female in the study area seldom participate in resource decision-making. Key informants indicated that many woman receive and control money to purchase food or other household necessities, while the men retain complete control over all resources, including inheritances and livestock.
“…the father will bring the income and the mother will decide how to spend the money, and I think this may make easy for the mother to get the services”(IDI, male adolescent dhandama)
Adolescent married, and unmarried women frequently discussed how men control assets and resources in very different ways, and how this control is influencing women's decisions to use essential care services such as FP. Women KII in Tuli Guled explains:
“…the bread winner of my family is my husband, I don't have any separate income and my husband has the decision marking power over the resource he earns” (IDI, woman _Tuli Guled)
In contrast, some married men agree that they should discuss their finances and resources with their wives at every stage. Many married men also stated that having unequal access to and control over assets and resources influences females’ decision to use healthcare services, including family planning. a KII in Wajale states:
“….my wife and I make decisions together regarding the salary and other resources but if the girl is not included in the decision-making process, the effect may come since you don’t share what happen whether something added or deducted. And the girl sees challenge therefore, it is good to share everything whether something added or deducted and should be involved in giving advises as well as taking decisions” (KII, male, Wajale)
Regarding equitable distribution of resources, the study probed each group if PPFP services were equally accessible to boys and girls, young and old, married and single, people from various geographic locations, religious or cultural backgrounds, and ethnic group who does not speak local language and identified that the service is equally accessible to all without discrimination.
“…yes they get the services equally, everyone is equally treated, the workers stand to give service when people come and ask them what they need” (IDI, Woman, Fafan)
Community level
The study further assessed the accessibility of PPFP's to users across all social sectors, and identified scant societal barriers to PPFP access. Service providers follow non-discrimination in the provision of services, and it has been reported that no one is denied access to the services because of his/her identity, marital status, residence, or other factors. KII (MCH coordinator) in Elbah explains:
“…we don't consider the background of the person, we simply provide the services, maybe we can give more health awareness to those who lack knowledge." (IDI, MCH coordinator, Elbah)
In the study area, there is a consensus among participants (almost all) on the importance of women of reproductive age involvement in budget planning and decision-making. At this point the study further assessed the importance participating women in planning and decision making. Most of the participants argues, women participation empowers them to express their demands more freely besides enhancing the service delivery and budget allocation on women priorities and needs. However, the study identified scant inclusion of women in budget and decision-making processes, which may be one reason why PPFP and other reproductive services are not accessed and used, as most participants mentioned. The Obosha CEO strengthened this point as follows
“I haven't yet seen that woman participate during decision making. If the women participate in decision making, they would have a chance to tell their needs so that their needs would have been considered during budget allocation and the service delivery would increase, otherwise there would be shortage for what women needs” (IDI, Cobosha CEO)
Women and girls at the reproductive ages know the benefits of FP, the available contraceptive methods, and locations to access services, however, the acceptance of PPFP is still in doubt and mostly the elderlies and the uneducated member of the society associate it with infertility. With this limitation in mind, the analysis of identifying the challenges and opportunities of integrating PPFP and RMNACH provides a good example of the ways in which socio-cultural and religious factors shape local lives.
According to the FGD and KII results the community members that are benign to PPFP are the young generation, and see family planning as a way of empowering women. They believe family plaining helps a family to establish a healthy economy, family and relationship in the family. For instance, an adolescent from Tuliguled raised the following:
“…Somali people are against taking family planning except only few people who are young and educated. A women who take the family planning operates invisibly., the community; particularly, the elderly and uneducated people marginalizes and discriminates a woman who takes family plaining services.” (IDI, male Adolesecnt, Tuli Guled)
Health care professionals, religious leaders, and elders were identified as potential change agents, with a capacity and presence in the community to change the existing negative perception about FP services and the stigma and marginalization to women who use FP. The results of this study demonstrated the need for access to information. An approach that focuses on how the FP and access to modern contraceptive assists women, girls’ children and family in general to achieve health and healthy social and economy. Regarding this, a KII in Degahbour substantiated this;
“…Let them strengthen the connection between the community and the health centers, let them establish a social mobilization team at the kebele level, which is the work of the health office. When the committee members are established, they hold a monthly meeting. It is one of the strategies that we have implemented that leaded us to make the improvement. And provide regular awareness on a monthly basis, let the community see them. Health extension workers or health arm development should be called and shared the plan and tell them. Strengthen monitoring and evaluation. Because this project is very profitable. It can be used to create integrated services that are not only Postpartum or post abortion family planning care” (IDI, Degahbur CEO).
Institutional and policy level
The availability of PPFP service in healthcare facilities is essential for family planning initiation and continuation. To offer a full range of contraceptive services that meets individual preferences, all forms of contraceptive methods have to be readily available in health facilities, along with adequate health care personnel. Lack of the long-acting FP like IUCD and permanent methods at lower-level health facilities are considered one reason for poor accessibility and utilization of FP services in the study area.. Healthcare facilities informants identified mixed contraceptive methods at health facilities as appropriate toto fulfill clients’ needs. Moreover, lack of information about FP, the available FP services and poor supply chain management of PPFP are the factors reported to impede the accessibility and use of FP. In this regard, the CEO of Obosha health center mentioned the following:
“… All the types of the user's choice are available except IUCD type, People can get FP services at any time except if there is stock out of drugs or if the staffs go for training to other place " (IDI, Obosha CEO)
Furthermore, many participants stated that health facilities that provide FP services in urban area are easily accessible, indicating scant physical barriers. However, some people in rural areas face geographical barriers to access and are not within reasonable distance. Regarding the distance of health facilities, Gursum MCH focal person asserted the issue as follows:
“the health center is located at middle of the town, hence it doesn't take more time to visit even people don't use transport except if the client is from remote kebeles where there is not the service is available". (IDI, Gursum MCH focal person)
Similarly, there are issues that specifically affect the accessibility of some FP services at lower primary care facilities. Some study participants, for instance, some contraceptive methods such as; long-acting FP and injections are not accessible at health posts. Compared to urban area, health facilities in rural area encounter transportation problem to reach the facility resulting in poor access of PPFP. In this regard, postpartum women interviewed in mentioned the following:
“We walk long distance to access health services, and this discourage me to go to health centers with my wife and provide FP service and get any relevant to decide which type of FP to use with my family” (KII, woman, Bombas)
The CEO of Ararso health facility further adds:
“Most of the villages are far from health centers. The farthest is 30km, which is only accessible by car. Sometimes there is a place outside the catchment area that comes to us and we provide the services and sometimes we send them back with our ambulance.” (KII, Araso CEO)
Cost related barrier were not identified as an obstacle to uptake FP services, almost all participants of the study asserted that PPFP service was provided without charge..
However, lack of buildings and equipment to provide family planning services have been raised as a challenge. Even though there is better availability of human resources that can provide FP services, they performances is hampered by the available infrastructure and equipment.
Practice, roles and participation of Women
Individual level
The study areas are charactered by early marriage and scant use of FP. Due to the communal perception to marriage, the cultural practice, peer pleasure and lack of economic opportunities, it is not strange to observe a girl marrying before the age of 18. Surprisingly, the age at marriage is usually decided by couples and not any other person or institution.
“There are parents who don't want their girl to attend school I think the formal education as alien and something that spoil the culture. This factor forces the girl to get married early because she thinks that the only to get relief from this condition is to marry. The practice continues despite lots of efforts made to minimize it “(Dhandhama, FGD father)
Different participants on the in-depth interview and FGD reported that husbands may not allow their wives to go outside and access the service FP services. In this regard, the father who participated in an FGD discussion at Dhandama raised the following: “[If the wife goes to health facility to use FP service], he [her husband] may point her that she doesn't trust ALLAH”. The same group also raised the existence of changes in recent years where mobility restrictions on mothers have become lesser from time to time. From the study, the movement restrictions and the ban to use FP services were found differing among educated men as reported by an adolescent interviewed in Dhandama:
“…If the husband had education he would accept her, because he knows that this service is good for the life of his family but if he hadn't any education, he act up on whatever he heard from the society" (Dhandhama, Adolescent male)
Data from women and girls regarding women’s and girls’ role in the community and how they use their time were gathered during the field work from the respective research areas. The findings indicates that most the time of women and girls were consumed by managing and care children at home and working on domestic works, such as caring and looking after children, elders, cooking and washing clothes. These domestic work and the household burden often found preventing mothers from seeking maternal health care including family planning as one respondent reported:
The domestic work and the household burden often preventing mothers from seeking maternal health care including family planning. Respondent from Dhadamane reported the following
“…If the mothers have someone who can look after the children, they can visit the health center but if they don't have anyone who can look after the children it will be difficult for them to visit the health center". (Adolescent male Dhadhamane).
Contrarily, some women were also found working outside the domestic work to bring income for the household in Tog Wajale and Kebribeyah. There is a general feeling amongst in the study area women economic empowerment is the best available option to them to enhance their health wellness and increase the FP uptake. There are also situations where some women work and generate income for the household. Now a days it is not strange to see women working while husbands and men sitting with their friends idle. Such instance are giving positive impetus to women to be economically active and look for opportunities outside the domestic works. In the study area, economically viable family were observed hiring maidservant to reduce domestic workload.
Similar narration was given by a mother respondent:
“Those women who have maidservant at their home can go and get the injection but if the woman has more children and don't have maidservant they can't go and get the injection"
Another important point raised in relation to economy was the issue of finance which prevented some mothers to seek the IPPFP was narrated by one respondent:
“There are mothers who can't visit health facilities due to financial problems and some other restrictions and this have effect on the service usage". (IDI, Gabagabo mother)
There was another construct which focused the importance of the shared decision between the couples for the use of the IPPFP:
"the women are free so she can go and get the service they want, what is expected from them is to inform their husbands where they want to go and what they want to get so that they can take permission from their husbands" (IDI, Gabagabo mother)
With regard to girls, most of the time they are expected to assist their mothers and share the domestic workloads. Some adolescent girls also participate in social activities. Otherwise, they reported the activities of the adolescent girls are the same at different seasons.
"Though the activities that girls carry out are the same in the whole year but currently it seems that they conduct some other activities like participating social works activities and sport activities" (IDI, HC CEO)
There are differences on how educated and uneducated and men and women adolescents use their time. The educated and employed girl stay most of her time at work place. And the community as well as the family accepts it as long as she earns benefit. Students, on the other hand spend their time on studying and attending classes regardless of their sex. However, the way boys and girls spend their spare time differs; in most of the study areas boys were observed spending their time eating Khat with their peers. In this regards a father in Goljano reported the issue as follows:
“Most of the men in this town chew chat and mother & girls are the one who manage most of the household activities” (Father at Goljano)
For adolescent boys, they are expected support the father by engaging in productive works including livestock keeping, working on farm activities like digging and harvesting the farm. Their role changes with the geographical area. In rural they spend with on farm activity and livestock raring. Some fathers reported that they usually dig and work in the farm which they said is heavy work, but don't have another option.
Community Level
In SRS, Fafen Zone community where this study is conducted misconceptions in the community about the use of IPPFP and maternal health services is common. The study made FGD and KII to identify the community awareness about FP and IPFP and the majority of the discussants low awareness, which could be caused by cultural barriers and the taboo to use IPPFP. women restriction movement partial decision making by men as reported from the FGD discussion were also major impediments of the uptake of FP. Regarding this, adolescent male in Fafan identified the issue as follows:
“…Restriction affects the use of family planning service, if the woman is not allowed to go by herself to health service center and cannot make a decision for herself including the use these services without her husband permission, then she will prefer to abstain rather than getting divorced so she will deliver yearly one or two child (twin)”. (Adolescent male, Fafan FGD)
An adolescent in Goljano also added
"…Still the previous Somali culture exists here which states women can't go anywhere without permission of her husband, so I believe still in this period that women can't do anything with her permission and this have negative repercussion on the use of IPPFP.”
There were also traditional values and beliefs among the community which may be barrier to the IPPPAFP. They believe that if recently delivered women go outdoor she and her baby will become sick or get allergy.
“Women in postpartum shouldn't come out from her home, even she shouldn't do any task”.
Some participants, on the other hand, mentioned that these cultural practices are now changing and it depends on the women’s will to stay or not to stay.
The recognition and focus on the effect of early marriage in contrast to earlier perspective is changing. The study observed sound change and participants identified the consequences of early marriage including physical, social and psychological effects associated with it. However, there is still gap on uptake of FP among the newly married couples as there is high desire and social pressure for baby.
"…of course, marrying at early age affects the use of these services. Most young couples are not mature enough to make decisions and even they don't know how to deal with marriage related issues. After the wedding they may even separate or divorce so early". (Gabagabo, IDI father)
Similarly, in Dhandhabane, a father participated in FGD added the following;
“…women use contraceptive, especially who are at their young age experiences a menstrual cycle disruption, which in turn affect psychologically. Such experience discourage the contraceptive uptake among the newly married couples before giving the first birth” (Dhandhabane FGD, fathers)
Participants identified the different functioning women to women support groups. In most of the study area women support each other during different ceremonies like marriage, death or in cases when women face challenges in maternal health service utilization and in the post-partum ceremonies. These women support groups can be good opportunity to enhance FP use in the community. They also reported that women who participate in different networks use IPPFP compared to others.
“There are different groups like "Umul gargaar" group, this group works a lot in Dhandhabane. For instance besides disseminating health awareness in the community, recently they were observed in MCH helping recently delivered postpartum mothers. The participation in Umul gargaar depends on the person’s desire, whether to use the service or not, but the more the women participate in such group activities the more they decide to use the service" (Dhandhabane, MCH focal)
In addition to the above social gathering and informal groups there are also formal structures like 1 to 5 groups who participate on different awareness creation activities under the assistance and organization of the local administration.
Institutional or policy level
Health facility managers and department heads usually are busy with administrative activities, including managing OPD services and MCH services. Department heads also play a roles on creating awareness creation on the benefits of (IPPFP/PAFP) services using through broadcast media and other social gatherings, and capacity building trainings for the service providers.. In addition to these they also provide plan annual plans, mobilize resources for the health facilities
With regard to the leadership roles, both IDI and FGD participants noted changes in attitude towards the women’s role in leadership. They reported that currently women assume leadership of different offices like women’s office and the community support this as far as she is educated. They added that women leadership role, particularly in the health sector, may help to enhance the IPPFP and PAFP service use.
Knowledge, belief and perception
Individual level
The findings of the study revealed that there are no behavior related barriers for both young adolescent girls and old women regarding utilization of FP service for people living in urban areas, where people are educated and aware of the advantage of FP service. An interview conducted with CEO of Jijiga health center supports this idea, where he said:
There are no behaviors that have any effect on utilization of family planning.
Some welcoming behaviors are being demonstrated by girls that can be precursor for FP use like delaying marriage to expected years with a hope to prevent some complications, utilization of FP when needed, breastfeeding their newborn and birth spacing up to 2 years. In this regard, the CEO of Ararso health center described things as follows:
….the girl’s behavior involves not rushing into marriage until the girl's pelvic floor is capable of carrying the child, she should give spacing between children up to 2 years and gives the breastmilk…
Preferring educated woman for marriage is also becoming common that can be a signal for delay of pregnancy either through modern method or natural methods. This view was supported by one of the District experts from Bombas where he asserted the following:
…… previously people don't like women who didn’t marry early and attend education, but, currently a girl may complete her education successfully and marry at middle age. Thus, it is not surprising to find girls who have bachelor degree and want to peruse their master’s education. - So, people currently prefer educated women. The community understood that educated people are good
It is also important to note that there is a clear link between child spacing, livelihood and religious belief. People believe that Allah will feed them all and every child has its own destiny and define fortune; thus, you find people using this as an excuse for not properly use family planning. In this regard, one of FGD participants from Dhandhame District, for instance, said:
“… ALLAH will feed my children, so I won't use these services"
There are also occasions where women decided secretly to use FP service hiding from their husband, but when their husband understand the issue legal challenges will happen not only to the wife but also to health professionals involved with the service provision. The major reason for the husband for not allowing their wife to decide in using the services are related to religious factors. The willingness and consultation of the husband is, hence, a key to FP utilization. An Educative experience reflected by CEO of one Health center affirm such an occasion:
The decision of the FP usage is the partners decision, it's been a short time since we got through this issue, a man whose wife was implanted with implano has sued up to the court level not only his wife but also health professionals. The girl wanted the family planning but the man said no asking ‘did I told you to insert?’ later the implano was removed from the girl and that is how we solved it. Therefore, the biggest challenge is that of the partner, they ascribed that the religion of Islam does not allow the use of family planning. Therefore, the partner should be consulted
Still, even if there are circumstances where the couples make decisions jointly, the influence and final decision of the husbands are overt. An interview made with 18 years old adolescent male from Dhandhama District strengthened this point when he said:
“The decision belongs to the couple, so if the wife requests to use the service, her husband may accept or reject"
Community level
Knowledge, belief and perceptions at community level can have a positive facilitation role or can be a barrier for the utilization of FP services. For instance, there are believes that if the mothers visited health centers for any health service including FP, she will be frightened of getting allergy from health centers. Such perceptions and myths at community level may not only hinder FP utilization but also affect total health seeking behavior. An interview conducted with a District level expert corroborated this as follows:
“….If the mother wants to visit health center people will say ‘Waad Shaashoon’ [you might get allergy]. So how to break such believes needs to work on it."
There also times where a newly married girl at young age wants to use FP service, but avoids to do so fearing of being labeled by the community as infertile. An MCH focal person interviewed in Gursum District has elaborated this point as follows:
“…...girls who marry at early age might accept to use the service, but she will be afraid of being labeled in society as infertile …." (MCH focal person, Gursum District)
Though there were times where women who use FP services were perceived by the community as if they are converting their religion and are also considered as infertile, there seems a change in perception among the community from time to time as people become aware of the benefits of using FP as a result of the awareness raising efforts of health professionals. An expert interviewed in Bombas District has elaborated this point as below:
"…. Community used to consider the woman who use this service, as a person who converted her religion and she was used to be isolated from the society, people also perceive that she would be infertile. But all that perceptions are being fade and the community encourage the women to use the service because they understood its benefits"(District health office expert, Bombas Distric)
The community can be considered as a change agent, if they get necessary information, and can be engaged as partners in order to bring a change on FP service utilization. This is because there is a tendency for people to abide with collective values shared in their respective community. The study findings revealed that the community can positively influence its members in relation to the use of FP, after they got necessary awareness from health professionals. In this regard, CEO of Tulli-Guled Health center shared his feeling during an interview with him as follows:
When the communities are told regarding family planning utilization, even though many of them understand, there are some who challenge the girl who wants to take the family planning, but when we tell them the benefit, they understand and you may see finally they recommend the girls to take family planning…...
Institution/Policy level
When it comes to institutions, the findings of the study imply that the contribution of the religious institution is neglected and even under estimated. Role of religious scholars is immense on FP use if they are taken as active partners, otherwise they may negatively influence the society. Some ordinary people think and believe it is good for children, woman and the family, so they encourage women who need it while others still discourage it its use from religious point of view. For instance, an expert from Goljano District has described his experience on the matter as follows:
“People are mixed, those good people will support her because they know that this important for her life and for her child and also for the family and some religious scholars may not support and they say this is against our religion but that is due to knowledge gap"
Legal rights and status
Individual level
Regarding the legal rights of the recently delivered/aborted mothers to use the family planning services, some of the participants noted that there are no legal restrictions that prevent recently delivered/aborted women from using family planning services. There may be, however, mobility restrictions to women during the postpartum period which may constrain them from going to health centers and receive the service.
“….Recently delivered mothers are allowed to use these services, though there are cultural barriers that makes mothers not to visit outside in postpartum period, there are still strong women who don't consider such barriers and use the service during postpartum period" (IDI_Adolescent Male)
Another participant mentioned the availability of a law that allow family planning for the girls:
”….Yes, I heard that there is legal law which permits the girls to take the family planning” (IDI_Adolescent girls Jijiga).
Community level
The majority of the interviews has some idea about how do the recently delivered/aborted mother access PP family planning information and resource from the healthcare facilities, they get information mainly from TV and health professional.
“Mostly, they hear when they go to the hospital and give birth in the hospital. if they were women who understand or if they were not, the health professional will make understand specially they give when the mother is pregnant or when she give birth” (IDI_ Adolescent girls).
Other participants stated that:
"people can access information about family planning by contacting health professionals and also they may access information from anybody who knows about it" and the community will support because it will be good the mother's health and I don't think anyone will oppose or come against for getting access of information" (IDI_ Adolescent Male)
The community aware the importance of health care and believe to use different stakeholders such as religious leaders to disseminate the information about family planning and other health care service and increase the acceptability.
"Yes there are people who support mothers to access the information and these different levels of community members including religious scholars, because the people knew that health care is important for the society and that they can get access of the different services at the health centers" (FGD_father_Dhadhamane)
Institutional and policy level
Despite the existence of well-established laws and policies regarding the family planning, there seems to be a big gab in its dissemination. As a result, people do not seem to be aware of the existence of a law that permits women to use FP services. Husbands, for instance, forbid their wives from using FP services while it is against their rights.
“Since most of the decisions belong to the man, the women may ask him whether she can take the family planning services then he my reply to her by saying do you want to make me "GABLAN" (a Somali language that mean you want to make me someone who don't have children). This is the reason why family planning coverage is low in Somali society as most of the decisions belong to men so if the women ask their husband to use the services they don't allow and if the women use secretly it will bring conflict.” (FGD _ Male adolescent)
Some participants further mentioned that institutions like health facilities, schools and media especially TV channels play a paramount role in creating awareness among the community about the legality of using FP by women.
“We see a lot of advertisements in the media such as TV channels, it is taught in the 7th and 8th grade at schools and even the doctors teach about it health facilities”… (FGD_Adolescent girls)