Family planning is one of the major cost-effective interventions to reduce maternal and child mortality, yet its use remains low in sub-Saharan Africa [1, 2]. The use of effective modern contraceptive methods has been linked to prevention of unplanned pregnancy and abortions, and reduction of repeat pregnancies, which are a great risk to the health of the mother [2, 3]. Globally, over 200 million women have an unmet need for family planning—that is, they would like to either space or limit their births, but are not using any method of contraception to achieve their fertility desires [4, 5]
United Nations Sustainable Development Goal 3 (SDG 3) stipulates the need for joint efforts to ensure healthy lives and promote well-being for all people at all ages. In sub-Saharan Africa, unmet need for family planning has remained continually high and corresponding contraceptive prevalence is low [6]. It is evident that many women who wish to use contraceptive methods meet hindrances linked to access, misconceptions, and availability of the different methods [7, 8]. Moreover, the United Nations global goals further highlight the need for inclusive growth for all with an ambitious goal of “leaving no one behind” by supporting the neglected/ignored population subgroups.
The poor are classified among the vulnerable, excluded, and marginalized/discriminated population groups [9]. Furthermore, reducing unmet need has a significant effect on maternal and child health outcomes and helps women fulfill their fertility intentions [8, 10]. There is no doubt that investment in family planning would yield great benefits and save costs related to maternal health care [11]. In many countries, the low level of use of modern contraception translates into high fertility levels, as in Uganda, which is one of the countries in the region with the highest fertility rates, at 5.4 children per woman [12, 13]. While the benefits of using contraception are known, given the nearly universal knowledge of family planning among women and men, prevalence of any contraceptive method use remains low in Uganda at only 35% among married women [14].
A review of the vulnerable groups depicts the poor being left behind, yet they are in great need of family planning services [15, 16]. The poor have the lowest contraceptive prevalence among all population groups, especially in low-income countries. Findings on differential effects of household wealth status on modern contraceptive use and fertility among women in Malawi, for example, showed that the prevalence of ever use of modern contraceptives was significantly higher among women in the richest wealth quintile compared with the poorest, and the pattern was similar for current contraceptive users [15]. Similarly, over the years the Demographic and Health Surveys (DHS) have shown inequalities in the use of family planning methods between women in poor and rich households.
Notably, in the most recent DHS survey in Uganda, the total fertility rate (TFR) was highest in the lowest wealth quintile, at 7.1, and lowest in the highest wealth quintile, at 3.8. This is consistent with contraceptive prevalence being lowest in the poorest wealth quintile, at 25%, and highest in the richest quintile, at 49% [14]. Unmet need for family planning is highest in the poorest wealth quintile, at 39%, and lowest in the richest wealth quintile, at 23%. Important to note is that the percentage of the demand for family planning satisfied by contraceptive use is much lower in the poorest wealth quintile, at 50%, compared with the richest wealth quintile, at 72% [14]
Research among rural women of reproductive age has shown that many factors significantly influence the uptake of modern family planning methods, including marital status, religion, cost of services, and proximity to care. Additionally, fear of side effects, husband’s disapproval, and desire for more children are reasons for nonuse of family planning [17], [18][19]. Husbands are considered key decision-makers regarding women’s health seeking and uptake of family planning [20]. Some studies have found that unmet need for family planning was more likely among women who had discussed family planning with their partners and whose partners disapproved of family planning [21].
Demand for family planning is considered to include women currently using modern contraception and women with unmet need for spacing and limiting births. Most of the studies done in the area of family planning focus on contraceptive use, the contraceptive methods used, and socioeconomic and demographic determinants of contraceptive use [20, 22]. Studies of demand for family planning tend to focus on demand by method [ 23, 38] and in the postpartum period [24, 25]. However, little research has been done on the factors that determine demand for family planning by wealth quintile, specifically among poor women. A further analysis of DHS data for the period 1985 to 2006 that examined unmet need and demand for family planning in Uganda found that unmet need was high among the different population groups [38].
Intermediate factors that could help to explain demand for family planning are related to exposure to family planning messages, availability of health facilities, and preference factors including education, cost of services, transportation and proximity to a facility, discussion of family planning with partners and with health workers, employment status, and others [17, 22–24]. In a systematic review of how user fees influence contraceptive use in low- and middle-income countries, findings suggested that a price increase in family planning commodities affected contraceptive use among the poor [26]. In India, in a study among women who were not using family planning, a majority mentioned fear of side effects as a reason for nonuse [27, 28]. Demand for family planning remains an intricate issue, as different population groups seem to have barriers to accessing modern contraceptive methods, particularly poor women from rural areas and underserved communities.
In Uganda, the Ministry of Health is making efforts to provide high-impact interventions meant to achieve better health outcomes through investment in an improved maternal, newborn, child, and adolescent reproductive health plan. The need to empower the population to demand and have access to family planning commodities is pertinent not only in Uganda overall, but also among many vulnerable groups within the country. There is limited evidence to show the contribution of factors influencing the demand for family planning among poor households. Most of the existing studies have separated the key concepts including the socioeconomic and demographic, and examined them independently as factors influencing unmet need or modern contraceptive use among different population groups [17, 21–23, 25, 27]. The survey reports present descriptive unmet need for the entire population with no explanatory factors for the same or demand for family planning. This study therefore seeks to examine the factors influencing demand for family planning among poor women in a resource-limited setting.
Conceptual Framework for Demand for Family Planning
The conceptual framework guided by Integrative Model of Behavioural Prediction (IMBP) model states that a persons individual attitudes towards an issue, their norms and behavioural control would predict intention which then predicts ones behaviour. Implying that the differences in beliefs among individuals is as result of effect or experience one has generated overtime that influences their attitudes, norms and efficacy. In this framework, we propose that the distal variables (individual) including women's age, religion, region, residence, education attainment, employment, exposure to family planning messages work through behavioural and normative beliefs, environment factors, intention to influence one's demand to family planning.
Similarly, in this study we propose that the background characteristics including the demographic and socioeconomic factors work through the intermediate variables, including health facility associated variables [22, 24, 29], the individual preferences, and exposure to family planning messages to influence a woman’s demand for family planning [30].
In conceptual framework, we propose that a woman’s current age and level of education would have an influence on her need or preference (behavioral and normative beliefs and motivation) for using contraception. Educated women would be more likely to prefer fewer children given that their perceived norm for side effects would not be a deterrent for use, are able to discuss family planning with a health care provider at a health facility, and have access to health services compared with uneducated women with a preference for more than four children and living in a rural area. The intention as depicted in the individual's discussion with a health worker about family planning or being told about family tremendously influence their demand for Family planning. The model further proposes the use skills and abilities as one the key component is behavioral prediction, in this case knowledge for about contraceptives is important for utilization. In Uganda, knowledge of contraceptive methods is the country is nearly universal [39] which is an important predictor for the behavioral prediction.