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Research Article | Open Access | 10.31586/crph.2022.299
POOLED PREVALENCE AND CONTEXTUAL DETERMINANTS OF CONTRACEPTIVE UTILIZATION AMONG
REPRODUCTIVE-AGE WOMEN IN THE GAMBIA: EVIDENCE FROM 2013 – 2020 DEMOGRAPHIC
HEALTH SURVEYS
Amadou Barrow1,*, Afape Ayobami2 and Erin M. Reynolds3
1
Department of Public & Environmental Health, School of Medicine & Allied Health
Sciences, University of The Gambia, Kanifing, The Gambia
2
Kaduna State AIDS Control Agency, Ministry of Health and Human Services, Kaduna
State, Nigeria
3
Health Services, University of Southern Indiana, Evansville, Indiana, USA
Received April 12, 2022
Revised May 12, 2022
Accepted May 20, 2022
Published May 22, 2022
ABSTRACT
Background: Family planning (FP) methods have been found as an efficient
approach of reducing fertility and are therefore widely supported in order to
decrease population growth, particularly in poor nations. Promoting
contraception availability among women (15 – 49) age has also been shown to be
an efficient public health strategy for improving maternal and newborn health
outcomes. This paper aimed at exploring the pooled prevalence of contraceptive
uptake and its contextual determinants among women of childbearing age in The
Gambia. Methods: The Gambia Demographic and Health Survey (GDHS) in both 2013
and 2019-20 was used for this study. Data were obtained from a pooled 22,098
women aged 15-49 (10,233 for 2013 and 11,865 for 2019-20) through a stratified
two-stage cluster sampling approach. Percentages and chi-square tests were used
and variables with p-value <0.05 were included into the model. A multivariable
logistic regression model was used to assess the predictors of contraceptive
usage at 95% confidence interval (CIs) with computed adjusted odds ratios
(aORs). All the study data were analyzed using Stata version 15. Results: The
weighted pooled prevalence of modern contraceptive utilization in The Gambia was
10.1%. Younger age, compared with women aged 25-29; 30-34; 35-39; 40-44; primary
education (aOR=1.25, 95% CI=1.05-1.49); secondary education (aOR=1.57, 95% CI=
1.32-1.85); Higher education (aOR=1.90, 95% CI=1.34-12.69); living in urban
areas (aOR=1.49, 95% CI= 1.25-1.79); parity 2-4 (aOR=1.21, 95% CI= 1.01-1.47);
told about FP at health facility (aOR=2.97, 95% CI= 2.61-3.38), and no desire
for many children (aOR=1.96, 95% CI= 1.62-2.37) were more like to use modern
contraceptives among Gambian women. Conclusion: The programme certainly needs to
consider improvements in the quality of care being offered to acceptors.
Government agencies should target these programs and campaigns on regional FP
demands and provide suitable culturally sensitive and regionally adaptive
services to the communities' contexts. The programme should intensify its
efforts in rural and urban settings to improve accessibility to and availability
of FP services.
1. INTRODUCTION
Family planning (FP) methods have been found as an efficient approach to
reducing fertility and are therefore widely supported to decrease population
growth, particularly in poor nations [1]. Promoting contraception availability
among women of reproductive age has also been shown to be an effective public
health strategy for improving maternal and newborn health outcomes [2]. Numerous
studies demonstrate that increasing contraceptive use directly reduces maternal
deaths by decreasing unexpected pregnancies, adolescent pregnancies, unsafe
abortions, and high-risk pregnancies, as well as allowing for pregnancies to be
spaced out [1, 2, 3]. The risks of morbidity and mortality associated with
unsafe abortions are significant for women of all ages in most underdeveloped
countries [4]. By preventing unplanned pregnancies, FP has numerous health
benefits [5, 6, 7]. These benefits include decreased human immunodeficiency
virus (HIV) transmission to newborns [8], decreased maternal mortality and
morbidity [9], decreased neonatal, infant, and child mortality [10, 11], more
significant employment and educational options for women (and men) who can
postpone childbearing, and decreasing reliance on often dangerous abortion [9].
Certain contraceptives, such as condom use, have been hailed for their role in
reducing sexually transmitted infections (STIs), including HIV/AIDS [1].
There are approximately 1.9 billion women of childbearing age (15-49 years) on
the planet in 2019 [12]. 1.1 billion people worldwide require FP; 842 million of
these utilize contraception now, whereas unmet contraceptive needs affect 270
million people [12, 13]. Globally, the current estimated amount of FP required
to meet Sustainable Development Goal (SDG) indicator 3.7.1 was 75.7% in 2019
[12]. FP services are also critical to reaching SDG number five, which calls for
gender equality as well as women and girl empowerment [12]. Nonetheless, fewer
than half of the demand for FP in Africa's middle belt was supplied [12]. This
demonstrates their inability to make the essential choices to avoid and prevent
undesired pregnancies [14]. Unintended pregnancy is one of the outcomes of this
unfulfilled demand [15]. In general, 39 per 1000 women aged 15-49 receive
induced abortion out of the 73.3 million abortions performed each year [16].
Around three in ten pregnancies and six in ten unwanted pregnancies resulted in
an induced abortion, whereas more than seven in ten are considered unsafe and
happened in Africa [16]. As a result, Africa has the highest risk of dying from
unsafe abortion [4].
Recently, The Gambia's National Indicators for FP satisfaction with modern
contraception were 37.6% in 2017 [17] and 43.9% in 2019 [18], with rural areas
reporting 40.3% satisfaction with FP and a cumulative marginal difference of
5.2% lower than urban areas [18]. At the Local Government Area (LGA) level,
Basse (22.5%), Mansakonko (37.9%), and Kuntaur (39.9%) satisfied the least FP
demands, which is slightly more than the 2015 and 2017 numbers []. Additionally,
these LGAs have the lowest uptake of FP services in the country [20]. In The
Gambia, rural women have a somewhat higher unmet demand for FP (25%) than urban
women (24%) [18]. At the LGA level, Basse has the largest unmet requirement for
FP (30%) while Janjanbureh has the lowest (18%) [18]. Regional variation in The
Gambia may be explained by a variety of socioeconomic and cultural
characteristics, including religion, ethnicity, cultural traditions, patriarchal
cultures in nature, female education, and FP delivery modalities [20, 21]. The
Gambia has a total fertility rate (TFR) of 4.8, a general fertility rate (GFR)
of 149 per 1000 women between the ages 15-49, a maternal mortality ratio of 289
(confidence interval: 204-375), and a pregnancy-related mortality ratio of 320
(CI: 231-409) per 100,000 live births, with minor differences in rural regions
[18]. Only 18.9% of married women use any method of contraception, compared to
17.1% who use modern techniques and 1.8% who utilize traditional methods [18].
Contraceptive use is still relatively infrequent in The Gambia [17, 18, 20, 21].
Generally, there have not been studies on prevalence and determinants of
contraceptive use that focus on combining both 2013 and 2019/20 DHS surveys
across women in The Gambia. Thus, this paper aimed at exploring the contextual
determinants of pooled prevalence of modern contraceptive usage among women of
reproductive age in The Gambia.
2. METHODS
2.1. DATA SOURCE
Data from the Gambia Demographic and Health Survey (GDHS) in 2013 and 2019-20
were used for the analysis, a stratified two-stage cluster sampling approach was
used to create a population-based sample. Following the probability proportional
to the size of the Enumerated Areas (EAs), 281 clusters/EAs were selected in the
first stage of both surveys. The second stage involved a methodical selection of
25 households from each cluster/EA. In 2013 and 2019-20, from 281 households
11,279 and 12,481 women aged 15–49 were initially sampled, however, only 10,233
and 11,865 of them were interviewed successfully from 2013 and 2019-20
respectively. This resulted in 91% and 95% response rates which were taken into
account for detailed analysis. Interviews with women aged 15 to 49 years old
were used to collect data for the study. In The Gambia, through the USAID-funded
MEASURE DHS programme, ICF International provided technical and financial
assistance to the Ministry of Health in collaboration with the Gambia Bureau of
Statistics (GBoS) who implemented the survey.
2.2. VARIABLE SELECTION AND MEASUREMENT
Outcome variables. The study outcome variable was contraceptive use among
sexually active women (aged 15-49) excluding pregnant women. This variable was
derived from the question “current contraceptive use by method type” in the
dataset, the four responses were: “no method”, “folkloric method”, “traditional
method”, “modern method”. Contraceptive use was recoded into “No contraception
=0” for those who do not use any method, “Traditional =1” for those using
folkloric and traditional methods and “Modern=2” for those using modern
contraceptives.
Explanatory variables. Twenty independent variables were utilized in the study
based on a thorough literature review and datasets availability; the variables
are listed in Table 1.
2.3. STATISTICAL ANALYSIS
The authors conducted a descriptive analysis by calculating the proportion of
women using contraceptives (either traditional or modern). The datasets were
combined and we calculated women’s use of contraceptives by type based on their
socio-demographic characteristics. The chi-square test was used to identify the
association of modern contraceptive uptake with independent variables. Study
variables with p-value <0.05 were included into the model. Lastly, we used
multivariable logistic regression model to assess the predictors of
contraceptive usage at 95% confidence interval (CIs) with computed adjusted odds
ratios (aORs). All the study data were analyzed using IBM SPSS version 25.
2.4. ETHICAL APPROVAL
The datasets used in this research were population-based datasets that are
freely available in the public domain. For reasons of confidentiality, specific
characteristics that could be used to identify participants in the study were
excluded. As a secondary study, MEASURE DHS/ICF International granted the
authors permission to use the datasets. Also, prior to the survey, the DHS
project gained ethical approval from the Gambia's Research Ethics Committee.
Table 1
Definition of independent variables used in the analysis
3. RESULTS
3.1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF REPRODUCTIVE-AGE WOMEN IN THE GAMBIA
As shown in Table 2, the mean age (±SD) of women using contraceptives was 32.0
(±7.6). Two-thirds (65%) are married, 44% have no formal education, and half of
the women reside in urban areas. More than 97% practice Islam. Just over half of
the women (54%) had their sexual debut before 18 years of age and more than 60%
have had at least one child. Only 20% were told about FP in the health facility
and only 13% do not have a desire for more children. Half of the women claimed
to have joint decisions with their partner on contraceptive usage and only 11%
of the women used contraceptives.
Table 2
Characteristics of weighted sample population (GDHS 2013-2019/20)
3.2. UTILIZATION OF CONTRACEPTIVES AMONG GAMBIAN WOMEN (GDHS 2013-2019/20)
Over the years, overall contraceptive use increased from 7.3% in 2013 to 14.1%
in 2019/20, as shown in Figure 1.
Figure 1: Showing contraceptive use & non-use among women of childbearing change
in the Gambia (2013-2019/20)
Figure 1
Showing contraceptive use & non-use among women of childbearing change in the
Gambia (2013-2019/20)
As shown in Table 3, adolescents (15-19) and younger women (20-24) had lower
contraceptive use of 1.3% & 7.8%, respectively, compared with women aged 30-34
and 35-39 with contraceptive use of 18.2% & 18.6%, respectively. Contraceptive
use was 14.8% among married women, 13.0% among women with a higher level of
education and 12.6% of these women live in urban areas. It was noted that 9.4%
of them were in the middle wealth quintile. Contraceptive peaked among those at
parity above 5 (19.3%) and those told about family planning at the health
facility (31.6%). It was observed that 15.8% of those using contraceptives heard
about family planning on the TV while 13.0% heard about family planning on the
radio. Also, contraceptive use was high (22.7%) among women who don’t desire
more children and 19.8% of those who used contraceptives are covered by health
insurance.
Table 3
Contraceptive use among Gambia women of childbearing age: 2013-2019/20 pooled
data
3.3. DETERMINANTS OF CONTRACEPTIVE UPTAKE AMONG GAMBIAN REPRODUCTIVE-AGE WOMEN
(GDHS 2013 -2019/20)
Predictors of modern contraceptive uptake on pooled data 2013-2019/20
Based on the result from pooled data as shown in Table 4, age was associated
with modern contraceptive use, as women aged 25-29 (AOR=1.67, 95% CI=
1.14-2.45), 30-34 (aOR=2.12, 95% CI= 1.41-3.21), 35-39 (aOR=1.91, 95% CI=
1.23-2.94) and 40-44 (aOR=1.89, 95% CI= 1.18-3.05) had higher odds of using
modern methods of contraception compared to women less than 24 years old.
Furthermore, women living in the urban area had higher odds (aOR=1.49, 95% CI=
1.25-1.79) of using modern contraceptive methods than rural dwellers. Educated
women had increased likelihood of using modern contraceptives method compared to
women with no formal education. Those at parity two to four had increased odds
of using modern contraceptives than those with less than two parities (aOR=1.21,
95% CI= 1.01-1.47). Those told about family planning at the health facility had
a higher odds of using modern contraceptives (aOR=2.97, 95% CI= 2.61-3.38).
Women who had no future plans for more children had increased likelihood of
using modern contraceptives (aOR=1.96, 95% CI= 1.62-2.37) than women with plans
for more children.
Predictors of modern contraceptive uptake for GDHS 2019/20 only
Table 4 shows the logistic regression results on the factors associated with
modern contraceptives used among Gambia women. In the adjusted model, age was
associated with modern contraceptive use, as women aged 30-34 had higher odds
(aOR=1.84, 95% CI= 1.13-2.98) of using modern methods of contraception compared
to women less than 29 years old. Furthermore, women with secondary education had
increased odds (aOR=1.27, 95% CI= 1.04-1.56) of using modern contraceptive
methods than those without education. Those told about family planning at the
health facility had a higher odds of using modern contraceptives (aOR=2.31, 95%
CI= 1.98-2.69). Women who are married or living with their partner had higher
odds (aOR=1.23, 95% CI= 1.06-1.44) of using modern contraceptives than unmarried
women. Women who had no future plans for more children had increased odds of
using modern contraceptives (aOR=2.11, 95% CI= 1.68-2.66) compared to women with
future plans for more children. Finally, women who delivered in government
facilities had higher odds (aOR=1.31, 95% CI= 1.06-1.63).
Table 4
Determinants of contraceptive uptake among Gambian reproductive-age women (GDHS
2013 -2019/20)
4. DISCUSSION
The paper explore the aggregated prevalence of modern contraception use in The
Gambia from the 2013 GDHS to the 2019/20 GDHS, to ascertain the contextual
determinants of its utilization in order to help in informing policies and
intervention prioritization across the country. In the logistic regression
analysis, women’s age, place of residence, education, parity, household wealth
index, having been told about FP at health facilities, desire for more children,
work status, and place of delivery were significant determinants of modern
contraceptive utilization in The Gambia. This result will assist practitioners
and authorities in designing successful ways to increase maternal health service
utilization, including contraceptives, especially modern FP methods.
The pooled prevalence of modern contraceptive utilization in The Gambia was
10.1%. Our study showed lower contraceptive uptake which is smaller than
previous studies done in The Gambia [20, 21]. The low uptake of modern
contraceptives might be due to their health-seeking behavior, higher education
status, an obvious source of information, less negative cultural influence
towards FP services, and availability of health facilities including hospitals
[22, 23]. In The Gambia, modern contraceptives were not widely used. One
probable explanation is that cultural and behavioral factors are the primary
impediments to contraceptive use among women [24].
The mean age of maternal women was similar to studies done in The Gambia [20,
25] and Nigeria [26, 27]. A more significant proportion of the women were in
their prime reproductive years, and contraceptive utilization increased as their
age advanced. It was also asserted that as a woman's age progresses, she would
achieve the desired family size [28]. Thus, younger women are bound to
experience a higher risk of overall unmet need for FP [29]. More than
three-fourths of women had up to secondary education levels and are in contrast
with a study done in Osun State, Nigeria on a lower side [30]. There are
observed high parities across regions of The Gambia, which could be explained as
a result of the Islamic faith being the predominant religion in The Gambia. In
addition, rivalry and competition in most polygamous settings might also
influence high parity seen as each woman would want to outnumber her counterpart
regarding the number of living children she has, the woman’s ability to bear
children is seen as a stabilizing influence on her marriage and in some Gambian
culture, men have to prove their virility by the number of children they have.
Male child preference for the families is also a significant determinant for
high parity, although it is beyond the focus of this research. Some related
studies in the Gambia looks into parental choice regarding son preference [20,
21] and Nigeria, where more women were married [27, 31].
The study revealed that urban settings utilized modern contraceptives more than
rural dwellers. These could be attributed to cultural and religious variations
as rural communities are culturally disinclined as compared to urban areas [21].
Furthermore, women having been told about FP by health workers at health
facilities increases their tendencies toward utilizing modern contraceptives. As
part these were shown in this paper, additional barriers such as fear of side
effects, male son preference, and cost have been identified as barriers to the
use of FP services for poor, rural women in previous studies [20, 21]. In other
research, the most common reasons for not using contraceptives were the
husband/partner's resistance and the fear of negative effects [21, 32, 33]. Male
decision making on women’s uptake of contraceptives further justifies the
significant role of male involvement and spousal communication, especially in
rural settings, regarding the unmet need for FP. However, some studies in SSA
have found that use of contraception increases if a woman has previously
discussed contraception, been exposed to mass media about FP, or approves of FP
[25, 34, 35]. However, this study also shows that the women desire not having
many children increases their chances of using modern contraceptives. As a
result, despite their wish to limit and space childbirths, women are likely to
give birth to additional children since they do not use contraception. Thus, a
society that encourages high investment levels per child is essential for
receptivity to ideas about family size determination [36].
STRENGTHS AND LIMITATIONS
We employed a nationally representative dataset, ensuring that the study's
results can be generalized to Gambia's women of reproductive age. In addition,
due to the large sample size, extensive reporting of modern contraception
prevalence was possible. However, the studies used cross-sectional data,
implying that no causal relationships were determined.
CONCLUSION
The utilization of modern contraceptives was very low across age groups, rural
areas, low/no formal education, low parity, and those with a desire to have more
children. The program must consider improvements in the quality of care provided
to acceptors. Also, community leaders should be more actively involved in the
MCH programme. Government agencies should target these programs and campaigns on
regional FP demands and provide suitable culturally sensitive and regionally
adaptive services to the communities' contexts. The programme should intensify
its efforts in rural and urban settings to improve accessibility to and
availability of FP services. Future studies should look into the healthcare
systems and service-related factors that prevent women in the Gambia from using
modern contraceptives.
DECLARATIONS
Acknowledgement
The authors thank the MEASURE DHS project for their support and for free access
to the original data.
Funding
The authors have no support or funding to report.
Availability of data and materials
Data for this study were sourced from Demographic and Health surveys (DHS) and
available here: https://www.dhsprogram.com/data/available-datasets.cfm
Authors’ contributions
AB & AA conceptualized the study and prepared the study design, reviewed
literature, analysis of data and wrote the results. AB, AA & EMR critically
reviewed the manuscript for its intellectual content. AB had final
responsibility to submit for publication.
Competing interests
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Ethics approval for this study was not required since the data is secondary and
is available in the public domain. More details regarding DHS data and ethical
standards are available at: .
Consent for publication
No consent to publish was needed for this study as we did not use any details,
images or videos related to individual participants. In addition, data used is
available in the public domain.
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reproductive age group in Ogbomoso, Oyo State, Nigeria. Open Access J
Contracept 7:33–40[CrossRef] [PubMed]
28. Wangila SW (2001) “Factors Underlying Unmet Need for Contraception in
Kenya”. Unpublished M A . Thesis, PSRI: Umversity of Nairobi. 68–82
29. Bhandari G, Premarajan K, Jha N, Yadav B, Paudel I, Nagesh S (2006)
Prevalence and determinants of unmet need for family planning in a district
of eastern region of Nepal. Kathmandu Univ Med J KUMJ 4:203–210
30. Oyedokun AO (2007) Determinants of Contraceptive Usage: Lessons from Women
in Osun State, Nigeria. J Humanit Soc Sci 1:1–14
31. Odusina E, Ugal D, Olaposi O (2012) Socio-Economic Status, Contraceptive
Knowledge And Use Among Rural Women In Ikeji Arakeji, Osun State, Nigeria.
Afro Asian J Soc Sci 3:1–10
32. Haque M (2010) Unmet Need for Contraceptive: The Case of Married Adolescent
Women in Bangladesh. Int J Curr Res 9:29–35
33. Pradhan J, Dwivedi R, Dwivedi R (2015) Why Unmet Need for Family Planning
Remains High in Bangladesh: A Community Level Analysis. J Womens Health
Care 04:1–7[CrossRef]
34. Gupta N, Katenda C, Bessinger R (2003) Associations of mass media exposure
with family planning ttitudes and practices in Uganda. Stud Fam Plann
34:19-31.[CrossRef] [PubMed]
35. Kayembe P, Fatuma A, Mapatano M, Mambu T (2006) Prevalence and determinants
of the use of modern contraceptive methods in Kinshsa, Democratic Republic
of Congo. Contraception 74:400-406.[CrossRef] [PubMed]
36. Mace R, Colleran H (2009) Kin Influence on the Decision to Start Using
Modern Contraception : A Longitudinal Study from Rural Gambia. Am J Hum
Biol 21:472–477.[CrossRef] [PubMed]
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Barrow, A., Ayobami, A., & Reynolds, E. M. (2022). Pooled prevalence and
contextual determinants of contraceptive utilization among reproductive-age
women in The Gambia: Evidence from 2013 – 2020 Demographic Health Surveys.
Current Research in Public Health, 2(1), 1–14. Retrieved from
https://www.scipublications.com/journal/index.php/crph/article/view/299
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(2015) Barriers to modern contraceptive methods uptake among young women in
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26. Ogboghodo EO, Adam VY, Wagbatsoma VA (2017) Prevalence and Determinants of
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Southern Nigeria. J Community Med Prim Health Care 29:97–107
27. Olugbenga-Bello AI, Adeyemi A, Adeoye O, Salawu M, Aderinoye A, Agbaje M
(2016) Contraceptive prevalence and determinants among women of
reproductive age group in Ogbomoso, Oyo State, Nigeria. Open Access J
Contracept 7:33–40[CrossRef] [PubMed]
28. Wangila SW (2001) “Factors Underlying Unmet Need for Contraception in
Kenya”. Unpublished M A . Thesis, PSRI: Umversity of Nairobi. 68–82
29. Bhandari G, Premarajan K, Jha N, Yadav B, Paudel I, Nagesh S (2006)
Prevalence and determinants of unmet need for family planning in a district
of eastern region of Nepal. Kathmandu Univ Med J KUMJ 4:203–210
30. Oyedokun AO (2007) Determinants of Contraceptive Usage: Lessons from Women
in Osun State, Nigeria. J Humanit Soc Sci 1:1–14
31. Odusina E, Ugal D, Olaposi O (2012) Socio-Economic Status, Contraceptive
Knowledge And Use Among Rural Women In Ikeji Arakeji, Osun State, Nigeria.
Afro Asian J Soc Sci 3:1–10
32. Haque M (2010) Unmet Need for Contraceptive: The Case of Married Adolescent
Women in Bangladesh. Int J Curr Res 9:29–35
33. Pradhan J, Dwivedi R, Dwivedi R (2015) Why Unmet Need for Family Planning
Remains High in Bangladesh: A Community Level Analysis. J Womens Health
Care 04:1–7[CrossRef]
34. Gupta N, Katenda C, Bessinger R (2003) Associations of mass media exposure
with family planning ttitudes and practices in Uganda. Stud Fam Plann
34:19-31.[CrossRef] [PubMed]
35. Kayembe P, Fatuma A, Mapatano M, Mambu T (2006) Prevalence and determinants
of the use of modern contraceptive methods in Kinshsa, Democratic Republic
of Congo. Contraception 74:400-406.[CrossRef] [PubMed]
36. Mace R, Colleran H (2009) Kin Influence on the Decision to Start Using
Modern Contraception : A Longitudinal Study from Rural Gambia. Am J Hum
Biol 21:472–477.[CrossRef] [PubMed]
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