The objective of this study was to examine the predictors of demand for FP satisfied with modern methods (mDFPS) in urban Malawi and to identify the sub-groups of urban women underserved with modern contraceptives. The study analysed data from the 2015-16 Malawi DHS data, using a CHAID decision tree analytic technique. The results for the full sample showed that demand for FP satisfied with modern methods was higher among women with children, Chewa/Tumbuka/Lomwe women, and women residing in the central region. The least demand satisfied with modern methods was among women with no children, and who had not heard FP advertising on television.
The most significant predictor of demand for FP satisfied with modern methods was the number of living children women had. The women with no children had a lower demand satisfied with modern methods relative to those with children. This finding is consistent with the results of previous studies conducted in sub-Saharan Africa and LMICs(20,21). An analysis of contraceptive use among adolescents in 73 LMICs found that married adolescents without children had the lowest median modern contraceptive prevalence in all regions of the world, ranging from 2.9% in West and Central Africa to 29% in Latin America and the Caribbean(20). One study in Zimbabwe found that women with no children were eight times less likely to use modern contraceptives compared to those with one or more children(21). A plausible explanation of the finding in this study is that the desire to postpone first birth is weakly held among women with no children. Thus, the motivation to use modern contraceptives to satisfy their demand for FP is low. It is also likely that most of the women with no children are younger, and therefore face several barriers to accessing modern contraceptives. Encouraging women to postpone first birth and addressing both the demand and supply factors that inhibit women with no children from using modern contraceptives need to be prioritised if Malawi is to close the mDFPS gap between these women and their peer with one or more children.
The results also showed ethnicity as a significant predictor of mDFPS, and ethnicity was significant for women with one or more children. The women who had one or more living children and who were Chewa, Lomwe or Tumbuka had a higher mDFPS than those who were Ngoni, Yao or other minority ethnic groups such as Nkhonde and Sena. Malawi is a multi-ethnic country with fairly diverse cultural norms and beliefs regarding reproduction. However, the influence of ethnicity on modern contraceptive use is not well understood. As shown in the results, Ngoni, Yao and women of other minority ethnic groups in urban areas are underserved with modern methods relative to Chewa, Lomwe and Tumbuka women. The Yao ethnic group is predominantly Muslim and is generally associated with conservative cultural norms that value sexual initiation ceremonies, early marriages and large families(22). With regards to the Ngoni, a major cultural feature is patrilineal descent where children are affiliated to their fathers’ kin group. It is known that women in patrilineal descent systems have limited autonomy in decision making regarding childbearing(23). The above cultural norms probably inhibit modern contraceptive use among Yao and Ngoni women who need such contraceptives. Women of minority ethnic groups such as the Nkhonde and Sena also probably face difficulties in accessing FP services due to language barriers or discrimination by contraceptive service providers. There is the need for further studies to investigate cultural norms, beliefs and other factors that constrain modern contraceptive use among Yao, Ngoni and other ethnic minority women in urban Malawi.
The analysis further showed region of residence as the most significant predictor of mDFPS among Chewa, Lomwe and Tumbuka women. The women that were residing in the central region had a significantly higher mDFPS than those in the southern and northern regions. This finding is consistent with the results of the 2015-16 DHS nationwide which shows that the northern and southern regions have a low mDFPS among married women relative to the central region(16). A plausible explanation of this finding is the low concentration of health facilities especially facilities that offer reproductive services in the northern and southern regions. For example, one study that mapped private health facilities, which are crucial for expanding access to FP services, in Malawi found that only 14% of private facilities with nurse midwives were located in the northern and southern regions respectively compared to 71% in the central region. Astonishingly, there were no private mobile clinics in the northern region and only 33% of such facilities were in the southern region compared to 67% in the in the central region(18).
Exposure to FP information via text message(s) on phone was the most significant predictor of mDFPS among Ngoni, Yao and women of other minority ethnic groups. Unexpectedly, it was observed that the women that were exposed to FP information via text messages had a lower mDFPS than those that were not. Specifically, about 58% of the Ngoni, Yao and women of other ethnic groups that had accessed FP information via text messages on phone had their demand for FP satisfied with modern methods compared to approximately 76% of those that did not. Even though FP programmes are increasingly taking advantage of the ubiquity of mobile phones in sub-Saharan Africa to deliver contraceptive information via text messages to women and couple, there is little evidence of the effect of such interventions on contraceptive uptake. One study that evaluated the impact of a mobile reproductive health platform in Kenya (m4RH) which delivered contraceptive information via text messages found an increase in m4RH consumers’ contraceptive knowledge, but there was no increase in contraceptive use among them(24). Even though the FP Costed Implementation plan for Malawi recommended the use SMS text messages to distribute accurate contraceptive information, this study found that women with access to FP information via text messages had a lower mDFPS. While we are not sure of the source(s) of the text messages delivered to the women in the current study, it is possible that these messages reinforce misconceptions about FP, and therefore discourage modern contraceptive use. It is known that the emergence of social media platforms including WhatsApp and Facebook messenger allow for the easy circulation of unreliable information from dubious sources including information on FP. There is the need for further studies to investigate the content, sources and effect of such messages in Malawi and Africa at large.
As shown in the results, women with no children are severely underserved with FP services, with only 48% of them having their demand for FP satisfied with modern methods. Among these women, exposure to FP information on TV was the best predictor of mDFPS. Approximately two-thirds of the women with no children who were exposed to FP messages on TV had their demand for FP satisfied with modern methods compared to 4 in 10 of those that were not exposed to FP messages on TV. Contrary to the results on the effect of exposure to FP information via text messages, this finding suggests that viewing FP messages on TV improves the chances of using modern contraceptives. Television is a credible source of information in the Malawian context, thus FP information on TV is more likely to be accurate, create awareness, increase knowledge and induce contraceptive use. The finding in this study is consistent with the results of previous studies in the region and elsewhere(25,26).
For the women in union, the results showed that demand for FP satisfied with modern methods was highest among Chewa, Tumbuka and Lomwe women whose partners had primary or no education, and who did not know the fertility preference of their partners. The least demand satisfied with modern methods was among Ngoni, Yao and other ethnic minority women who were aged 15-19 and 40 years and above, and were Catholic, SDA/Baptist or Muslim.
Overall, ethnicity was the strongest predictor of mDFPS among women in union. Similar to the results for the full sample, Chewa, Lomwe and Tumbuka women in union had a higher mDFPS than Ngoni, Yao and women of other minority ethnic groups. The fact that ethnicity was the most significant predictor of mDFPS among women in union suggests that socio-cultural norms that influence women’s contraceptive use behavior are at their strongest in sexual unions. Efforts to address sociocultural norms inhibiting women’s use of modern contraceptives in urban areas in Malawi need to prioritise those in union, especially Ngoni, Yao and women of other minority ethnic groups.
Contrary to expectation, the results showed that Chewa, Lomwe and Tumbuka women whose partners had no education or primary education had a significantly higher mDFPS than those with partners of secondary and higher education. Even though previous studies in LMICs show a strong positive association between educational attainment and modern contraceptive use, there is evidence that better educated women in urban sub-Saharan Africa consistently report higher use of traditional methods than their less-educated peers (27). While most of the studies reporting high traditional method use among better educated urban women do not include the educational attainment of their partners, it is likely that partners with secondary and higher education disapprove of modern methods due to side effects. It is also possible that FP programmes in urban Malawi are focusing less on couples of higher socio-economic status including women with partners of secondary and higher education because of the wrong assumption that such women are already contracepting or have fewer barriers to accessing modern contraceptive methods.
Furthermore, the study found that household wealth status was the most significant predictor of mDFPS among women with partners of secondary and higher education. Counterintuitively, women in the poorer and poorest categories together with those in the richest category had a mDFPS that was 15% higher than their peers in the richer and middle categories. The fact that women in the poorer and poorest wealth categories belonged to the same sub-group as those in the richest category in terms of having a relatively higher mDFPS suggests that disadvantage in household wealth does not automatically translate into disadvantage in mDFPS. Other factors including motivation for contraceptive use and fear of side effects which were not included in this study determine women’s capacity to satisfy their demand for FP with modern methods. There is the need for further studies to investigate the counterintuitive relationships between socio-economic status and mDFPS observed in this study.
For the women whose partners had no education or primary education, the fertility preference of the couple was the most significant predictor of mDFPS. Women who had the same fertility preference as their partners had a lower mDFPS relative to those whose partners wanted more or fewer children and those who did not know the fertility preference of their partners. Research on fertility preference in Malawi shows that couple with the same fertility preference are those who tend to want a child in the next three years(28). This suggests that the women reporting the same fertility preference as their partners in this study are those wishing to postpone or space pregnancy/childbirth but not to stop. In such instances, women are typically less likely to use modern contraceptives to satisfy their demand(28,29). Interestingly, we also found that all the women that did not know the fertility preference of their partners had their demand for FP satisfied with modern methods. This suggests that when women do not know the fertility preference of their partners they assume lack of or less opposition from those partners on modern contraceptive use, and are therefore likely to have their demand for FP satisfied with modern methods.
As shown in the results, Ngoni, Yao and other ethnic minority women in union who were aged between 20 and 39 years, the prime reproductive childbearing ages had a significantly higher mDFPS than those aged 15-19, 40-44 and 45-49 years. Studies in sub-Saharan Africa consistently identify adolescent girls aged 15-19 years as the most underserved group with modern contraceptive methods(30). In general, reproductive health and family planning services in most countries in the region including Malawi are not adequately oriented towards meeting the needs of adolescents. Thus, adolescents disproportionately face many barriers in accessing modern contraceptives including stigma, cost of services and lack of adequate knowledge. The finding in this study is therefore consistent with the findings of previous studies in the sub-region.
With respect to relatively older women, those aged 40 years and above, studies show that they are among those with the highest demand for FP for stopping childbearing (31). It is likely that most urban women in Malawi aged 40 years and above have already attained their desired fertility, and would therefore like to use long-acting and permanent methods (LAPMs) to stop childbearing. Yet, short-term methods such as pills and injectables which are prone to discontinuation and may not satisfy the peculiar needs of these women are still the dominant modern contraceptive methods in Malawi, with less than 10% of all contraceptive users relying on LAPMs(32,33). One study in the capital of Malawi, Lilongwe, found that majority of the FP clinics did not offer IUD or female sterilization services(33). In addition, relatively older women at the end of their reproductive years are often left out of FP discussions and policies due to the perception, sometimes wrongly, that they are menopausal, have infrequent sex or lack a regular partner. Family planning messages and services are therefore rarely targeted at these women to satisfy their demand.
Among the adolescents (15-19 years) and older women (40 years and above) in this study, religious affiliation was the most significant predictor of mDFPS. About 68% of Anglican, CCAP and Other Christian women had their demand for FP satisfied with modern methods compared to just 36% among Catholic, SDA and Muslim women. This finding is consistent with the results of previous studies in Malawi (34–36). Overall, fundamental Catholic, Muslim and conservative protestant denominations such as the SDA believe that it is God who controls the number of children women have. Therefore, modern contraceptive use is viewed as violating or interfering with God’s law on procreation. In Malawi, even in urban areas, where upwards of 90% of women are affiliated with either Christianity or Islam, it is likely that such conservative religious views inform women’s reproductive behaviour, especially contraceptive use. The fact that religion significantly predicted mDFPS among adolescents and older women suggests that religious constrains to modern contraceptive use are particularly severe among these already vulnerable and underserved groups.
Limitations of the study
Even though this study is one of the few studies to examine mDFPS among urban women in sub-Saharan African using CHAID analysis, it has two key methodological limitations. Firstly, the study uses cross sectional data from the 2015-16 Malawi Demographic and Health Survey which does not allow for causal inferences to be made from the findings. Secondly, the CHAID analytic technique used does not take into account the hierarchical structure of the Demographic and Health Survey data. Despite these limitations, the method used in this study revealed a complexity of interactions in the predictors of mDFPS that may be difficult to tease out in conventional regression analysis.