One hundred and three community participants were involved with this study, consisting of 25 males and 78 females. The mean age for the males was 23.8 years and the females 26.4 years. Unplanned pregnancy was high in this study population, as 73.7% (n=45) of the female and 87% (n=7) of the male participants who reported a pregnancy, classified them as unplanned. Contraceptive use was high with 83.5% of participants reporting some form of modern contraceptive use, either in the past or currently. Male condoms were the most commonly used method (75%, n=65), followed by the depo medroxyprogesterone acetate (DMPA) injection (36%, n=31).
Thematic Results
A model (figure 1) was created that aided with contextualising the findings. The boxes capture the overarching themes, while the circles show the thematic codes that were used. Five components were established from the data: No use, vulnerable use, compelled use, conditional use, and autonomous use. The components of the model demonstrate how barriers and motivations to use contraception can move along a continuum and that they can have different outcomes in various contexts. An overlapping of barriers was noted as shown in figure 1 below.
[Insert Figure 1 here]
No use
The most significant barriers reported as no-use barriers were related to the healthcare system. These factors that broadly include access and quality of care factors are explored in detail elsewhere, see Kriel et al. (2021), and Kriel et al (2022, in progress). Individual-level factors included lack of information, rumours, fer, religious beliefs, pregnancy desire, and not having engaged in sex yet.
Lack of information was a widely cited reason why people do not use contraception. One participant explained that they are often not aware of the available methods:
You would say or say hay I do not know what is there, and they would say oh you don’t know the thing you came to inject with you see? They do not explain to you everything and give you information and say there is this and that and that and that and that.
[Females without children, FGD, P3]
An adolescent participant explained how unintended pregnancies can happen because young people do have adequate information about contraception:
But then we do not sleep [have sex] because we want kids, mistakes happen, (Group laughs). You see, you [have] sex thinking that you are just stealing a bit. It would just happen, maybe by mistake you get pregnant, but that you won’t be aiming [for] that. You are still new in this thing, so you would [not] know that you have to go to the clinic and get an injection. You will see when it is late maybe after you got pregnant that ‘hey I should have gone to the clinic’.
[Rural Adolescent Females, FGD, P1]
One participant’s explanation on forgetfulness, and rumours and misinformation about side effects demonstrated their decision to not use contraception:
Yes me, as I said I used to forget pills, and the three years injection (Implant) I usually hear that it kills, this and that the Depo injection makes you wet. So I’m not using anything, I hear a lot of things so.
[Rural Young Adult Females, FGD, P9]
Fear of different methods was a reason for non-use. Another participant reported how her fear of female condoms prevented her from using them:
It is just that the female one (condom) is not common. I don’t know if it is not common because it is scary. I become scared of the way it is presented, the way you use it […] I saw it, you become afraid to give it to a man.
[Rural Adult Females, FGD, P4]
Fear of being injected was cited as another reason to not use injectable contraceptives:
I have never tried it (injectable contraception). My problem now is that I am a coward (all laughing). I have never tried. I use condoms because I’m scared of being injected.
[Married Females, FGD, P5]
Religious beliefs can also prevent contraceptive use as one young adult participant explained:
I say it is there in religion because, especially the born again [Christians], isn’t that a person is not allowed to have sex with a person if they are not married. But you find […] there is a person she has sex with. Now she can’t go do family planning because she will be scared that in the clinic people that know her, will see her that she is born again but you do family planning. You find that she in that way fall pregnant.
[Rural Young Adult Females, FGD7]
Another important reason to not use contraception was the desire to have a baby as this participant pointed out:
There are those who say, ‘I don’t see the need and will not inject [with injectable contraception] because I do not have a baby yet’, which means [there is] a decreased chance of having a baby, let me have a child first.
[Rural Young Adult Females, FGD, P9]
Some young adolescent participants reported that they had not begun using contraception because they had not yet engaged in sex.
F: Why you are not preventing pregnancy? Not using contraception or not using family planning, can you tell me?
P10: Because I have not started having sex as yet.
P6: I have not started having sex as yet too.
[Rural Adolescent Females, FGD]
However, other adolescents pointed out that it is important to use contraception even if they are not having sex at the time:
Can I please say this, if you are on family planning that does not means you have to do family planning because you have started having sex. You have to do family planning because you will say ‘I don’t do family planning, not do it today’, [but then] go to a boy, after that the boy will break you and get [you] pregnant.
[Rural Adolescent Females, FGD, P7]
Vulnerable use
Vulnerable use is use that is threatened or disrupted in some way. Reports of discontinuing (stopping), changing, interrupting, and covert use of methods showed how vulnerable use can influence contraceptive use patterns. Vulnerable use patterns were most commonly reported in the data.
Forgetfulness was a key factor that resulted in inconsistent use and was mainly discussed with regards to the oral contraceptive pill, but also included discussions about missed visits for either re-injection or follow-up for the Implant.
One female participant explained how gendered roles and tasks within the household can result in forgetting to take contraception:
I am at home I have to take a pill [contraceptive pill] maybe there are lot of things in my head I must bath the children, wash the dishes, I must cook you see, there is too much, I will forget that I have to take pills.
[Rural Young Adult Females, FGD]
Another female participant explained that if a person forgets to take their oral contraceptive pill at the correct time, they can fall pregnant easily:
You have to have an exact time. If you drink them [referring to the oral pill] at 8, it’s always 8 for all on that time. Because […] if that time comes and you forget the time, you can easily get pregnant.
[Women without children, FGD P3]
Participants also pointed out that forgetfulness can interfere with the effectiveness of injectable contraception. One participant described how people can fall pregnant while on injectable contraception because they forgot their re-injection date:
[H]ow do you get pregnant while on contraceptives? It is you who miss your injection dates, or you fail to wait for the time.
[Rural, Adult Female FGD, P5]
Another participant described how she uses her phone to remind her of her re-injection date in order to avoid having another unintended pregnancy:
I make sure that I set alarm on my phone so that on the 4thI go to the clinic because I don’t want to repeat the mistake of falling pregnant again […].
[Rural Young Adult Females, FGD, P4]
There were also reports that forgetfulness can play a key role in returning to the clinics for removal and replacement of the Implant:
With 3 years [Implant] you forget. You can insert it today I am sure that you don’t count that okay it’s 2015, 2016 and 2017 I have to go back. You forgot long time ago, and you have missed your date.
[Urban Young Adult Females, FGD, P1]
Lack of information could also lead to interrupted use as one participant explained:
It means that problem that we are facing is lack of knowledge. (Mhh, exactly, yes all of them agreeing with her). It is the thing that we are facing because we listen to half and forget. If you have [a] running tummy and [you are] on contraceptives... [the] pills or injection gets interrupted in the system. That means people needs to be educated and know that other things [can] prevent [contraception from working]. And know that even what you are using is not 100% safe. So you have to do 1, 2 and 3 so that you are in the right situation.
[Married/in-union women, FGD, P6]
Side effects were the most discussed reason for discontinued use. One female participant explained how menorrhagia influenced her decision to stop using contraception:
I started with Depo. I injected with it, but I still continued bleeding because when the [contraceptive] pills started to make me sick I was bleeding and I was taking them every day. I'd bleed till the next collection date then go to the clinic so the doctor then said I must stop using them.
[Married Females, FGD, P4]
Amenorrhoea was another side effect that resulted in discontinued use of contraception. This side effect was often associated with the belief that the womb is ‘blocked’, dirty or being damaged:
Okay I was on the 2 months injection [referring to Nur-Isterate Injectable]. It was locking my periods […] I did not like that [..]. So, I decided to leave it because of [not having] periods. I think it is something that should come out sometimes. So yes, I then left it [Nur-Isterate injectable] because of that and I’m still not using it now.
[Women without children, FGD P4]
One participant believed that amenorrhoea due to contraceptive use could lead to infections, and therefore it was important to discontinue contraceptive use:
It ends up not being right. In others it damages the womb […] it is this blood that was supposed to…. this is the blood that is making you sick that is causing an infection […] that’s why you have to take it [referring to the Implanon NXT Implant] out when it supposed to come out. It’s the blood that has been stored all these years and it was not coming out.
[Women without children, FGD P3]
Another associated amenorrhoea with being ‘dirty’:
[S]he then stopped [her contraception], then she got her periods. [T]hose who are doing Life Science [referring to a school subject] they know that if you are a female there has to be blood coming out of your body, that is dirty, there has to be dirt that is coming out of the body.
[Rural Adolescent Females, FGD, P6]
Weight gain was another important side effect, as one participant noted:
I was injecting with Depo 3 months I stopped using it [contraception] because it was making me very fat. I moved from size 30 to size 34 I stopped […].
[Married Females, FGD, P7]
There were numerous reports about changing contraceptive methods. These were mostly associated with side effects, as one participant explained:
I left it [2-monthly injectable] because I heard that there was the 3-years [Implant]. I inserted the Implant, but it has lots of side effects. I’m even from the doctor because of the side effect. I just had to change it. The doctor said I must go back to 2-months I must change it.
[Females without children, FGD, P3]
Covert use discussions were also raised under this theme as discovery of use could result in discontinuation. One participant described how she has to hide her family planning card from her male partner to continue using her contraception:
USFG_C007: I go for injection come back and hide my card, on my date I go and come back there at the clinic, I don’t tell him.
USFG_C008: Because he wants a child.
Facilitator: The reason you hide the card is because he wants a child?
USFG_C007: Yes. I am not ready for a child.
[Females without children, FGD]
Compelled use
Compelled use reasons included discussions about external influences that could be the reason for use. Examples of these included peer pressure, male partner influence, and parents insisting that their children use contraception. A notable factor in compelled use is that once the external force is removed contraceptive use will most likely stop.
One female participant from the married/in-union group explained how adolescents influence each other, and how males can pressure their female partners to not use contraception– and in particular to not use condoms. She also highlights how insufficient information about various contraceptive methods can result in unplanned pregnancies:
A child [referring to an adolescent girl] is going to use a condom [but an adolescent] boy will convince her not to use it when they have sex. [She will then] get pregnant. If she knew about other methods she was going to use them because they fall pregnant at the age of 11 [and] 12.
[Married/in-union women, FGD, P4]
Male participants in particular noted how peer pressure can influence contraceptive use. One adolescent male participant explains how friends and alcohol use can negatively influence contraceptive use (especially condoms):
The thing that makes us not to go, as youth, dislike using these prevention methods it is the influence that we get from other people that we befriend, our peers who are- who don’t use these things. We as youth like to say that we have bad luck you see, but we put money together to buy alcohol and when we are drunk and we have sex without using prevention methods because we are influenced by this alcohol that we have been drinking.
[Adolescent Males, FGD, P4]
One female participant, a parent, explained how she had taken her daughter to the clinic to get contraception. Once the mother’s influence was removed the daughter stopped using the method:
I am the one who once went with my child. I just thought let me speak to the clinic sister because I am a mother. I went with her, and the clinic sister said it is better that she takes a decision on her own. I didn’t know too well, but I knew that I wanted her to use these pregnancy prevention methods. I initiated that she uses the injection, but what I have noticed is that she has stopped.
[Rural Adult Females, FGD, P4]
Conditional use
The participants described situations where contraceptive use was conditional and where a specific goal was the motivation to use contraception. These motivations included factors such as completion of school, economic factors, pregnancy prevention, and health related motivations such as not having a period or gaining weight.
An adolescent participant pointed out that using contraception was important so that they can complete school:
In my view contraceptives are right, [especially if] you are still a student. If you are having sex, you must not get a child but continue with school.
[Rural Adolescent Females, FGD, P5]
Male participants also cited the rationale for pregnancy prevention, including economic factors that influenced contraceptive use:
My partner and I, we use condoms, when I am with her. Because the other thing I am trying to prevent is the issue of expenses, and she also understands that […] because life is not yet the way I want it. I am trying to run away from having children all over.
[Adult Males, FGD, P7]
Another often reported reason to use contraception for purposes other than pregnancy prevention was to not have a period. A healthcare provider participant explained:
Some they like family planning because some injections stop their periods, so any reason mainly she will not receive her periods.
[HCP, Group 2, P5]
While gaining weight was a problem for some people, others found this to be a reason to use contraception, as a healthcare provider describes:
There are people who like gaining weight. Some said ‘I heard that it makes people gain weight sister. I do not like this body I have it does not give me pleasure. I am asking for the prevention methods so that I will gain weight.
[HCP, Group 2, P6]
Autonomous use
Ideal use situations were discussed as motivations to use contraception and can be defined as autonomous use. These accounts captured situations where participants used contraception without any significant obstacles that could prevent or interrupt use. Pregnancy prevention, own decision making, and improving the quality of life were cited as examples of autonomous use.
Making decisions about contraception, own decision making, was raised as being important for a woman to use contraception autonomously:
Really family planning is up to a woman, to think for herself. Males never think the way you think because at the end it us that feel more pain than males.
[Married Females, FGD, P2]
One female participant explained how contraception helped her after she had had her first baby – highlighting how her decision making about pregnancy prevention was important to improve her quality of life:
I think that family planning is the right thing especially nowadays because things are expensive. It helped me because I had a baby while I was still young. I went off family planning and got another baby after 10 years.
[Urban Adult Females, FGD, P6]
Another female participant described how using contraception was important to increase the quality of her life:
I like it [contraception] because if you’re using it sometimes you can be free that no I cannot get pregnant anyway, now I can continue making my dreams things I like to do [come true].
[Urban Young Adult Females, FGD, P4]