Socio Demographics Characteristics
A total of 530 women in union at the time of data collection were interviewed from 930 households, accounting for a response rate of 95.4%. The mean age of the respondents was 30.76(± 6.872 SD) with a minimum age of 18 years (Table 1). More than half percent of women (51.7%) were between the age of 25 and 34 years. The mean age at the first pregnancy was 20.17(±3.53SD) years. More than a quarter (26.6%) of women in union has not attended formal education while only 12.3% of those who attended formal education had completed secondary education. The average number of children a woman had was 4.3(± 2.4 SD). 216 women (42%) had five or more children. Additionally, 37.7% of women spaced the last two children less than 24 months. 14% of the participants reported that they had ever lost a child less than 5 years old.
Family Planning
In this study, 94.3% of women, reported to know at least one type of contraception with 94.2% knowing at least a source of acquiring contraceptives. Only 22.6% of women who desired to space their next birth more than 2 years were using a contraception method at the time of interview. The most prevalent modern contraceptive method was the injectable accounting for 40%, followed by implants used by 24.6% of women. The male preservative, Intra Uterine Device (IUD), pills and sterilization represented 10.8%, 6.2%, 3.1% and 1.5% respectively. 13.8% of women who adhered to any form of contraception reported to be using natural contraceptive methods. Among women not on any form of contraceptives, the following reasons were cited: side effects (51%), absence of menses since delivery which is considered as postpartum or postpartum amenorrhea in case it exceeds six weeks (18.8%), religious beliefs (12.9%), partner opposition (8.4%), partner absenteeism (6.4%) and lack of awareness about family planning services (2.5%). Among women on modern contraception, 68% reported that they were not informed about eventual side effects at the time they started utilization.
Table 1: Socio-demographic and obstetric characteristics
Characteristics
|
Categories
|
n (%)
|
95% CI
|
P-value
|
Age of mother
|
18-24
|
104 (19.6)
|
18.3 – 20.1
|
0.105
|
25-29
|
136 (25.7)
|
21.4 – 26.6
|
30-34
|
138 (26.7)
|
22.3 – 29.5
|
35-39
|
83 (15.7)
|
12.7 – 18.6
|
40-44
|
46 (8.7)
|
7.2 – 9.5
|
45+
|
23 (4.3)
|
3.9 – 5.2
|
|
|
|
|
|
Educational level of Women
|
No formal education
|
141 (26.6)
|
23.5 – 28.6
|
0.118
|
Uncompleted Primary education
|
197 (37.2)
|
32.3 – 40.2
|
Completed primary education
|
49 (9.2)
|
7.2 – 10.8
|
Uncompleted secondary education
|
91 (17.2)
|
14.3 – 19.5
|
Completed Secondary School
|
48 (9.1)
|
8.4 – 10.9
|
University education
|
4 (0.8)
|
0.2 – 1.9
|
|
|
|
|
|
Parity
|
≤4
|
298 (58)
|
56.6 - 60.7
|
0.034*
|
5-7
|
162 (31.5)
|
27.5 – 33.1
|
≥8
|
54 (10.5)
|
6.2 – 14.8
|
Birth interval between the last two children
|
<24 months
|
173 (37.7)
|
37.7
|
<0.001*
|
|
≥24months
|
286 (62.3)
|
62.3
|
*Chi-square relationship statistically significant
There was a statistically significant negative association between last two children birth intervals and family planning utilisation (p-value <0.001). Those who had longer intervals between the two last births were less likely to adopt any family planning method as spacing had been considered as a natural family planning method.
Table 2: Adjusted Odds Ratio (controlling for cofounders) predicting women’s use of family planning based on background characteristics
Characteristic
|
aOR (95%CI)
|
P-value
|
Age of Mother
|
|
|
18-24
|
4.26 (1.88 – 9.45)
|
0.070
|
25-29
|
5.04 (2.09 – 10.27)
|
0.038*
|
30-34
|
3.17 (2.68 – 7.75)
|
0.142
|
35-39
|
2.15 (1.42 – 9.83)
|
0.354
|
40-44
|
2.03 (1.37 – 10.83)
|
0.412
|
45+
|
Ref
|
Ref
|
Educational level of Women
|
1.31 (1.11 – 1.49)
|
0.183
|
No formal education
|
1.21 (0.89 – 5.53)
|
0.621
|
Uncompleted Primary education
|
1.32 (1.13 – 2.31)
|
0.319
|
Completed primary education
|
2.91 (0.72 – 4.12)
|
0.213
|
Uncompleted secondary education
|
3.11 (1.31 – 5.40)
|
0.081
|
Completed Secondary School
|
1.94 (0.86 – 5.28)
|
0.003*
|
University education
|
Ref
|
Ref
|
Parity
|
|
|
≤4
|
1.72 (1.35 – 2.01)
|
0.002*
|
5-7
|
1.03 (0.76 – 3.82)
|
0.172
|
≥8
|
Ref
|
Ref
|
Birth interval between the last two children
|
|
|
<24 months
|
2.84 (1.92 – 3.41)
|
<0.001*
|
≥24months
|
Ref
|
Ref
|
* Statistically significant associations at 95% CI (two tailed) from logistic regression
Logistic regression showed that women aged 25 to 29 were 5.04 times (95%CI 2.09 – 10.27 p=0.038) likely to use family planning methods compared to those aged above 45 years. Furthermore, completing secondary school was significantly associated with using family planning (aOR 1.94 95%CI 0.86 – 5.28 p=0.003). Women with four or less children were 1.72 times likely to use family planning in comparison to those with eight or more children (Table 2).
Findings from Focus-Group Discussions
The participants of the focus group discussion were women of reproductive age (between 15 to 49 years old), men whose spouses’ age was within 15 to 49 years, administrative and religious leaders. Each of the 18 collines was represented by an even number of women and men selected from the above group of people.
The results of the quantitative phase showed low uptake of the family planning methods. The qualitative phase was undertaken to understand the reasons justifying the quantitative results. Large family size emerged as a key theme which resonated with most participants irrespective of the colline of residence.
Considering the desired number of children expressed by each group, the discussion was directed towards the different barriers that hamper the achievement of the ideal family size as many families were having more children than they wished to have.
Desired number of children
Both men and women agreed that it was very hard to sustain a large family in the present socio-economic situation. Most participants suggested that at most four children was ideal to achieve a decent standard of living.
A female participant in a colline, Gatete described how she would have preferred to practice family planning earlier in her life:
“I have five children, but I wish I had three because life is very expensive nowadays.” (FGD woman, Gatete colline)
“I think four children are enough to be brought up and educated properly”. (FGD man, Gitwe colline)
Barriers of Contraceptive use
Fear of side effects
From the findings, fear of contraceptives’ side effects was reported as the main reason for underutilisation and discontinuation modern contraceptive methods. Rumours regarding the side effects of family planning which included bleeding, cancer and infertility propagated by other community members had largely contributed to this communal fear.
“I know one lady who started using modern contraceptive after her second pregnancy. Later on she abandoned to get the third child but failed to conceive.” (FGD Woman, Migera colline)
This climate of fear had been used as an avenue exploited by religious leaders and other anti-family planning people to make contraceptives unpopular:
A male participant said, “Church leaders often instruct the faithful that the use of modern contraception is the cause of the increase of cancer cases that occur nowadays.” (FGD man, Gashasha colline)
In addition, some participants had shared their personal experience with side effects and how this was conceived by their spouses and the community as a whole. Personal experiences had deeply shaped continuation of family planning and although there was wide community consensus on the adverse effects of family planning, side effects created preconception which encouraged family planning discontinuation as soon as side effects emerged:
“I have used injectable and I experienced continuous bleeding. I went back to the hospital and obtained some medicines and I have since abandoned the modern contraceptives method.” (FGD woman, Cabara colline)
In addition, the issue of side effect management at the health system level was raised during the discussions.
“There should be qualified personnel to deliver quality health care to follow those side effects cases closely and inform the people who are coming for family planning services about the side effects that may occur. If the health practitioner cannot give medicines to resolve the side effects issue, the patient will give up the use of family planning methods.” (FGD man, Mushishi colline)
Further, participants were concerned about increased fees to treatment of side effects despite receiving the family planning for free. This concern had metamorphosed into a fear which served as a disincentive for not only initiating family planning but also, continuation for those that subscribed:
“I know a woman who have used an IUD but experienced side effects. This woman had to pay a lot of money for her treatment and then discouraged other women to consider any modern contraceptive methods.” (FGD man, Mushishi colline)
Religious beliefs
In conservative communities, religion forms an integral section of the life and in the case of deciding the use and continuation of family planning, religion is a major determinant. From the focused group discussions, we learned that natural family planning which consists in identifying the signs and symptoms of fertility during a menstrual cycle and practising sexual abstinence during the fertile period to avoid pregnancy was the only method that most of the religions recommended. This influence from religious leaders and conceptualization of modern family planning as a sin served as a deterrent for most women:
“Our community health workers always sensitize about family planning but their teachings conflict with church teachings which say that modern family planning is a sin of killing. When it is known that a church follower has adhered to one of those methods, she will be suspended from the church services. That is the reason many individuals have given up the use of modern contraceptive methods.” (FGD man, Kabwayi colline)
Cultural beliefs
Culture as expected, was found as a determinant of family planning and this emerged as a theme from the focus group discussions. For some participants they cannot limit the family size when they have only girls on the other hand, they prefer many children because some of their offspring may eventually die and in that case, they hope that at least some will survive and support the family. Other women perceived increased family size of a man as a security to their marriage:
“In Burundian culture we are afraid of having few children. For instance, if we go for vasectomy and death takes all the children, it will not be possible to reproduce again.” (FGD man, Kanenge colline)
“In our community, women with many children think that their husband will not seek extra marital children and therefore do not adhere to family planning methods.” (FGD woman, Kanenge colline)
Spousal communication gap
Both men and women agreed that they do not openly discuss the optimal number of children and how family resources could support child upbringing.
“I could say that there is a lack of communication between husband and wife. Otherwise, if they were communicating effectively, they could convince each other and reach a common understanding on how to achieve family planning.” (FGD woman, Kabwayi colline)
Unbalanced power and gender roles
Group discussions also reflected the fact that men do not participate in family planning sensitization and do not take any responsibility towards family planning, yet they have a predominant role in family decision-making including childbearing.
“Women are victims of men who do not understand family planning policies. They spend most of the time in bars and when they come at home, they are drunk and force us into sexual intercourse while we are in our fertile period and we get unplanned pregnancies in that way.” (FGD woman, Karagara colline)
Discouragement from family planning adherence by health practitioners
Some participants shared that in their health facility, they have encountered health practitioners who were religious and discouraged patients in adopting family planning methods. They advise them to consider only natural methods and emphasize the fact that modern contraceptive methods have many side effects.
“Some medical staff are against modern contraceptive methods because of their side effects. If the health practitioners doubt on those methods, we will be more doubtful about adopting any form of modern contraception methods.” (FGD man, Migera colline)