Recent assessments have highlighted the importance of psychosocial obstacles to contraception, particularly in settings where the demand for fertility remains high. In Burkina Faso, although women and men express the desire to space out pregnancies, they still desire large families. This is especially true of men, who are thus less committed to FP (Ministère de la Santé 2017). Most women lack autonomy of choice about health issues, and indeed, only 8% of them make independent decisions about their health care (INSD and MACRO 2012). Other obstacles, such as fear of side effects, appear to be widespread in the population (Ministère de la Santé 2017), as they constitute 25% of the stated reasons for contraceptive discontinuation (INSD and MACRO 2012).
These results contrast with earlier research findings, which established that the availability of quality services is an essential factor in contraceptive use (Skiles et al. 2015). However, access to contraception, like access to health, is a multidimensional concept. A recent summary of this literature proposes to approach access to contraception through six dimensions (Choi, Fabic and Adetunji 2016). Four of these pertain to supply: geographic accessibility, service availability, administrative accessibility, affordability. These authors also note that two of those dimensions (cognitive and psychosocial access) are more relevant and challenging than the others because, in addition to being related to contraceptive demand, they are still prevalent in low-income countries as substantial progress has been made with respect to obstacles on the supply side (Choi, Fabic and Adetunji 2016). Those two dimensions can be encapsulated within the same topic of psychosocial accessibility, which we have divided into four dimensions (Zan, Rossier and Moreau, forthcoming):
Dimension 1: Contraceptive knowledge
This dimension encompasses knowledge of contraceptives and includes knowledge of where these contraceptives may be sourced, the mechanisms of use, associated side effects of contraceptive methods, and their management. The lack of accurate, objective, and reliable information (from formal sources) is considered the root of rumors about contraception (Dehlendorf et al. 2020; Gilliam et al. 2004; Pazol et al. 2018). The "diffusion of innovations" theory (Rogers 2010) holds that an idea will spread through populations if it is consistent with the community’s values, beliefs, and needs. This theory links the spread of formal knowledge about contraception to local sociocultural perceptions of fertility and sexuality. Indeed, in a setting that values large families and the control of sexuality within marriage, any idea that tends to discourage contraceptive use will spread easily and will be valued over information from health professionals (Gilliam et al. 2004). Earlier research has already observed that the dissemination of rumors regarding side effects must represent the social disapproval of contraception (Casterline et al. 1997).
Dimension 2: Fear of side effects
The spread of rumors (informal local knowledge) depicting contraception negatively in turn increases fears of side effects, which reduces adoption among potential users or continuation among current users. Indeed, the decision to commence contraception and vigilance in contraceptive use are based on a balance between feelings (i.e. emotions) about contraceptive methods and feelings about pregnancy avoidance (Miller 1986). For example, people often voice their fears around the risks of primary or secondary infertility relating to the side effects of contraception when explaining their choice (Sedlander et al. 2018). Ultimately, a woman in need of contraception may end up not using it if the fears of side effects supersede her motivation to avoid pregnancy. Many studies have demonstrated that fears of side effects constitute populations central reservations about and major barriers to the current and future use of contraceptive methods (Bongaarts and Bruce 1995; Sondo et al. 2001).
Dimension 3: Approval of contraception
Approval, regarded as a positive or negative assessment or valuation of a behavior (Rossier and Bernardi 2009), is also important when it comes to contraceptive adoption. Many studies have found that approval is a major determinant of contraceptive use (Islam and Hasan 2016). In a study on several countries in sub-Saharan Africa, some scholars used DHS questions on a woman’s approval (which have since been removed) and her perception of her husband’s consent as indicators of attitudes toward FP. They concluded that "attitudinal resistance" remains a major barrier to contraceptive use (Cleland, Ndugwa and Zulu 2011). However, a study in rural and urban Burkina Faso (Rossier 2007) refined the notion of approval by distinguishing between the approval of contraception in different life situations: before marriage, or birth spacing, and for birth limiting. This study found that approval was firm for spacing but uncommon before marriage and weak for limiting, which connects to the still-unfavorable social representations of premarital sexuality and the limitation of family size in this environment.
Dimension 5: Contraceptive agency
Many studies have shown that women’s autonomy, decision-making, and empowerment are associated with contraceptive use (Bamiwuye et al. 2013; Ghose et al. 2017; Sedlander et al. 2018). Agency is defined as the ability to choose and act upon one’s choice (Kabeer 1999; Sapin, Spini and Widmer 2007). Women’s agency, measured through measured decision-making and freedom of movement, is found to be associated with women’s contraceptive use in lower- and middle-income countries (James-Hawkins et al. 2018). However, agency may differ across practices: a woman may be freer to engage in socially approved practices, while stronger social control may be expected for less approved practices, such as contraceptive use. Therefore, it is necessary to measure agency not in general but specifically for contraception.
Based on the literature and the contraceptive landscape in Burkina, the need to collect and analyze data on the four dimensions of psychosocial access is justified. In this paper, we use that framework and the data collected on the four dimensions in PMA2020 Round 6 in 2019 to reach the three objectives. First, we will study the relationship between these varied psychosocial dimensions. Second, we describe the relationship between them and contraceptive use. Third, we will analyze the associations between those dimensions, other individual characteristics, contextual characteristics, and contraceptive use.