Family planning utilization in Zambia has increased in the past years, from 15% in 1992 to 48% in 2018 (CSO, 2018). There is uncertainty if this progress is cross cutting or only specific to certain socio-economic groups. This study therefore, sought to examine socio-economic related inequalities of family planning service utilization amongst women of reproductive age (15–49 years) in Zambia.
This study shows that family planning use declines beyond age 30 and continues to decline until menopause at age 49 years which could be because of satisfied parity and onset of menopause. This is in line with other studies that found that as women approached menopause, loss of partner or acquired the desired number of children, the use of family planning services decreased (Atuahene et al., 2016). There is, to some extent, an inverse U-shaped association between age and family planning utilization with the probability of use attaining a maximum in the age range 20–29 years and gradually decline at older ages. These results are anticipated as it reflects a decreasing need for family planning services among older women entering menopause. As shown by estimated average marginal effects, women in the 35–49 age group were 25.64% less likely to utilize family planning services than the 15–19 age group.
This study also revealed that married women were more likely to use family planning services because they were more sexually active. On the other hand, unmarried women were less likely to use family planning services because of fear of stigmatization in society as they were not married and unlikely to be given priority by healthcare providers (United Nations, 2017). The positive average marginal effect reinforces this conclusion that moving from not married to married, a woman’s likelihood of family planning utilization is increased. This finding does not support the previous studies that showed that married women used less family planning compared to the unmarried because they had a childbearing obligation (Lemba et al., 2014). In addition, Lemba and others (2014) asserted that men have continued to appreciate having a lot of children despite their economic status and that having a lot of children was a part of status in the society (Lemba et al., 2014). The differences between the current study and Lemba et al., 2014 study may be due to differences in the sample sizes and the geographical location of the studies. Lemba et al., 2014 looked at a more localized population in Kazungula district of Southern province with a sample size of 137 men and women of reproductive age, while this study used data from 2013–2014 ZDHS, a nationally representative survey, with a sample size of 12, 498 women of reproductive age.
Further, women with an education and those whose ideal number of children is met were more likely to utilize family planning services. This is because women with higher education and those with more children were more likely to make rational decision on reproductive health issues and achieved satisfied parity, respectively (Amentia et al., 2015). In addition, the more literate one is the more likely they are to be engaged in other economic activities that may disrupt their reproduction.The findings of this study are similar to that of the previous studies that revealed that education is important in utilization and improvement of family planning services (Larsson & Stanfors, 2014; Amentie, 2015). On the other hand, the more children a woman has, the more likely they are to use family planning services because of their achieved satisfied parity. In other words, those without children were not likely to use family planning services as they needed to conceive compared to those with children. This is in disagreement with Blackstone et al. (2017), who found that men in the rural areas for instance, despite their economic status, appreciate having a lot of children which to them is a status in society and would only use family planning services when there is parity satisfaction.
Our study also found that women from richer households used family planning more, which could be because they were more likely to have more access to reproductive health knowledge and therefore have an enhanced ability to make decisions regarding their fertility. Their economic status could also give them means and access to reproductive health services that others may not access. In addition, urban women were more likely to utilize family planning services compared to their rural counterparts which could be due to high literacy levels, and availability and accessibility of family planning services as the health facilities were within reach, as was found by Aslam and others (2016).
This study’s findings further revealed that underutilization of family planning combined with lack of wealth and lack of education are some of the key factors that determine the rural-urban gap. The argument is that, the rural poor have less income compared to their urban counterparts leading to the parallel disparities that exists between them in family planning utilization. This finding supports the findings of a previous study that showed that socio-economic gap or differences in family planning utilization exists and had persisted among women and this had disadvantaged the poor (Aslam et al., 2016).
Urban women of childbearing age were engaged in economic activities that could give them the ability and power to purchase the family planning commodity. Some urban women would utilize family planning services as they could be in employment, and due to career development. Thus, moving from rural areas to urban areas increases the probability of family planning utilization. This finding of this study is similar to Kabonga et al. (2010) who found that rural women had little or no income compared to their urban counterparts and this meant that fertility was high in the rural compared to urban areas.
The concentration curve and indices results showed that utilization of family planning services are in favour of or advantaging wealthier and urban women. This is not surprising since wealth is correlated with education which facilitates the increase to use (Ortayli & Malarcher, 2010). This finding supports previous studies that showed that higher socioeconomic status improves the use of family planning services (Aslam et Al., 2016). Studies show that economically self-sufficient women are more likely to utilize contraception as it enhances their ability to make rational decisions on reproductive health issues (Ortayli, 2010). Regarding the right to use family planning services, while economic status does prevent women from making sole decision about their reproductive health, it could, however, initiate a demand for contraception (Hindin et al., 2014; Amalba et al., 2014).
The Oaxaca – Blinder decomposition results showed that education had a bigger effect in urban than in rural which could imply that the urban population is much better off than their rural counterparts as the disparity in education is in favour of the urban women. The findings of this study are similar to that of the previous studies that revealed that there was low utilization of family planning services which could have been attributed to low education levels. This could be influenced by the ability of individuals to judge when care should be sought (Ashraf et al., 2009). Furthermore, Stanfors et al., 2014 found that educational level and higher income lead to an increase in demand for the resources involved in acquiring contraceptives. Other studies also revealed massive socioeconomic gap in health and health care utilization among women of reproductive age due to lower secondary and tertiary levels of education (Aslam et al., 2016; Groot et al., 2018).
Our study found that religion has no effect on family planning use. This could imply that belonging to a particular religion or denomination did not have an influence on family planning use. This result is not in support of some empirical evidence which has demonstrated that religious influences may lead low uptake of family planning despite high knowledge and awareness among women of reproductive age (Kabonga et al., 2010; Mubita-Ngoma and Kadantu, 2010).
4.1 Implications for policy and practice
This study shows that socioeconomic inequalities in the utilisation of family planning services have persisted, primarily in rural areas despite the policy by the Ministry of Health to integrate family planning services into Mother and Child Health services. The policy was inadequate to increase family planning service utilization to about 58% by 2020 in Zambia. Therefore, there was need for the government to integrate family planning services into every stage of service delivery at Primary Health Care. Additionally, there is need by the government to intensify on interventions such as awareness about importance of utilization of family planning services in the community. This is easier said than done, but can be introduced slowly in line with the existing capacity in the health facilities.
Integration at all levels can be the beginning, and then slowly increase the capacity to handle the increase in family planning services utilization. Further, there was need for all health care workers to under-go training in family planning services. This was to ensure provision of all types of contraceptives in all health facilities to reduce family planning inequalities. Practice (service provision at primary level) was one way of reducing inequalities in family planning service utilization thus by increasing capacity of the health care providers who trained on how to offer different types of family planning services in order to match a woman’s fertility intentions. Furthermore, there is also need to offer family planning services at all points of health service delivery at all times in order to increase uptake.
4.2 Limitations
Our study had a number of limitations. First, the study opted to use data on sexually active women of childbearing age as data was readily available. Second, even though data was readily available, the variables were limited as the data was not meant for this research. Third, the limitation in the number of covariates chosen had an effect on the power and robustness of the results. This study did not measure some variables such as side effects, cultural expectations or beliefs and accessibility which might also affect the rural-urban gap in the use of family planning services. However, the broader picture was still clear and the most imperative factors explaining use of family planning have been captured.