The primary goal of this analysis was to determine if HIV + versus HIV- women, and HTP versus NHTP women in fragile regions would exhibit differing FP knowledge profiles and/or report receiving FP information at different rates. For every category of modern FP knowledge, HIV + women demonstrated a higher level of awareness when compared to HIV- women in initial tests of independence. When covariates were controlled in the multivariate logistic regression models, HIV + women did not show higher odds of knowing about female or male sterilization; but still demonstrated higher odds of knowing about all other categories of modern FP. Likewise, HTP women demonstrated higher knowledge of every modern method of FP except for male sterilization in tests of independence. In the logistic regression models, HTP women showed higher odds of knowing about every category except for again, male sterilization. It would have been reasonable to expect that HIV + women would show higher knowledge of FP methods that also have sexually transmitted infection (STI) prevention capabilities (e.g., male and female condoms). However, the magnitude of the knowledge difference between HIV + and HIV- women was similar for several FP methods that had no STI prevention capabilities (e.g., the pill and implants). In other words, the CIs of the AORs for knowledge of FP methods with and without STI prevention capabilities overlapped. With respect to messaging, HIV + women were more likely than HIV- women to recall being given FP information by a provider at a recent visit to a healthcare facility. However, despite the fact that like HIV + women, HTP women are at an increased risk of future pregnancy complications [64–71], they were not more likely than NHTP women to be given FP information at a recent healthcare visit. HTP women did however exhibit higher odds than NHTP women of recalling encountering FP messaging via TV and radio. Since TV and radio messaging could not have been targeted in a way that would have resulted in HTP women having higher environmental exposure to the messages than NHTP women, it is possible that HTP women's past pregnancy experiences sensitized them to subsequent information related to that experience, making them more likely to notice the messaging and/or remember having been exposed to it. But, as establishing that was not the goal of this research, it would need to be explored in further specialized studies.
Although the primary focus of this analysis was not to compare countries, it is important to note that Burundi, Malawi, and Zimbabwe had committed to the United Nations Foundation's Family Planning 2020 (FP2020) initiative several years prior to the DHS being carried out in those countries; whereas Cameroon, DRC, Guinea, Cote d'Ivoire, and Niger either committed to FP2020 in the same year in which the DHS was carried out or years after . The time prior to implementation of the DHS with which institutions in Burundi, Malawi, and Zimbabwe had to implement FP initiatives as a result of their commitment to FP2020 could have impacted the results for these countries. As of August 2021, Angola has not committed to FP2020.
When country of residence, HIV status, and HTP status were used to categorize respondents, the percentage in each category reporting knowledge of 'at least one modern method' of FP was relatively high. However, results indicated that relying on this metric alone was misleading with respect to holistically assessing FP knowledge, since the percentage of respondents with knowledge of each individual FP method was highly variable. For example, over 85% of respondents from Niger reported knowledge of at least one modern method, but only 18.3% and 50.8% had knowledge of IUDs and male condoms, respectively. Over 95% of HIV + women knew at least one modern method, but only 41.7% knew of male sterilization. Likewise, the percentage of respondents knowing at least one modern method was above 90% in HIV-, HTP, and NHTP women; but only about half of HIV- women knew about IUDs, 60.8% of HTP women knew about implants, and 61.1% of NHTP women knew about female condoms. Therefore, researchers assessing FP awareness are encouraged to not only focus on the percentage of women knowing at least one modern method, but to also take heed of the levels of awareness of specific FP subcategories, which will provide a more precise understanding of where gaps in FP knowledge in their populations of interest exist.
Knowledge and awareness, along with the provision, availability, and positive attitudes about FP are prerequisites to an individual ultimately using contraception. In one of the few studies that looked at FP in FCS, low use of contraceptives by women in a union was associated with low prevalence of FP knowledge in six local FCS regions in Sudan, Uganda, and the DRC . Beyond the connection between FP knowledge and subsequent contraception use, one should also take into account the trends of demand for contraception not satisfied in countries within our sample when considering this study's implications. Slaymaker et al.  showed that between 1995 and 2018, Burundi, Malawi, Niger, and Zimbabwe demonstrated a decrease in the proportion of women who were sexually active and needing, but not using modern contraception. In Cameroon and the DRC there was no notable change in this proportion, while in Guinea and Cote d'Ivoire the proportion of women who were sexually active and needing, but not using modern contraception increased . Angola was not included in their analysis . While there is a degree of good news in the fact that this proportion decreased over time in Burundi, Malawi, Niger, and Zimbabwe, the most recently measured proportion of women who were sexually active and needing, but not using contraception in the countries within our sample, with the exception of Zimbabwe, were still extremely high. Moreira et al.  found that in Guinea (2012), 75.7% of the demand for contraception was not satisfied. This percentage was 70.7% in Angola (2015), 58.0% in Cote d'Ivoire (2011), 56.4% in the DRC (2013), 53.5% in Niger (2012), 50.9% in Burundi (2016), 46.4% in Cameroon (2011), 25.2% in Malawi (2015), and 14.0% in Zimbabwe (2015) . For comparison purposes, this value was recently about 10% in the USA  and 8.6% in Columbia . Decreasing these percentages is crucial for improving equity and gender issues, and health in general of women, families, and communities. When creating FP educational interventions meant to contribute to that cause, it is important that women with certain reproductive and/or sexual health histories be targeted due to their increased risk of a variety of negative outcomes. With that in mind, it is encouraging that our study indicates that HIV + and HTP women in fragile regions seem to have been reached as evidenced by their higher levels of FP knowledge across most categories. However, the other side of this could be an indication that women that do not have easily recognizable reproductive or sexual health histories may not be proactively reached as much as necessary. In other words, women that do not fall into identifiable "at risk" categories may be falling through the cracks, thereby perpetuating the cycle that results in women experiencing outcomes like HIV diagnoses or terminated pregnancies in the first place.
There are several limitations to this study. Although the target population was fragile regions, there were many fragile and/or conflict-affected countries not able to be included because DHS and/or AIS datasets were not available for them, or they did not meet other inclusion criteria outlined in the methods section. In fact, it is debatable how to even classify regions as FCS. We chose the WBG classification system since it is standardized and used as a guideline by a variety of international development stakeholders. Another limitation is that the classification of pregnancy termination by DHS included women who had miscarried, had a stillbirth, and/or undergone an abortion. These three events, and the circumstances leading up to them can be quite different. It would have been useful if these subcategories could have been analyzed separately. Lastly, this study was based on a cross-sectional survey with self-reported measures and therefore recall bias may have been an issue, temporality of observations and causation cannot be ascertained, and intercountry analyses are of limited value since the DHS surveys for each country were done in different years. Also, social desirability bias could have played a part in women misrepresenting their knowledge of FP. Despite these limitations, this study has several strengths. First, the DHS IPUMS data management tool allowed for a high degree of standardization, harmonization, and comparability between variables. The breadth of variables available in DHS enabled the inclusion of appropriate covariates in the regression models and allowed for robust descriptive analyses of HIV + and HTP prevalence across a variety of sociodemographic, reproductive, and sexual health subgroups, which alone provides useful information. This study is the only one to our knowledge that investigated trends and determinants of subcategories of FP knowledge along with FP messaging outcomes in a multi-country FCS target population using nationally representative surveys. Lastly, since DHS surveys are repeated approximately every five years, longitudinal follow-up analyses will be possible.