Socio-Economic Disparities in Use of Family Planning Methods among Pakistani Women: Findings from Pakistan Demographic and Health Surveys

Predictors of voluntary uptake of modern contraceptive methods in rural Sindh, Pakistan

The use of modern contraceptive methods (MCMs) has been stagnant for the last decade in Pakistan. The second most populous province, Sindh reports 25% of MCMs use. Various factors including demographics and health services utilization are associated with the uptake of family planning services. This research aimed to identify and assess specific predictors of MCMs among women aged 15-49 in two districts of Sindh-Matiari and Badin. A cross-sectional household survey was conducted from October 2020- December 2020. In total, 1684 Married Women of Reproductive Age (MWRA) 15-49 years were interviewed. For the selection of eligible respondents, a two-stage stratified cluster sampling strategy was used. Univariate and multivariable logistic regression was used to determine the predictors for the use of MCM. Use of modern methods of contraceptive was 26.1% (n = 441). Statistically significant socio demographic predictors of MCM included: number of children 4 or more (AOR: 5.23; 95%CI: 2.78-9.84), mother having primary education (AOR: 1.73; 95% CI: 1.26-2.36), and husband having middle education (AOR: 1.69; 95% CI: 1.03-2.76). Maternal health services indicators included: postnatal care of mother (AOR: 1.46; 95% CI: 1.09-2.05); women who were visited by Lady Health Workers in their postnatal period and were counselled on family planning (AOR: 1.83; 95% CI: 1.38-2.42). Since the primary purpose of using modern contraceptive methods is for limiting pregnancies, there is a potential to promote awareness about the benefits of birth spacing as part of implementing a more integrated approach to family planning. The integration of family planning services within maternal and newborn child healthcare services effectively promote the voluntary adoption of modern contraceptive methods. The role of Lady Health Workers in family planning counseling and service provision and uptake is important in the context of Sindh and should be fostered further by opportunities for capacity building and their empowerment.

Male Involvement in Family Planning Decisions in Malawi and Tanzania: What Are the Determinants?

The participation of males in joint spousal decisions is urgently needed in achieving the fundamental indicators of reproductive health. The low involvement of males in family planning (FP) decision-making is a major determining factor in low FP usage in Malawi and Tanzania. Despite this, there are inconsistent findings regarding the extent of male involvement and the determinants that aid male participation in FP decisions in these two countries. The objective of this study was to assess the prevalence of male involvement in FP decisions and its associated determinants within the household context in Malawi and Tanzania. We used data from the 2015-2016 Malawi and Tanzania Demographic and Health Surveys (DHSs) to examine the prevalence and the determinants inhibiting male involvement in FP decisions. The total sample size of 7478 from Malawi and 3514 males from Tanzania aged 15-54 years was employed in the analysis by STATA version 17. Descriptive (graphs, tables and means), bi-variate (chi-square) and logistic regression analyses (unadjusted (U) and adjusted odds ratio (AOR)) were performed to identify the determinants associated with male involvement in FP decisions. The mean age of respondents in Malawi was 32 years (±8 SD) and in Tanzania, 36 years (±6 SD), with the prevalence of male involvement in FP decisions being 53.0% in Malawi and 26.6% in Tanzania. Being aged 35-44 years [AOR = 1.81; 95% CI: 1.59-2.05] and 45-54 years [AOR = 1.43; 95% CI: 1.22-1.67], educated (secondary/higher) [AOR = 1.62; 95% CI: 1.31-1.99], having access to media information [AOR = 1.35; 95% CI: 1.21-1.51] and having a female head of household [AOR = 1.79; 95% CI: 1.70-1.90] were determinant factors of male involvement in FP decisions in Malawi. Primary education [AOR = 1.94; 95% CI: 1.39-2.72], having a middle wealth index ranking [AOR = 1.46; 95% CI: 1.17-1.81], being married [AOR = 1.62; 95% CI: 1.38-1.90] and working [AOR = 2.86; 95% CI: 2.10-3.88] were higher predictors of male involvement in FP decisions in Tanzania. Increasing the role of males in FP decisions and involvement in FP utilization may improve uptake and continuity of FP usage. Therefore, the findings from this cross-sectional study will support redesigning the ineffective strategic FP programs that accommodate socio-demographic determinants that may increase the likelihood of male involvement in FP decisions, especially in the grassroots settings in Malawi and Tanzania.

'The wife should do as her husband advises': Understanding factors influencing contraceptive use decision making among married Pakistani couples-Qualitative study

This paper explores the perceptions and attitudes of married couples which prevent them from using modern contraceptive for purpose of family planning, based on semi-structured interviews with 16 married couples from rural Pakistan. This study, with married couples, not using any modern contraceptives, discussed issues of spousal communication and religious norms using qualitative methods. Despite near universal knowledge of modern contraceptives among married Pakistani women, the use continues to be low, with high unmet need. Understanding the couple context about reproductive decision making, pregnancy and family planning intentions is imperative to helping individuals fulfil their reproductive desires. Married couples may have varying intentions and desires about family size; a lack of alignment between partners may lead to unintended pregnancies and affect uptake and use of contraception. This study specifically explored the factors which prevent married couples from using LARCs for family planning, despite their availability, at affordable prices in the study area of rural Islamabad, Pakistan. Findings show differences between concordant and discordant couples regarding desired family size, contraceptive communication and influence of religious beliefs. Understanding the role that male partners play in family planning and use of contraceptives is important in preventing unintended pregnancies and improving service delivery programmes. This study also helped identify the challenges married couples, particularly men have in understanding family planning and contraceptive use. The results also show that while men's participation in family planning decision making is limited, there is also a lack of programs and interventions for Pakistani men. The study findings can support development of appropriate strategies and implementation plans.

Four in ten married women demands satisfied by modern contraceptives in high fertility sub-Saharan Africa countries: a multilevel analysis of demographic and health surveys

BACKGROUND

Demand satisfied with modern contraceptive can be seen on both a health and economic level. Additionally, family planning helps to regulate fertility, prevent unintended pregnancies and their consequences. Thus, the aim of this study was to identify the magnitude of demand satisfied with modern contraceptive among married/in-union women in ten high fertility sub Saharan African countries.

METHODS

Recent Demographic and Health Surveys that included a weighted sample of 43,745 women of reproductive age provided the data for this study. All statistical analyses were conducted once the data had been weighted, and Stata version 16.0 was used. A multilevel mixed-effect binary logistic regression model was fitted. To determine statistically significant individual and community-level factors associated with demand satisfied for modern contraceptive, odds ratios with a 95% confidence interval was generated. A p-value less than 0.05 was declared as statistical significance.

RESULTS

Overall, demand satisfied to use modern contraceptive in high fertility sub-Saharan Africa countries was 39.53% (95%CI: 39.06, 39.98). Women aged 25-34 (AOR: 1.34, 95%CI: 1.26, 1.42) and 35-49 (AOR: 1.28, 95%CI: 1.20, 1.38), women education: primary (AOR: 1.35, 95%CI: 1.27, 1.44) and secondary (AOR: 2.05, 95%CI: 1.90, 2.21), husband education: primary (AOR: 1.26, 95%CI: 1.18, 1.35) and secondary (AOR: 1.54, 95%CI: 1.43, 1.66), husband residence (AOR: 1.75, 95%CI: 1.60, 1.91), media exposure (AOR: 1.22, 95%CI: 1.15, 1.29), wealth index: poorer (AOR: 1.1, 95%CI: 1.02, 1.19), middle (AOR: 1.18, 95%CI: 1.08, 1.28), richer (AOR: 1.37, 95%CI: 1.26, 1.49) and richest (AOR: 1.34, 95%CI: 1.56, 1.89), number of children: 4-6 (AOR: 0.48, 95%CI: 0.43, 0.55) and above 6 (AOR: 0.39, 95%CI: 0.29, 0.59), perceived distance to the health facility not big problem (AOR: 1.11, 95%CI: 1.04, 1.15), urban residence (AOR: 1.18, 95%CI: 1.10, 1.27), high community level poverty (AOR: 0.85, 95%CI: 0.74, 0.97) were significantly associated with demand satisfied for modern contraceptives.

CONCLUSION

Only four in ten married reproductive age women demands satisfied with modern contraceptives in high fertility Sub Saharan African countries. Modern contraceptives should therefore be more widely available, especially in rural areas and for those living away from health facilities. Also, increasing media exposure and education, providing financial support, and making contraceptive access easier for married women from poor households are important interventions that need to be put in place.

Impact of Sociocultural Factors on Contraceptive Use: A Case Study of Pakistan

Background

The use of birth control methods is influenced by complex and competing socioeconomic and demographic factors. Regardless of the complexity of the behavioral approach of women, the utility of contraceptive methods in providing the opportunity of choice is well paired. This study examined the factors driving the usage of contraception and the impact of contraceptive practices on population growth in Pakistan. We also perused the quantification of sociocultural contraceptive use. Methodology. The Pakistan Demographic and Health Survey (PDHS, 2017-18) dataset collected by the National Institute of Population Study (NIPS) was used for all analyses. We applied the frequentist logistic regression model and multinomial logistic regression model in assessing factors impacting contraceptive practices. Bayesian logistic and multinomial regression models were also implemented to compare estimates. The regions and provinces in Pakistan were considered as different clusters, thereby introducing hierarchical structures in the regression model.

Results

The study revealed a distinctive highly significant negative effect on contraceptive use and women's age. The odds ratio (OR) for women aged 25-34, 35-44, and above 44 was 1.242, 1.155, and 0.638, respectively, which shows that the OR of contraceptive use decreases in women aged 25-44. Our study showed the superior performance of the Bayesian model in highlighting disparities among the various cultural streams existing in the country. Estimates of the Bayesian analysis of competing models indicated that the Bayesian models provide powerful estimates compared to the classical models.

Conclusion

Our results indicated that contraceptive use is almost relevant to sociodemographic factors (education, age, language, partner, work, etc.). Women with no formal education living in rural areas were not aware of the use of contraception, thereby not using it. Contraceptive use and methods are most probably influenced by the age and the number of children of women. We recommend that high-quality education, counseling, and widespread access to contraceptives should be prioritized in family planning healthcare in all areas of the country, especially rural areas.

The Dominant Factors Affecting the Low Participation of Young Women Ever Married in the Family Planning Program (KB) in Papua Province (2017 IDHS Data Analysis)

BACKGROUND: Participation in family planning (FP) among young women who have ever married is the spearhead in reducing the Total Fertility Rate in Papua Province. However, the percentage of FP use in Papua Province in Papua Province is still very low, at 74.88%. This study looks at the dominant factors that influence the low participation of ever married young women in FP programs in Papua Province. METHODS: This study is a cross-sectional study using data from the 2017 Indonesian Health Demographic Survey, conducted for ± 1 month. The sample in this study was 414 married young women in Papua Province in 2017. Data analysis in this study is the same way as multivariate analysis of risk factor models, which was processed using the STATA 12 application. RESULTS: The final result of the multivariate analysis in this study was the household expenditure group variable (OR was 1.89 with a 95% CI value: 1.75–1.92), place of residence (OR 1.75 with 95% CI: 1.70–1.90), and age at first sexual intercourse (OR 2.34 with 95% CI: 2.24–2.48). In contrast, the most dominant variable that affects the low participation in FP use among young women who have ever been married in this study is the age of first sexual intercourse. CONCLUSION: This study recommends the need for crosssectoral collaboration to socialize the Generation Planning (Genre) program in schools and universities in all corners of Papua Province.

Factors associated with modern contraceptive demands satisfied among currently married/in-union women of reproductive age in Ethiopia: a multilevel analysis of the 2016 Demographic and Health Survey

OBJECTIVES

Regardless of the local and international initiatives, excluding exempting services, demand satisfied for contraceptives remains low in Ethiopia. This circumstance is supposed to be attributed to different level factors; however, most were not well addressed in the previous studies. Therefore, this study aimed at assessing the magnitude and individual, household and community-level factors associated with demand satisfied for modern contraceptive (DSFMC) methods among married/in-union women of reproductive age.

DESIGN

Cross-sectional study.

SETTING

A community-based study across the country.

PARTICIPANTS

Randomly selected 9126 married/in-union women had participated using a structured questionnaire.

OUTCOME

DSFMC methods among married/in-union women of reproductive age.

RESULTS

DSFMC methods in Ethiopia was 39.5% (95% CI 38.5% to 40.5%). Women aged 35-49 years (adjusted OR (AOR): 0.43, 95% CI 0.32 to 0.58), Muslim religion (AOR: 0.58, 95% CI0.43 to 0.78), husband lived elsewhere (AOR: 0.42, 95% CI 0.29 to 0.60), joint decision making to use (AOR: 1.30, 95% CI 1.04 to 1.62), good knowledge (AOR: 1.57, 95% CI 1.32 to 1.86) and wealth status of poorer (AOR: 1.56, 95% CI 1.17 to 2.06), middle (AOR: 1.77, 95% CI 1.33 to 2.35), richer (AOR: 1.96, 95% CI 1.49 to 2.59), and richest (AOR: 1.49, 95% CI 1.05 to 2.08), pastoralist regions (AOR: 0.28, 95% CI 0.18 to 0.42), and agrarian regions (AOR: 1.72, 95% CI 1.21 to 2.44) and rural residency (AOR: 0.56, 95% CI 0.37 to 0.82) were factors significantly associated.

CONCLUSIONS

Women's age, religion, the current living place of husbands and women's knowledge were individual-level factors. Household wealth status and mutual decision making to use were household-level factors. Region and residency were households and community-level factors associated with DSFMCs. Increasing the accessibility of modern contraceptive methods to women in rural areas and pastoralist regions, those living separately, engaging religious leaders and men in the programme, would increase their satisfying demand.

Exploring Readiness for Birth Control in Improving Women Health Status: Factors Influencing the Adoption of Modern Contraceptives Methods for Family Planning Practices

Background: Pakistan is the world’s sixth most populated country, with a population of approximately 208 million people. Despite this, just 25% of legitimate couples say they have used modern contraceptive methods. A large body of literature has indicated that sexual satisfaction is a complex and multifaceted concept, since it involves physical and cultural components. The purpose of this study is to investigate the impact of influencing factors in terms of contraceptive self-efficacy (CSE), contraceptive knowledge, and spousal communication on the adoption of modern contraceptive methods for family planning (FP) under the moderating role of perceived barriers. Methods: Data were collected using an adopted questionnaire issued to married women of reproductive age belonging to the Rawalpindi and Neelum Valley regions in Pakistan. The sample consisted of 250 married women of reproductive age. SPSS was used to analyze the respondents’ feedback. Results: The findings draw public attention towards CSE, contraceptive knowledge, and spousal communication, because these factors can increase the usage of modern methods for FP among couples, leading to a reduction in unwanted pregnancies and associated risks. Regarding the significant moderation effect of perceived barriers, if individuals (women) are highly motivated (CSE) to overcome perceived barriers by convincing their husbands to use contraceptives, the probability to adopt modern contraceptive methods for FP practices is increased. Conclusions: Policymakers should formulate strategies for the involvement of males by designing male-oriented FP program interventions and incorporating male FP workers to reduce communication barriers between couples. Future research should address several other important variables, such as the desire for additional child, myths/misconceptions, fear of side effects, and partner/friend discouragement, which also affect the adoption of modern contraceptive methods for FP practices.

A Cross-Sectional Study to Assess the Frequency and Risk Factors Associated with Cesarean Section in Southern Punjab, Pakistan

The increasing frequency of cesarean section (CS) is a major public health issue, and it is on the rise in Pakistan. A cross-sectional study approach was used to assess the frequency of CS and its contributing factors, along with the assessment of knowledge in mothers who had undergone CS in one of the under-developed regions of Pakistan. Data collection was done by using a self-developed study questionnaire. The statistical package for social sciences (SPSS) was utilized for the statistical analysis. During the study period, a total of 173 (69.7%) women have given births by CS; among those, 104 (60.1%) were elective/planned CSs while 69 (39.8%) were emergency CSs. The higher CS frequency was significantly associated with younger age (p = 0.03) and pre-term gestational age (p < 0.001). Pregnancy complications, such as gestational diabetes, hypertension, preeclampsia/eclampsia, and vaginal bleeding, were the significant risk factors for CS (p < 0.001). The highlighted contributing factors to CS in the current study were preterm of gestational age, mothers of a younger age (20–24 years), and mothers that belong to urban populations. These risk factors can be addressed by implementing community-focused educational interventions during the gestational period. The sample size in this study was small; therefore, the results cannot be generalized to the whole population.

Utilization of family planning methods among currently married women in Pakistan: Insight from Pakistan Demographic and Health Survey 2017-2018

In Pakistan, like other developing countries, utilization of family planning methods is a serious public health concern among married women. Researchers in the study focused on utilization of family planning methods among married women and their exposure to media messages. The researchers used retrospective analysis of secondary data of 3334 married women. Our research findings reveal that married women have a very limited access to media service messages promoting utilization of family planning methods. It is discussed that women with exposure to media messages about the utilization of family planning significantly utilized birth control behavior than women who had not heard and seen any media message. The authors concluded that married women in the country particularly in rural areas have a very limited access to media messages promoting family planning which causes non-utilization of family planning methods. It is recommended that different programs and awareness messages on media should be started to promote family planning and married women's access to media programs should be ensured.

Female adolescents' reproductive health decision-making capacity and contraceptive use in sub-Saharan Africa: What does the future hold?

INTRODUCTION

Given the social, economic, and health consequences of early parenthood, unintended pregnancy, and the risks of HIV infection and subsequent transmission, there is an urgent need to understand how adolescents make sexual and reproductive decisions regarding contraceptive use. This study sought to assess the association between female adolescents' reproductive health decision-making capacity and their contraceptive usage.

MATERIALS AND METHODS

Data was obtained from pooled current Demographic and Health Surveys (DHS) conducted in 32 countries in sub-Saharan Africa (SSA). The unit of analysis for this study was adolescents in sexual unions [n = 15,858]. Bivariate and multivariable analyses were conducted using Pearson chi-square tests and binary logistic regression respectively. All analyses were performed using STATA version 14.2. Results were presented using Odds Ratios [OR] and adjusted Odds Ratios [AOR]. Statistical significance was set at p<0.05.

RESULTS

The results showed that 68.66% of adolescents in SSA had the capacity to make reproductive health decisions. The overall prevalence of contraceptive use was 18.87%, ranging from 1.84% in Chad to 45.75% in Zimbabwe. Adolescents who had the capacity to take reproductive health decisions had higher odds of using contraceptives [AOR = 1.47; CI = 1.31-1.65, p < 0.001]. The odds of contraceptive use among female adolescents increased with age, with those aged 19 years having the highest likelihood of using contraceptives [AOR = 3.12; CI = 2.27-34.29, p < 0.001]. Further, the higher the level of education, the more likely female adolescents will use contraceptives, and this was more predominant among those with secondary/higher education [AOR = 2.50; CI = 2.11-2.96, p < 0.001]. Female adolescents who were cohabiting had higher odds of using contraceptives, compared to those who were married [AOR = 1.69; CI = 1.47-1.95, p < 0.001]. The odds of contraceptive use was highest among female adolescents from the richest wealth quintile, compared to those from the poorest wealth quintile [AOR = 1.65; CI = 1.35-2.01, p<0.001]. Conversely, female adolescents in rural areas were less likely to use contraceptives, compared to those in urban areas [AOR = 0.78; CI = 0.69-0.89, p < 0.001].

CONCLUSION

The use of general and modern contraceptives among adolescents in SSA remains low. Therefore, there is a need to strengthen existing efforts on contraceptives usage among adolescents in SSA. This goal can be achieved by empowering these young females, particularly those in the rural areas where the level of literacy is very low to take positive reproductive health decisions to prevent unintended teenage pregnancy, HIV/AIDs and other sexually transmitted infections. This approach would help reduce maternal mortality and early childbirth in studied SSA countries.

Delivering reproductive health services through non-state providers in Pakistan: understanding the value for money of different approaches

BACKGROUND

Delivering Reproductive Health Results(DRHR) programme used social franchising (SF) and social marketing (SM) approaches to increase the supply of high quality family planning services in underserved areas of Pakistan. We assessed the costs, cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches.

METHODS

Financial and economic programme costs were calculated. Costs to individual users were captured in a pre-post survey. The cost per couple years of protection (CYP) and cost per new user were estimated as indicators of cost efficiency. For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year (DALY) averted.

RESULTS

Approximately £20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs. Based on programme data, the cumulative cost-efficiency of the entire DRHR programme was £4.8 per CYP. DRHR activities would avert one DALY at the cost of £20. Financial access indicators generally improved in programme areas, but the magnitude of progress varies across indicators.

CONCLUSIONS

The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes. This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low- and middle-income settings. Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.

Factors associated with contraceptive use among young women in Malawi: analysis of the 2015-16 Malawi demographic and health survey data

Background

Although Malawi is one of the countries with highest Contraceptive Prevalence Rate (CPR) in Sub-Saharan Africa, pregnancies and fertility among young women remain high. This suggests low up take of contraceptives by young women. The aim of this study was to investigate the factors associated with contraceptive use among young women in Malawi.

Methods

This is a secondary analysis of household data for 10,422 young women aged 15-24 years collected during the 2015-16 Malawi Demographic and Health Survey (MDHS). The sample was weighted to ensure representativeness. Descriptive statistics, bivariate and multivariate logistic regressions were performed to assess the demographic, social - economic and other factors that influence contraceptive use among young women. Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) with their corresponding 95% confidence intervals (95% CI) were computed using the Statistical Package for the Social Sciences version 22.0.

Results

Of the 10,422 young women, 3219 used contraception representing a prevalence of 30.9%. The findings indicate that age, region of residence, marital status, education, religion, work status, a visit to health facility, and knowledge of the ovulatory cycle are significant predictors of contraceptive use among young women in Malawi. Women who were in the age group 20-24 years (AOR = 1.93; 95% CI = 1.73-2.16), working (AOR = 1.26; 95% CI = 1.14-1.39), currently married (AOR = 6.26; 95% CI = 5.46-7.18), knowledgeable about their ovulatory cycle (AOR = 1.75; 95% CI = 1.50-2.05), and those with primary education (AOR = 1.47; 95% CI = 1.18-1.83) were more likely to use contraceptives than their counterparts.

Conclusion

This study has demonstrated that several social demographic and economic factors are associated with contraceptive use among young women in Malawi. These findings should be considered and reflected in public health policies to address issues that could be barriers to the use of contraception by young women. Strengthening access to family planning information and services for young women is highly recommended to reduce pregnancies among young women in Malawi.

Demand for family planning satisfied with modern methods among sexually active women in low- and middle-income countries: who is lagging behind?

Background

Family planning is key for reducing unintended pregnancies and their health consequences and is also associated with improvements in economic outcomes. Our objective was to identify groups of sexually active women with extremely low demand for family planning satisfied with modern methods (mDFPS) in low- and middle-income countries, at national and subnational levels to inform the improvement and expansion of programmatic efforts to narrow the gaps in mDFPS coverage.

Methods

Analyses were based on Demographic and Health Survey and Multiple Indicator Cluster Survey data. The most recent surveys carried out since 2000 in 77 countries were included in the analysis. We estimated mDFPS among women aged 15–49 years. Subgroups with low coverage (mDFPS below 20%) were identified according to marital status, wealth, age, education, literacy, area of residence (urban or rural), geographic region and religion.

Results

Overall, only 52.9% of the women with a demand for family planning were using a modern contraceptive method, but coverage varied greatly. West & Central Africa showed the lowest coverage (32.9% mean mDFPS), whereas South Asia and Latin America & the Caribbean had the highest coverage (approximately 70% mean mDFPS). Some countries showed high reliance on traditional contraceptive methods, markedly those from Central and Eastern Europe, and the Commonwealth of Independent States (CEE & CIS). Albania, Azerbaijan, Benin, Chad and Congo Democratic Republic presented low mDFPS coverage (< 20%). The other countries had mDFPS above 20% at country-level, yet in many of these countries mDFPS coverage was low among women in the poorest wealth quintiles, in the youngest age groups, with little education and living in rural areas. Coverage according to marital status varied greatly: in Asia & Pacific and Latin America & the Caribbean mDFPS was higher among married women; the opposite was found in West & Central Africa and CEE & CIS countries.

Conclusions

Almost half of the women in need were not using an effective family planning method. Subgroups requiring special attention include women who are poor, uneducated/illiterate, young, and living in rural areas. Efforts to increase mDFPS must address not only the supply side but also tackle the need to change social norms that might inhibit uptake of contraception.

Electronic supplementary material

The online version of this article (10.1186/s12978-018-0483-x) contains supplementary material, which is available to authorized users.