Midwifery 54 (2017) 35–60

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Midwifery
journal homepage: www.elsevier.com/locate/midw

Factors influencing use of family planning in women living in crisis affected MARK
areas of Sub-Saharan Africa: A review of the literature
⁎
Kelly Ackerson, PhD, RN, WHNP-BCa, , Ruth Zielinski, PhD, CNM, FACNMb
a
Western Michigan University, Bronson School of Nursing, 1903 West Michigan Avenue, Kalamazoo, MI 49008-5345, United States
b
University of Michigan, School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109-5482, United States

A R T I C L E I N F O A BS T RAC T

Keywords: Background: far too many women continue to die from pregnancy and childbirth related causes. While rates
Family planning have decreased in the past two decades, some areas of the world such as sub-Saharan Africa continue to have
Modern contraceptives very high maternal mortality rates. One intervention that has been demonstrated to decrease maternal mortality
Refugee is use of family planning and modern contraception, yet rates of use in sub-Saharan countries with the highest
Sub-Saharan Africa
rates of maternal death remain very low.
Women
Aim: to review available research and summarize the factors that inhibit or promote family planning and
contraceptive use among refugee women and women from surrounding areas living in Sub-Saharan Africa.
Design: a review of the literature.
Data sources: Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID,
power search, and PubMed databases.
Review methods: studies included were: (1) published in English from 2007 to present; (2) primary research;
and (3) focused on family planning and contraceptive use among refugee women and women in surrounding
areas. Findings were discussed within the framework of the Interaction Model of Client Health Behavior.
Findings: twelve studies met the inclusion criteria. Utilization of modern contraceptive methods was low.
Women were socially influenced to avoid the use of contraceptives by husbands and others in the community.
Reasons were a lack of trust in western medicine and the desire to have large families. Low socioeconomic status
and proximity of family planning clinics were barriers to access. Women believed that health care providers
were unqualified, many described being treated with disrespect in the health clinics. Knowledge and
understanding of contraceptives was low; while most women knew different methods were available, there
were many misconceptions. Believing that certain contraceptives cause death, infertility and side effects,
contributed to fear of use. This lack of knowledge and fear, even with the desire to space and limit births,
affected motivation to use contraception.
Conclusions: developing new approaches to educating women, men (husbands), community leaders as well as
healthcare providers is needed to address the multi-factorial issues that contribute to underuse of family
planning services, thus contraceptive use.
Implications for practice: while lack of access to family planning is a barrier to use, interventions that improve
access must be affordable and include education regarding contraceptive methods, preferably from those within
the community. However, education and access is not sufficient unless the issue of disrespect by healthcare
providers is addressed. Respectful and culturally sensitive care for all women, regardless of socio-economic
status or country of origin, must be provided by midwives and other women health providers.

Introduction
Efforts over the past two decades have succeeded in decreasing
maternal deaths worldwide from 750,000 per annum in 1990 to
330,000 per annum in 2015 (Alkema et al., 2016; Maternal health,
2016). Unfortunately, these successes are not uniformly distributed
across the developing world: maternal death rates are higher in poorer
countries and highest for the poorest women within those countries.
Since 1990 throughout the world, the gap in maternal mortality rates
between countries with the best outcomes and those with the worst has
doubled. Sub-Saharan Africa has the highest rate of maternal mortality
at 546 deaths per 100,000 (World Health Organization, 2015). In fact,

⁎
Corresponding author.
E-mail address: kelly.ackerson@wmich.edu (K. Ackerson).

http://dx.doi.org/10.1016/j.midw.2017.07.021
Received 7 January 2017; Received in revised form 31 July 2017; Accepted 31 July 2017
0266-6138/ © 2017 Elsevier Ltd. All rights reserved.
K. Ackerson, R. Zielinski Midwifery 54 (2017) 35–60

all 20 countries with the highest maternal mortality rates are located in Table 1
sub-Saharan Africa and 65% of all maternal deaths occur in this region Maternal mortality, fertility and Fragile State index for Sub Saharan African Countries.
Information obtained from Alkema et al. (2016), USAID (2016) and Messner et al.
of the world (Alkema et al., 2016). In addition, maternal mortality can
(2015).
be viewed as the “tip of the iceberg” with maternal morbidity as the less
visible underside of the problem. The WHO defines maternal morbidity Sub Saharan Country Maternal Mortality Total fertility rate Fragile
as “any health condition attributed to and/or aggravated by pregnancy Rate (deaths/ (children born/ States Index
and childbirth that has a negative impact on the woman's wellbeing” 100,000 live births) woman)

(Firoz et al., 2013). 1. South Sudan 2054 5.43 114.5

Why does pregnancy and childbirth continue to be fraught with risk 2. Chad 1100 4.68 108.4
for women in certain areas of the world? The three leading causes of 3. Somalia 1000 6.08 114.0
maternal death globally are complications from abortion, hemorrhage 4. Sierra Leone 890 4.83 91.9
5. Central African 890 4.46 111.9
and hypertensive disorders (WHO, 2015). However, the underlying
Republic
reasons why women die during pregnancy and birth are multifactorial, 6. Burundi 800 6.14 98.1
complex, and inter-related. In low-resourced countries, poverty, mal- 7. Guinea-Bissau 790 4.3 99.9
nutrition and disease contribute to the risk of pregnancy-related 8. Liberia 770 4.81 97.3
9. Sudan 730 3.92 110.8
complications such as anemia, hypertensive disorders, and hemorrhage
10. Cameroon 690 4.82 94.3
(WHO, 2009). Women experiencing pregnancy and childbirth-related 11. Nigeria 630 5.25 102.4
complications often receive too little care too late (Maternal health, 12. Leshotho 620 2.78 79.9
2016; Miller et al., 2016). Even though births occurring in health 13. Guinea 610 4.93 104.9
facilities have increased, many women still give birth at home without a 14. Niger 590 6.89 97.8
15. Zimbabwe 570 3.56 100.0
skilled health worker in attendance. In the event of complications
16. Republic of the 560 4.73 90.8
during pregnancy or childbirth, delays of hours or days in arriving at a Congo
health facility commonly occur. Many health facilities also lack the 17. Democratic 540 4.8 109.7
required infrastructure, personnel, and supplies to provide timely and Republic of the
Congo
adequate care (Maternal health, 2016; Miller et al., 2016). Women
18. Mali 540 6.16 93.1
report that they do not experience respectful, quality care, which 19. Mauritania 510 4.07 94.9
creates reluctance to seek care at health facilities during pregnancy 20. Mozambique 490 5.27 86.9
and childbirth (Lieberman, 2016). 21. Tanzania 460 4.95 80.8
An estimated 222 million women worldwide have an unmet need 22. Malawi 460 5.66 86.9
23. Angola 450 5.43 88.1
for contraception (Patel et al., 2016). Since rates of contraception use
24. Zambia 440 5.76 85.2
have an inverse relationship with fertility rates, greater utilization of 25. Cote d’Ivoire 400 3.63 100.0
modern family planning (FP) methods decreases the rate of maternal 26. Senegal 370 4.52 83.0
morbidity and mortality. Conversely, insufficient uptake of FP con- 27. Kenya 360 3.54 97.4
28. Gambia 360 3.85 85.4
tributes to morbidity and mortality in women and girls of reproductive
29. Ethiopia 350 5.23 97.5
age. Higher parity increases the probability that pregnancy will be the 30. Ghana 350 4.09 71.9
cause of death, as well as the risk of complications such as hemorrhage, 31. Benin 350 5.04 78.8
fetal malposition, and multiple gestation (Graham and Hussein, 2007; 32. Rwanda 340 4.62 90.2
Maternal health, 2016). Many of the sub-Saharan countries with high 33. Swaziland 320 2.88 86.3
34. Uganda 310 5.97 97.0
rates of maternal mortality also have some of the highest fertility rates
35. Burkina Faso 300 5.93 89.2
in the world (Table 1). In addition, pregnancy and childbirth at wider 36. South Africa 300 2.23 67.0
age ranges (< 19 and > 35 years of age) carry additional risks. When a 37. Comoros 280 3.76 83.3
young woman who has not reached maturity becomes pregnant, she is 38. Eritrea 240 4.14 96.9
more likely to be anemic, have obstructed labor, and have fewer 39. Madagascar 240 4.28 83.6
40. Gabon 230 4.49 71.3
resources for care during pregnancy and birth, all of which contributes 41. Namibia 200 2.25 70.8
to the risk of morbidity and mortality (Cavazos-Rehg et al., 2015). 42. Botswana 160 2.37 62.8
Older women also have a higher risk of pregnancy complications such 43. Cape Verde 79 2.34 73.5
as spontaneous abortion, hypertensive disorders, and multiple gesta- 44. Soa Tome and 70 4.67 73.7
Principe
tion (Cavazos-Rehg et al., 2015). Sub-Saharan Africa has the highest
rate of adolescent pregnancy (age 15–19) and the highest rate of
pregnancy in very young adolescents, with 10% of adolescents becom- Thus, the unique situation of refugee women most likely results in
ing a mother by age 16 (WHO, 2014). unmet FP needs due to an accumulation of factors such as poverty,
Conflicts and wars afflicting this area of the world contribute to instability, and lack of access to contraception (Berryman, 2013).
maternal mortality and morbidity by disrupting existing infrastructure, One of the Millennium Developmental Goals (MDG; United
access to health centers, and increasing sexual violence against women. Nations, 2016b) was to improve maternal health (Goal 5). Target 5A
The Fragile State Index uses 12 social, economic and political was to reduce maternal mortality by 75% between 1990 and 2015 and
indicators to provide a measure of the stability and challenges of a Target 5B was to increase universal access to reproductive health.
country. Countries are ranked on a scale from Very Sustainable to Very Neither target was achieved by the close of the 2015 target date. As the
High Alert (Table 1). Of the 20 sub-Saharan countries with the highest MDGs concluded, the Sustainable Development Goals became the new
maternal mortality rates, Lesotho is the only one ranking lower than agenda. Goal 3 is to achieve universal access to reproductive health
High Warning (Messner et al., 2015). care, which includes FP, by 2030 (United Nations General Assembly,
An additional consequence of conflicts and wars is migration, which 2015).
affects the health of those fleeing their homes as well as the population In order to achieve this goal, it is important to understand the
of the area of refuge (Miller et al., 2016). Access to health facilities and reasons for using or not using modern methods of contraception in the
FP is often already limited in resource-poor countries; the added areas where use of FP is lowest. While access to modern methods of
burden placed on existing resources by refugee populations taxes the contraception is a necessary condition for FP use, availability may not
already stretched health care infrastructure (United Nations, 2016a).

36
K. Ackerson, R. Zielinski
be sufficient to significantly increase utilization. We undertook a
preliminary literature search and found, to date, no review of the
literature related to refugee women and FP. Therefore, the objective of
this review is to explore the factors that influence the use of FP services
in women living in crisis-affected areas of sub-Saharan Africa.
Theoretical framework
The Interaction Model of Client Health Behavior (IMCHB; Cox,
1982) was used to inform this review. Objectives of this model are to
identify and suggest an explanation for the relationship between three
major elements: client singularity, client-professional interaction, and
health outcomes. For this study, client singularity includes background
variables (demographic characteristics [age, educational level], social
influences [partner, family, community, culture, religion], previous
health care experience [FP services], and environmental resources
[income, access to care]), and the dynamic variables of cognitive
appraisal (beliefs, knowledge and understanding), affective (emotional)
response and motivation (internal and external factors that contribute
to behavior).
The second element of the model is client-professional interaction,
which consists of four components: information, affective support,
decisional control, and professional/technical competencies. These
components identify the interaction between the client and the
provider (lay health worker, midwife, nurse, and/or physician) as a
major influence on health care behavior (seeking or avoiding FP
services).
The last element of the model, health outcome, includes utilization
of routine FP services, obtaining and using contraceptives, and
satisfaction with care. What happens between the client and the
provider (interaction) influences the health outcome. For example, if
the interaction between the woman and her provider is negative,
iterative (repeat) behavior in utilizing FP services may be affected,
contributing to her avoidance of FP services and, possibly, contra-
ceptive use.
This model has been used in research outside of the United States
(Haney and Erdogan, 2013; Myeong and So, 2014). Myeong and So
(2014) used the IMCHB for development of a reproductive health
program for immigrant women. We have also used the IMCHB in a
previous research study (Ackerson et al., 2015).
Methods
This narrative review summarizes and interprets the available
studies pertaining to FP use in refugee women. We chose this type of
review in order to utilize both qualitative and quantitative studies, and
to identify commonalities in findings across various populations of
refugee women living in sub-Saharan Africa and areas for intervention
as well as further research.
Identifying relevant studies
The literature review included a search of Cochrane Library,
Cumulative Index to Nursing and Allied Health Literature (CINAHL),
OVID, Power Search, and PubMed databases (see Table 2). Inclusion
criteria were as follows: original qualitative study, original quantitative
study, collected from refugee and non-refugee women living in sub-
Saharan receiving countries, and addressing FP. We had originally
limited our criteria to refugee women, however, evidence indicates
poorer health outcomes for non-refugee women living in receiving
countries, due to already limited healthcare resources becoming over-
burdened by the influx of refugees (Maternal health, 2016; Miller et al.,
2016). For that reason, we broadened the search to include non-refugee
women living in the receiving countries. We limited the search to 2007
to present and English language. Key search terms used included sub-
Saharan Africa, refugee, and a combination of FP and contracep*. We
37
Midwifery 54 (2017) 35–60
also conducted a Power Search listing each country in sub-Saharan
Africa as a key word (Table 3) to ensure that we did not miss relevant
published research that did not use sub-Saharan Africa as a specific
keyword. We chose not to use reproductive health as a key word
because of its broad definition that includes other areas of women's
sexual health (e.g., sexual health, childbearing, sexually transmitted
infections).
Selection of relevant studies
Excluding duplicates, 16 articles were chosen for full review. Of the
16, four were excluded based on content (refugee self-reliance, risky
sexual behavior, and health services for survivors of gender-based
violence), leaving 12 articles that met our inclusion criteria. Two multi-
country studies included refugees living outside sub-Saharan, specifi-
cally in Nepal (Tanabe et al., 2015) and Yemen (Whelan and Blogg,
2007). We chose to retain these studies for this review because only a
small percentage (30% in Tanabe et al. and 19% in Whelan & Blogg) of
participants were refugees in countries outside sub-Saharan Africa.
Additionally, because of the dearth of published studies, we did not
exclude studies where the methodology was unclear if the findings were
pertinent to FP utilization of refugee women in sub-Saharan Africa.
Finally, we did not exclude studies if they also addressed other issues as
well as FP (Tanabe et al., 2015; Whelan and Blogg, 2007). However, for
this report only the FP results are included.
Identifying relevant data
Each article was independently read by the authors with frequent
meetings to discuss and refine the findings. A table was created
(Table 4), which included: author, year of publication, country of
origin, aims/purpose, study population/sample size, methodology/
methods, and key findings. Using the IMCHB as a guiding framework,
the key findings from these 12 research studies were evaluated by both
authors for common themes related to refugees living in sub-Saharan
Africa and their use of FP.
Findings
Research design
The research designs of the 12 studies (Table 4) were varied,
although most were qualitative. Designs included qualitative (Chi et al.,
2015; Davidson et al., 2016; Furuta and Mori, 2008; Kiura, 2014;
Morof et al., 2007; Tanabe et al., 2015), qualitative analysis of primary
and secondary data of unknown origin (Mulumba, 2011), quantitative
descriptive (Dauda, 2012; McGinn et al., 2011), and mixed methods
(Nattabi et al., 2011; Okanlawon et al., 2010; Ouma et al., 2015;
Whelan and Blogg, 2007).
Sampling techniques were by convenience (Chi et al., 2015; Furuta
and Mori, 2008; Mulumba, 2007; Mulumba, 2011; Nattabi et al., 2011;
Okanlawon et al., 2010); purposive and random selection (Davidson
et al., 2016), cluster (Dauda, 2012; Tanabe et al., 2015); and stratified
(McGinn et al., 2011), systematic random (Ouma et al., 2015), and
random cross selection (Whelan and Blogg, 2007). Most of the data
collection occurred either in refugee camps or communities near
refugee camps (90%; n=9), with one collecting data in hospitals and
health centers (McGinn et al., 2011). Data were gathered in Burundi,
Darfur (north, south and west), Democratic Republic of Congo, Ghana,
Ethiopia (northern and eastern borders), Kenya, Sudan (southern and
eastern), Nigeria, Uganda (northern) as well as Yemen (Whelan and
Blogg, 2007) and Nepal (Tanabe et al., 2015). Countries of origin of the
refugees were identified in most of the studies and included Liberia
(Dauda, 2012), Eritrea (Davidson et al., 2016; Furuta and Mori, 2008),
Congo, Sierra Leone (Okanlawon et al., 2010) and Somalia (Davidson
et al., 2016; Kiura, 2014). Non-refugee participants included those
K. Ackerson, R. Zielinski Midwifery 54 (2017) 35–60

Table 2
Record for Searching the Literature.

Database searched Date of Search strategy and limiters Number and type of Estimate of relevant
search articles found articles

Cochrane Library 10/24/16 Key words: Sub-Saharan Africa, family planning, refugee 0 0
Cumulative Index to Nursing and Allied 10/26/16 Key words: Sub-Saharan Africa, family planning, refugee, 2 0
Health Literature (CINAHL) contracep*; limited 2006 to 2016 (no articles after 2012 were
found
OVID 10/26/16 Key words: Sub-Saharan Africa, family planning, refugee, 0 0
contracep*; limited 2006–2016
Power Search* 10/24/16 Key words: Sub-Saharan Africa, family planning, refugee, 10 7
contracep*; limited last 10 years; English language
Pub Med 10/24/16 Key words: Sub-Saharan Africa; family planning, refugee; 15 5
contracep*, limited 2006–2016

*
Power search includes collections in Open Access Journals, MEDLINE/PubMed, PMC (PubMed Central), GALE; ProQuest.

from Uganda (Chi et al., 2015; McGinn et al., 2011; Nattabi et al.,
2011; Ouma et al., 2015), Burundi (Chi et al., 2015), Democratic
Republic of Congo and Sudan (McGinn et al., 2011).
The sample sizes and characteristics varied among the studies. Most
of the studies provided age ranges, with overall range from 13 to > 49
years. Number of study participants ranged from 10 (Furuta and Mori,
2008) to a household survey study in which neither the total number of
participants nor the number of women interviewed was clearly
delineated (McGinn et al., 2011). Other studies included in their
sampling: lay health workers (n=32) and non-government organization
staff (n=37; (Chi et al., 2015), and service providers (n=4; (Kiura,
2014)). Another included categories of women and men camp leaders
(n=259), traditional birth attendants (n=66) and clinic health workers
(n=20; (Whelan and Blogg, 2007). However, because categories over-
lapped in their report, the number of participants in each category is
unclear.
Rates of contraceptive use
Current contraceptive use was reported in 42% (n=5) of the studies
(Furuta and Mori, 2008; McGinn et al., 2011; Mulumba, 2011; Nattabi
et al., 2011; Okanlawon et al., 2010; Ouma et al., 2015). Of these six
studies that reported current contraceptive use, the percentages ranged
from 1% (Furuta and Mori, 2008) to 54% (Ouma et al., 2015).
A small study (Furuta and Mori, 2008) found that only one of the 10
women used contraceptives, and this woman had undergone previous
abortions. Modern contraceptive use was reported as less than 4% in a
multi-country study (McGinn et al., 2011), and 18% of the female
participants in a study of HIV-positive men and women in Northern
Uganda (Nattabi et al., 2011) reported current use of modern contra-
ception (excluding condoms). Using contraception with intercourse
was reported by 33% of the women participants living in a refugee
camp in Nigeria (Okanlawon et al., 2010). Ouma et al. (2015) reported
that 54% (n=230) of the participants (rural, non-refugee women in
Northern Uganda) were using FP services.
Using the IMCHB as a guide, results from the 12 studies were
analyzed collectively in order to further explore rates of contraceptive
use and reasons for its use or non-use. The 5 themes identified from the
12 studies were societal influence, environmental influence, cognitive
appraisal, affective response, and motivation.
Societal influence
Societal influence, which can affect one's behavior, was a major
factor contributing to women's use of contraceptives for FP. Nine of the
12 studies found male influence to be the strongest factor in women's
decisions to utilize FP services. Some of the reasons males were against
contraceptive use were connected to misperceptions and mistrust of
“western” influence (Kiura, 2014; McGinn et al., 2011; Mulumba,
2011). Males wanted many children and use of contraception would
detract from this goal; therefore, the women were forbidden to use
contraception and did not receive support for contraceptive use from
male partners or family members (Davidson et al., 2016; Furuta and
Mori, 2008; Ouma et al., 2015). However, more educated males were
more positive about the use of contraceptives (Nattabi et al., 2011;
Okanlawon et al., 2010; Ouma et al., 2015). Interestingly, males who
needed to relocate to another camp were in favor of their wives using
contraception because a pregnancy could jeopardize the move (Kiura,
2014).
In 4 (33%) of the studies, religion seemed to influence the decision
to utilize contraception (Davidson et al., 2016; Furuta and Mori, 2008;
Kiura, 2014; Nattabi et al., 2011). In the Davidson et al. (2016) study,
which included both Somali and Eritrean women, religion seemed to be
a major influence towards non-use of contraceptives among the Somali
women (Muslim), but not the Eritrean women (Christian). However, in
a study that included only Muslim Somali participants, some women
reported that contraceptive use was against their religion while others
indicated that FP was acceptable in the context of child spacing (Kiura,
2014). In the other studies (Furuta and Mori, 2008; Kiura, 2014)
religion was not identified as a major influencing factor. Alternatively,
even if using contraceptives was against their religion, some women
were not deterred from seeking FP services from health centers as long
as those facilities were non-religious based (Nattabi et al., 2011).
Environmental influence
One's environment can affect health promoting behavior.
Environmental influence consists of income and access to the needed
health care services. Only one study provided information on income
(Dauda, 2012). Low income is associated with having less access to
health services, which includes FP care (Deaton and Tortora, 2015). In
addition, a barrier to obtaining FP services is that some health centers
were too far from the refugee camps (Dauda, 2012; Kiura, 2014; Ouma
et al., 2015; Whelan and Blogg, 2007). Even if the health center was in
close proximity to the camps, modern contraceptive methods other
than condoms were sometimes not available (Dauda, 2012; Furuta and
Mori, 2008; McGinn et al., 2011; Nattabi et al., 2011; Okanlawon et al.,
2010; Tanabe et al., 2015; Whelan and Blogg, 2007). While condoms
are an effective method of preventing pregnancy and protecting women
against sexually transmitted infections/diseases including HIV, con-
dom use is in the control of men, not women. Therefore, it may not be a
method of contraception that can help women space or limit births
when their male partner is not willing to use condoms.
Another issue was the perception that there were few qualified
health experts (Furuta and Mori, 2008; Kiura, 2014; McGinn et al.,
2011; Nattabi et al., 2011). The perception that health care providers
are not qualified, results in women trusting the information from
healthcare workers less than information given by community leaders
and/or members. If refugees do not have access to qualified and
informed health care providers, their knowledge and understanding of

38
K. Ackerson, R. Zielinski Midwifery 54 (2017) 35–60

Table 3 modern contraceptives and the benefits of spacing and limiting family
Record for Searching Individual Countries in Sub-Saharan Africa. size may be limited.
Database Date of Search strategy Number and Estimate of
searched search and limiters type of relevant Cognitive appraisal
articles articles
found Cognition is the ability to acquire knowledge (information aware-
ness) and understanding (interpretation of that information) gained
Power 11/3/16 1. Angola 1 0
search* 2. Benin 0 0 through interaction with others, personal experience, education,
3. Botswana 0 0 thought, and decision making. The knowledge base and understanding
4. Burkina Faso 3 0 of the participants in regards to contraception was low (Dauda, 2012;
5. Burundi 1 0 Davidson et al., 2016; Kiura, 2014; McGinn et al., 2011; Mulumba,
6. Cameroon 0 0
2011). Most were aware that there were different contraceptive
7. Cape Verde 0 0
8. Central 4 1† options, but believed that using certain contraceptives could cause
African infertility (Davidson et al., 2016; Kiura, 2014; McGinn et al., 2011;
Republic Mulumba, 2011).
9. Chad 2 0
Experiences and interactions with health care providers have great
10. Comoros 0 0
11. Congo 3 2† potential to positively affect cognition (Shafii et al., 2014). However,
(Brazzaville) several of the studies indicated negative experiences or interactions
12. Congo 2 1† with health care providers (Chi et al., 2015; Furuta and Mori, 2008;
(Democratic Kiura, 2014; Mulumba, 2011; Nattabi et al., 2011; Tanabe et al., 2015),
Republic)
which could negatively affect their intake and processing of information
13. Cote d’lvoire 0 0
14. Djibouti 2 0 (Nabi, 2015). Negative experiences with health care providers may also
15. Equatorial 0 0 contribute to the women being suspicious of the information imparted
Guinea to them by the provider.
16. Eritrea 1 0
How participants obtained their information regarding FP was
17. Ethiopia 1 0
18. Gabon 0 0
addressed in 33% (n=4) of the studies (Davidson et al., 2016;
19. The Gambia 1 0 Mulumba, 2011; Nattabi et al., 2011; Ouma et al., 2015). Sources of
20. Ghana 3 1† information included FP campaigns (Davidson et al., 2016); attending
21. Guinea 4 1 antenatal care, radio, other women in their communities using contra-
22. Kenya 6 2
ception, and health personnel (Mulumba, 2011); program managers
23. Lesotho 0 0
24. Liberia 1 0 who targeted women only (Nattabi et al., 2011); and health centers,
25. Madagascar 0 0 village health teams, and health educators (Ouma et al., 2015).
26. Malawi 1 0
27. Mali 0 0
Affective response
28. Mauritania 0 0
29. Mauritius 0 0
30. Mozambique 1 0 Lack of knowledge and understanding affects one's emotions
31. Namibia 1 0 towards an event or behavior (Nabi, 2003). Mistrust in the safety of
32. Niger 0 0 contraceptives was a major factor contributing to avoidance (Kiura,
33. Nigeria 2 1†
2014; McGinn et al., 2011; Mulumba, 2011; Nattabi et al., 2011;
34. Réunion 0 0
35. Rwanda 4 0 Okanlawon et al., 2010; Whelan and Blogg, 2007). This mistrust was
36. Sao Tome and 0 0 rooted in fear of death, infertility, reproductive capability, and side
Principe effects from contraceptives (Chi et al., 2015; Davidson et al., 2016;
37. Senegal 1 0 Kiura, 2014; McGinn et al., 2011; Mulumba, 2011). The belief that
38. Seychelles 0 0
39. Sierra Leone 1 0
condoms would remain inside a woman was also cited as a fear (Tanabe
40. Somalia 2 0 et al., 2015). Since experiencing side effects is not uncommon,
41. South Africa 1 0 especially within the first few months of starting a new contraceptive
42. Sudan 2 0 method, and access to health centers in these areas is limited, women
43. Swaziland 0 0
who experienced side effects from oral, injectable, or IUD contra-
44. Tanzania 1 1
45. Togo 1 0 ception may be unable to find information or access care. These women
46. Uganda 6 3† then may reach out to other women in the camps who may also have
47. Western 0 0 had negative experiences, thus continuing the cycle of fear and
Sahara mistrust.
48. Zambia 1 0
49. Zimbabwe 1 0
Medroxyprogesterone (injectable), which is one of the birth control
options commonly used in developing countries, is a method that can,
Note: and most often does, stop monthly menstrual bleeding. If women are
*
Power search includes collections in Open Access Journals, MEDLINE/PubMed, not properly educated or informed about this very common side effect,
PMC (PubMed Central), GALE; ProQuest.
†
they may think this equates to loss of reproductive capability. Given the
Searches contained duplicates of studies already reviewed. In addition to the country,
additional key words used for each search included ‘family planning’ and ‘refugee’.
emotional connection to being a mother and providing children (Baines
Search was limited to 10 years and English language; Text in bold represent new articles and Gauvin, 2014; Peddie and Porter, 2007), this may very well cause
meeting inclusion criteria and included in review. emotional distress and be a deterrent to contraceptive use.

Motivation

Motivation is a person's desire to behave in a certain way, or what

prompts a person to act. Several of the studies reported that women
wished to space births and limit family size (Davidson et al., 2016;

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Table 4
Review Artricles.

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)

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Table 4 (continued)
Furuta and Mori, 2008; McGinn et al., 2011; Nattabi et al., 2011;
Whelan and Blogg, 2007), which should result in motivation to access
FP services. However, the social influence of males (predominantly
against the use of contraceptives) may have mitigated the motivation to
space births and limit family size through the use of contraception
(Davidson et al., 2016; Kiura, 2014; Nattabi et al., 2014; Whelan and
Blogg, 2007). Prior negative experiences with health care providers
may also deter future motivation to seek FP services (Nattabi et al.,
2011; Tanabe et al., 2015). These influencing factors may contribute to
women avoiding the uptake of contraceptives to space births or limit
family size. Desire to limit family size was not universal. On the
contrary, some women had no desire to use contraceptives because
they wanted large families (Davidson et al., 2016; Furuta and Mori,
2008) to replace children lost (Mulumba, 2011). An additional factor
contributing to avoidance behavior was fear of contraceptive side
effects (Nattabi et al., 2011; Okanlawon et al., 2010; Ouma et al.,
2015). Fear is a powerful motivator in avoidance behavior (Nabi,
2003).
However, some female refugees did seek out, and use contra-
ception. Without their husbands’ knowledge, some females were using
contraception to prevent or space pregnancies (birth control pills and
injectables; Kiura, 2014; Nattabi et al., 2011). These women may have
decided to use contraception based on their individual needs, rather
than conforming to social norms/expectations or letting fear affect
their decisions. Women also reported taking oral contraceptives
secretively purchased from street vendors (Kiura, 2014), which they
perceived as safer, since the women feared a breach of confidentiality
from health center workers who were known to their camp or were
camp residents themselves. A drawback of women using contraception
in secret is that it does not contribute to changing the social norms of a
community towards acceptance of FP.
Of note, some women, for example, Somali refugee women living in
Kenya, (Kiura, 2014) did not feel that they needed to use contraceptives
to space births because of polygamy (husband would have access to
58
Midwifery 54 (2017) 35–60
other sexual partners). Others did not want to use contraceptives to
space births in order to prevent their partners from taking another
wife.
Discussion
Despite the benefits to maternal and infant health, utilization of
family planning services and contraception is low among refugee
women in sub-Saharan Africa. This review of the literature was an
exploration of the factors that influence utilization of FP methods for
women living in refugee camps and surrounding areas in sub-Saharan
Africa. Evidence indicates that women face multiple barriers to using
modern contraception that include, but are not limited to lack of access
to family planning services.
Social networks (influence) are important facilitators in learning
and changing societal norms (Behrman et al., 2002). In these commu-
nities, information about FP may be largely based on societal learning/
interaction since access to information from outside sources was
limited. While written material may be available (pamphlets or
posters), literacy rates are traditionally low in refugee populations in
sub-Saharan Africa, particularly among women which would limit their
understanding of this information (United Nations Educational,
Scientific and Cultural Organization, 2013). Therefore, the decision
to seek or avoid FP measures may be based on what the community
believes to be correct and socially acceptable (social influence) rather
than on accurate information.
While information delivery methods increased male and female
refugees’ awareness of FP methods, they may not address the personal
barriers contributing to avoidance, such as misperceptions and fear
regarding side effects as well as influence of male partners. It also
seems that information regarding contraception could have come from
people they are familiar with such as community leaders or members of
the community perceived to be the most informed. However, these
leaders and/or informed members of the society may also lack knowl-
K. Ackerson, R. Zielinski
edge and understanding contributing to misperceptions and fear. If one
hears consistent information from one group of people or source
(fellow refugees), they will tend to recall that information from
memory, which influences their decision making (Nabi, 2003).
Results of this review indicate that many women have only limited
access to health centers or FP services. Increasing utilization of FP
methods is a safe and affordable intervention that will not only
decrease maternal mortality, but also improve maternal morbidity,
infant mortality, women's opportunities for education, reduce poverty,
and decrease unsafe abortion (Mbizvo et al., 2013; USAID, 2016).
However, a single approach model can be marginally effective at best
and, at worst, may be unethical, as in the historical examples of forced
sterilization (Pernick, 1997). A lack of understanding of the cultural,
social, and economic factors have led to intervention efforts that may
be ineffective despite good intentions (Mwaikambo et al., 2011).
Focusing intervention efforts predominantly on women to promote
contraceptive use may be contributing to inadequate uptake (Olaolorun
and Tsui, 2010). Since men are an important social influence, they
should be included as participants in future studies in order to develop
socially acceptable interventions to promote FP. If FP becomes more
socially acceptable, then access to these services also needs to be
improved.
In order for modern methods of FP to be used, they need to be
available, affordable and acceptable. Interventions that make FP
methods more available and affordable is necessary but not sufficient.
Use of contraception increased in areas where it was more readily
available and not cost prohibitive for a population with few to no
discretionary funds. However, efforts to improve rates of contraception
uptake in low resourced areas such as sub-Saharan Africa should
include factors of acceptability (Mwaikambo et al., 2011). The contra-
ceptive methods were feared to cause health problems or infertility but
there was also mistrust of those promoting and encouraging them.
Particularly for refugee women, encouragement to utilize contraceptive
methods by those outside their community could be viewed as desiring
to limit or decrease the population or the community, which may foster
distrust. Because of low literacy rates in this population (United
Nations Educational, Scientific and Cultural Organization, 2013),
educational efforts that use picture based information and training
community health workers to provide factual, culturally appropriate
word-of-mouth information may be more acceptable and effective than
those using written materials (August et al., 2016). While maternal
mortality has decreased in recent decades, far too many women still die
from childbirth-related causes, particularly in sub-Saharan Africa.
Interventions designed to increase use of modern FP methods using
a variety of approaches to educate communities while also increasing
accessibility and affordability of FP methods are needed.
Conflict of Interest
None declared.
Ethical Approval
Not applicable.
Funding Sources
None declared.
Clinical Trial Registry and Registration number
Not applicable.
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