Professional Documents
Culture Documents
Proposal
Proposal
September 2023
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FACTORS ASSOCIATED WITH UTILISATION OF FAMILY PLANNING
SEBTEMBER, 2023
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Table of Contents
Table of Contents............................................................................................................i
CHAPTER ONE...........................................................................................................1
INTRODUCTION........................................................................................................1
CHAPTER TWO..........................................................................................................12
2.2. Family factors Influencing Family Planning Methods among Married Women of
Reproductive Age.........................................................................................................16
2.3. Health Facility Related Factors Influencing Family Planning Methods among
Married Women of Reproductive Age.........................................................................17
CHAPTER THREE......................................................................................................21
METHODOLOGY.......................................................................................................21
2.0. Introduction...........................................................................................................21
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2.3. Study Population and Target Population of the Study..........................................22
References....................................................................................................................26
Appendices...................................................................................................................30
Appendix I: Questionnaire...........................................................................................30
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CHAPTER ONE
INTRODUCTION
At the end of 2015, the sustainable development goals (SDGs) replaced the
sexual and reproductive health (SRH) services (United Nations, 2015). One of the
main targets to reach the SDGs (3.7 and 5.6) is to promote family planning (Starbird,
achieve the goals than their counterparts in conflict afflicted settings. The conflict
afflicted settings such as Somalia often have fragile health systems that can hardly
family planning methods in conflict afflicted like Somalia, studies that address the
utilization and associated factors of family planning services are urgently needed.
This study is therefore intended to serve the same purpose. This first chapter of the
proposal provides the background to the study, problem statement, purpose of the
Globally, women of reproductive age between 18-49 years married or in union using
modern family planning has increased in the recent past from 58% in 2017, to 61% in
Division, 2020).
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Although the number of women using modern family planning is increasing globally,
those that have unmet need is still very high as 222 million women want to space or
limit their pregnancies are not currently using modern family planning (Singh and
Darsh, 2013). More than one in ten women married or in union have unmet need of
modern family planning (WHO, 2017). As a result, more than 41% of the 208 million
pregnancies that occur each year worldwide, are unplanned which also result in
women seeking unsafe abortions, especially in countries where access to safe legal
abortion is highly restricted (Cleland et al., 2014). Approximately 13% of all maternal
deaths are due to abortion complications (Cleland et al, 2014) and about 0.3million
only 17% married women of reproductive age use a modern contraceptive. CPRs for
modern methods ranged from 1.2 percent in Somalia to 60.3 percent in South Africa
(World Bank, 2018) A recent review of demographic health survey for countries in
sub-Saharan Africa showed the relationship between the low contraceptive prevalence
rates with high unmet need has both led to increased unintended pregnancies and
increased maternal, infant and child morbidity and mortality (Foots et al, 2009). This has
been attributed among other factors; to shortfalls in health infrastructure and transport
show that women tend to seek long lasting family planning methods such as
intrauterine devices, Injectable and implants which are often not readily available.
Besides that, 214 million women (NFPSBCCS, 2018) want to avoid pregnancy are
not using safe and effective family planning methods, for reasons ranging from lack
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communities (Aviisah et al, 2017). This threatens their ability to build a better future
In Somalia, it has been revealed that despite the benefits of using modern family
planning, the modern contraceptive prevalence rate (mCPR) is still among the lowest
in Africa at 1.2% percent. Some s tudies demonstrate that Somali women have negative
attitudes and believe towards the use of contraceptives to space the birth of their children.
More often, the family planning is perceived to be prohibited by the Islam and large
families are favored (UNHCR, 2011). While many Islam scholars have explained in
details with reference to Quran about the family planning, many Somalis men and women
still misconstrued the Quran and misinterpret it to a larger extent. However, use of
associated factors. Hence, this study tries to understand examine the factors associated
with utilization of family planning methods among women of reproductive age (18-
45years) in Mogadishu-Somalia.
Consistent with the UN (2020), the worldwide fertility price has decreased from
3.2 births according to female in 1990 to 2.5 in 2019. The finest fertility price
The SHDS reports that fertility rates for Somalia remain very high at 6.9 children per
woman (SDHS, 2020) compared to National Demographic wish of 2.5 to harness the
demographic dividend. In the Somali region the overall demand and application of
family planning services have been found to be low. The prevalence of contraceptive
use by method based on the World Contraceptive Use 2019 estimated that about
female and male sterilization, intrauterine device (IUD), implant, injectable, pill, male
Consequently, low CPR and high FTR among the Somali women translates to close
child spacing which is related to increase in maternal and childhood morbidity and
However, if women use modern family planning there are chances of getting positive
economic, environmental and social benefits for families and communities like
improving maternal and child survival. Since it is not clear why women in Somalia
are not using modern family planning, it creates a knowledge gap that warrant studies
that focus on the factors associated with utilization family planning methods among
2. What are the personal related factors affecting utilization of family planning
Mogadishu – Somalia?
3. What are the family specific factors affecting utilization of family planning
Mogadishu - Somalia?
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4. What are the health facility related factors affecting utilization of family planning
Mogadishu – Somalia?
The purpose of the study is to examine the factors associated with utilization of family
Mogadishu - Somalia
Mogadishu - Somalia
H01: Personal, family, and health facility factors are not associated with the utilization
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Ha1: Personal, family, and health facility factors are associated with the utilization of
family planning methods among women of reproductive age (18-45 years) in Wadajir
This study is hoped to provide relevant information for the FP program that will support
increased FP uptake among the priority groups and thus harness the benefits associated
Health practitioners
The study will help health practitioners to understand the inherent factors which
Somalia. Building a deep understanding of these factors, will help to isolate and
classify those factors which may have been misconstrued due to religious assertions
Policy makers
This study will be useful in that both the local people and the policy makers will be
able to identify the pressing issues pertaining to low FP use among young women
Ministry of health
The findings will also be handy in tailoring family planning intervention programs
that will be used to guide the ministry of health and other relevant health bodies in
setting up plans and strategies relevant to Islamic religion that will enable Somali
Researchers
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This study will be helpful to other researchers in Somalia as it will act as a reference
for information in a related field. Further research is necessary to inform priorities and
Wadajir is one of highly populated districts of Mogadishu in Somalia and has the
highest number of health facilities offering family planning methods. This offers an
opportunity to examine why women of reproductive age are using or not using family
planning methods.
The study will focus on examining utilization of family planning methods as the
dependent variable and the associated factors (personal, family, and health).
The study will be focused on a period of 2 years, that is from 2023 to 2024.
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1.8. Conceptual Framework of the Study
Personal factors
Age
Level of education
Personal level of income Utilization of Family planning
Occupation methods
Number of children Pills
Attitudes IUD
Injections
Family factors
Decision making powers Implants/Norplant
Spousal communication Female condom
Family support
Nature of family Female sterilization
Lactational amenorrhea
Health system factors
Attitudes of FP service (LAM)
providers
Privacy of service
provision
Affordability of services
Counseling
Waiting time
Capacity of health
workers to offer FP
services
Demographic Factors: In this study, demographic factors will include; age, marital
status, education level, income levels, number of living children, and experience of
Age: In this study refers to the respondent’s years since time of birth to the time of the
study. It will be measured in complete years for instance; 18, 19, 20, 21
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Education level: Refers to the respondent’s highest level of educational attainment. It
Income levels: In this study refers to the respondent’s monthly income. It will be
has. It will be measured basing on the exact number of children in the household for
example; 1, 2, 3, 4.
Occupation: In this study will refer to whether the respondent is engaged in any
economic activity that earns her income. It will be measured on a nominal scale as 1 =
Yes, and 2 = No
Attitudes: In this study will refer to how the respondent perceives family planning as
Negative.
Family factors: In This study will refer to decision making powers, spousal
below:
Decision making powers: In this study refers to the ability of the respondent to
choose a method of limiting child birth without consulting her partner. It will be
measured nominally as; 1 = Woman alone, 2 = both man and woman, 3 = Husband
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Family support: refers whether the respondent is support by any of the family
members to use the family planning. It will be measured nominally as; 1 = Yes and 2
= No.
Service provider factors: In this study will include; attitudes of FP service providers,
reproductive age under 18 years, harassing and abusing clients, refusing to offer a FP
service because the provider religion is against the service and others. It will be
measured on self-constructed attitude index score indicating the personal feeling the
Privacy of service provision: In this study refers to a reserved or private room where
women of reproductive age receive birth control methods in the presence of only
Affordability of services: In this study refers to the respondent’s ability to meet the
costs which are involved in acquiring and using methods that limit child birth such as
transport costs, consultation fees and medical bills. It will be measured nominally as 1
= Yes, 2 = No
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Counseling: In this study refers to the respondent’s awareness of facts about all
available methods for limiting, space children, their related effects and which one is
most effective for them. It will be measured nominally as; 1 = Yes, 2 = Never given,
Waiting time: Refers to how long a respondent takes in the health facility while
receiving FP services. It will be measured on an ordinal scale as; 1= <1 your (short
currently using any family planning services or not during the time of the study. It
Spermicides
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CHAPTER TWO
This chapter provides the related literature on the factors influencing family planning
Reproductive Age
In one study Ethiopia FP use decreases as the age of women increases above from 30
years. In addition, there was a variation in the use of FP in different age groups.
Women of age group 25-29 years were the highest user among the group (Takele,
Degu & Yitayal 2012). In this study the reason for decreasing FP use as the age of
women increases was not mentioned. In reality, by the time women become above 30
they will have the desired number of children and FP use is expected to increase. In
addition, Morrison (2013) points out that age has been known to be one of the barriers
women (less than 18 years) or on the other hand young women are afraid or ashamed
analysis of 10,204 women from the 2011 demographic and health survey data of
Ethiopia, it indicated that younger women were more likely to used modern
contraception than older women. The current study will thus examine if a similar
A study in Ethiopia showed that Women’s literacy is associated with an increases use
of FP (Tilahun et al. 2013). In another study that explores women’s education and
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modern contraceptive Use in Ethiopia, Family planning use differs from in those who
did attend and did not attend school. Study result revealed that 80% of women who
have attended and 56% of women who have not attended school have used family
When the level of women’s education increases, FP use also increases. Fifty percent
of women who have attended primary and 65.3% of women who have attended
secondary school were used FP and the association was significant (Beekle &
McCabe, 2015). All study results showed that how girls’ and women’s enrolment in
In addition, Mona, (2013) mentioned that female education has been seen as a key
knowledge of contraceptive methods or of how to acquire them than are less educated
women because of their literacy, greater familiarity with modern institutions, and
A study from Kenya, religion was found to be the second most important determinant
which affects FP use negatively. Women from catholic faith were less likely to use FP
catholic religion (Okech, Wawire & Mburu 2011a). However a study from Tanzania
showed that those who are Catholics are more likely to use contraceptives and the
people are from the same religion, they have different thoughts about FP use.
In a study which analyzed the Perceptions and behavior related to family planning in a
rural area in the Oromia region, both Orthodox Christian and Muslim participants
believed that the timing to give birth is determined by God. So FP use is breaking the
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laws of God (Ieda 2012). These results show that the issue of religion is more
contextual. In addition, as it is the most sensitive area for intervention, it needs an in-
depth analysis.
Belay et al., (2016) V reports that various factors such as women's educational and
employment status and occupation, are associated with women empowerment for FP's
decision-making power. The authors note that employed women and those with
higher education status are more likely to have higher decision-making power
concerning their fertility, either individually or together with their partners, than the
Higher income of women enables them to have control over resources, to access
health care, information and to participate in decision making (OECD 2012). A study
from Kenya which analyzed contraceptive Use among Women of reproductive age,
the result revealed that women’s income was significantly associated with FP use.
Those women who have their own income are more likely to use FP as compared to
those who do not have their own income (Okech, Wawire & Mburu 2011a).
women’s desire to have more children will decline (Dibaba 2014; Bhargava 2012). In
another study when the number of living children increases the women’s chance of
using FP will increase. Based on their analysis, Women who had 3 to 4 children and 5
or more were 3.7 times and 7.4 times more likely to use family planning than who had
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Women with more living children were using family planning services more
compared to those with fewer children. Out of the women that were using family
planning services, 36 percent had 4 – 6 children, followed by those with between 1-3
living children at 30 percent. On the other hand, 17 percent of those respondents using
family planning services had between 7 – 9 living children, while 15 percent had no
living child. Women in Zimbabwe who had several children wanted to avoid further
pregnancies (Feldman and Maposhere, 2012). This reveals that the higher the number
of living children, the more the desire to use family planning services. This is because
those with more children might not be having desire for children as the desire has
already been satisfied. The desire for more children was attributed to many factors,
including a cultural perception that more children signified a source of wealth (Teresa
.c. 2005). Contraceptive use was 26.2% among women with three or more surviving
children compared with 19.0% of women with no surviving children (Agyei and
Migadde 1995).
In a study which analyzes the reproductive Health Knowledge and attitude among
Adolescents in Ethiopia, participants were asked about six questions to assess their
attitude towards adolescent service use. Their responses were ranged from completely
agree to disagree and the result revealed that individuals attitude is an influencing
factor in the use of health services (Tegegn, Yazachew & Gelaw 2016). We can see
that individual’s attitude towards the service use affects either positively or
negatively. Those who have positive attitude towards FP can utilize the service than
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2.2. Family factors Influencing Family Planning Methods among Married
In one study of FP practice and related factors of married women in Ethiopia, the
Those women who had more frequent discussion about FP with their husbands were
11 times more likely to use FP than those who had no discussion (Ko et al. 2010).
Similarly, association of FP use and partner discussion was also seen in other study in
In another study which analyzes the role of men in use of contraceptive use and fertility
preference in southern Ethiopia, the result showed that 90% of respondent approved FP
use of their spouse (Tuloro et al. 2006). According to Okech et al (2011), the use of FP is
much higher in those whose husband’s has consented than those who are not. The
probability of using FP in those women who gets their husband’s consent is 83% when it
is compared to those who do not get consent. So this shows that how men play a great
role on family planning use. Their involvement will have an important contribution in a
country like Ethiopia where the family system is patriarchal and is dominated by them
(MOH, 2011).
Spousal communication and agreement are crucial for the functioning of family,
allowing the to process and share information, ideas, and feelings and make decisions
about important issues, including family planning, that ensure family stability (Noller
& Fitzpatrick, 2015; Peterson, 2017). Spousal communication about family planning
is part of the rational decision-making process in fertility plans and one of the factors
associated with its approval (DeRose et al., 2004; Islam, Padmadas & Smith, 2015).
In addition, agreement on fertility intentions, desired family size, family planning, and
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the achievement of reproductive goals is beneficial to the family (Meekers &
2012).
planning was a significant predictor of contraceptive use in the study area. Sometimes
women think that their husbands oppose contraceptive use when in fact they approve.
Korra (2013) also adds that spousal internal discussion of family planning has a
significant positive impact in reducing both spacing and limiting needs. The studies
indicate that lack of communication about family planning between partners also
contribute to unmet needs but needs further analysis to find out if the same applies
Research has shown that extended family influences the decisions of both individuals
and couples within a society where extended kinship relations and lineage structures
have a determining role in social interactions (Char, Saavla & Kulmala, 2010;
Darwish & Huber, 2014). Family planning decisions are also affected by extended
family due to the nature of family dynamics (Char, Saavla & Kulmala, 2010).
Reaching mutual agreement about family planning is very complex because of the
roles of different actors such as the individual, couple, and people outside the family
(Bankole, 2013).
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2.3.1. Quality of services and family planning service
In a study by Khanal et al. (2014) found that limited capacity in health care delivery
can affect health care utilization. They found that lowly trained village health workers
who had only a few months of training, and had no high school level qualification
may have had affected the quality of health care delivered, hence preventing women
mothers who did not attend FP complained of limited availability of health services
Distance of health facility has a negative implication on the use of FP; when the
facility is located far away from the place where women are living the likely hood of
using the FP service is 3.3 lower than those who are living near the health facility
(Okech, Wawire & Mburu 2011b). In the same manner in another study those who
live in closer to the facility showed higher use of contraceptives. However the
Access to health facilities offering family planning services influence the use of
modern contraceptive methods of family planning. Katende et al, (2003) found out
that the vast majority of women (eighty-nine percent) who access family planning
planning, while sixty-two percent live in a community with at least one private-sector
source, and twenty-one percent have access to an NGO- operated source. They further
affirm that, short distances to the nearest family planning facility enable women to
seek family planning services. Their study concluded that Ugandan women with
access to family planning facilities use long term (the implant, sterilization)
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2.3.3. Affordability of services and family planning service
Cost is also one of factors according to Chacko (2015), some forms of contraception,
such as minor surgery (like vasectomy), carry a fairly significant amount of one’s
time and is very cost as compared to other options, such as condom or the calendar
cycle methods which are less expensive; hence, couples engage in them.
In one study which analyzed health workers' attitudes toward sexual and reproductive
health services for unmarried adolescents in Ethiopia, health workers were asked
about their attitude towards FP provision to unmarried adolescents. The result showed
that almost half (46.5%) of the participants had negative attitude towards FP provision
to unmarried adolescents (Tilahun et al. 2012). Health care worker attitude either
positively or negatively affects the use of FP. When they show positive attitude
women are more likely to use the service but when they show negative attitude it is
unlikely that for adolescents to go for FP. As it is demonstrated in another study, the
approach of HCW working in the FP has a direct effect in the use of FP services. The
likelihood of women to use service was 19% higher in those HCW showed good
attitude/friendliness than those HCW who were not friendly (Okech, Wawire &
2.3.5. Availability of health supplies, health providers and equipment and family
planning service
Shortages of drugs health providers and equipment can have serious effects relating to
utilization of health services. Kinungu (2012) in his study conducted in Jinja health units
in Eastern Uganda found an association between delays in mothers’ turn up for delivery
and shortage of trained staff, basic drugs, supplies and equipments. A similar study in
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South Africa- Kwazulu Natal, observed heavy workload, long hours, inadequate
staff and lead them to take their frustration out on patients hence compromising the
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CHAPTER THREE
METHODOLOGY
2.0. Introduction
This chapter highlights the methodological features and procedure for conducting the
study. These include the research design, location of the study, population of the
study, sample size, sampling techniques, data collection methods, Validity of the
study tools, and reliability of the study, data processing and analysis and ethical
section.
This will be a population based study that will employ a cross-sectional study design
with a quantitative approach. The quantitative approach will collect data from the
This study will be carried out in Wadajir district of Banadir region in Somalia.
situated on the Indian Ocean Coast of the Horn of Africa. Wadajir is one of highly
populated districts of Mogadishu in Somalia and has the highest number of health
why women of reproductive age are using or not using family planning methods.
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2.3. Study Population and Target Population of the Study
The study population will consist of women of reproductive age in Wadajir District.
The study will include women aged 18 – 45 years. Women of reproductive age that
will happen to have hearing and talking problems will not be included in the study, as
this leads to poor communication that might affect the data quality.
Sample size is calculated using Kish Leslie (1965). Assuming the degree of precision
of 5% and using a sample determination formula by Kish Leslie (1965), a sample is
determined as follows:
n = 1.96 ² * 0.291*(1-0.291)
0.05²
n = 317.038
n ≈ 317
The participants will be selected at house hold level from whereby simple random
sampling will be used to women aged 18 – 45 years from the four divisions of
Wadajir district which include Madina, Bulahubey, Zobe and Bandir in each division
a list of names of women aged between 18 – 45 years will be obtained from the
division registry. The names will be assigned numbers which will be written on
papers. The papers will be rolled and put in one basin where they will be mixed and a
rotary method.
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2.6. Data Collection and Study Instruments
Being a quantitative study, the survey method will be used to collect data. The data
closed-ended questions.
2.6.1. Questionnaire
questionnaire design for this study. Included in the questionnaire will Section A
which will capture data on personal factors Age, level of education personal, level of
Section B will capture data on family factors like Decision making powers, spousal
Section C will capture data on health system factors like attitudes of FP service
The data quality control will be achieved by ensuring the validity and reliability of the
2.7.1. Reliability
the stability and consistency with which the instrument measures the concept and
helps to assess the goodness of a measure. The method of internal consistency will be
adopted by the researcher; a pilot study will be carried out to check the consistency
and logical flow of the questions before data collection. The results will be fed into
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the SPSS computer software, to compute the Cronbach’s alpha for reliability testing.
2.7.2. Validity
Validity is the appropriateness of the instrument. Content validity will be used since it
focuses on the extent to which the content of an instrument corresponds to the content
that for an instrument to be accepted as valid, the average index should be 0.7 or
above. The researcher will consult colleagues, supervisors and other researchers, who
will review the instruments before sending them out for a pilot study. A total of 08
questionnaires will be administered during the pilot study; this will help to test the
content validity of the questionnaire and interview guide. The observations made will
enable the researcher to identify the mistakes and correct them before the actual data
collection. The content validity index (CVI) will then computed as follows;
The researcher will get approval by the Accord University, after which a letter from
the Dean of Accord University will be issued to the researcher that will be presented
The training of two research assistants will be conducted one week before the main
data collection exercise. The training will be done in a single day, with some breaks
between sessions, and it will cover issues to do with the objectives of the study, data
collection tool and the data abstraction process, the data collection methods and how
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to execute them, and ethics that will be considered. The research assistants will be
ones who are well conversant with the local language. Unless the research assistants
are well trained about the protocol, the study implementation will not start.
participants. The researcher will follow all the ethical guidelines that include getting
informed consent from the respondent before any study procedure and ensuring that
the respondents are aware of their voluntary participation and can withdraw from
participation at any time. Deliberate participation and privacy of the respondents will
Simple proportions will be used to describe categorical data at univariate level and
associations between the independent and dependent variables. The computed Chi-
Square test will be compared to the critical value 0.05 level of significance at a 95%
that resulted in a critical p value of less than 0.05 will be interpreted as being
significant. All the variables that will be found to be significant at the bivariate level
25
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Egeh, A. A., Dugsieh, O., Erlandsson, K., & Osman, F. (2019). The views of Somali
https://doi.org/10.1016/j.srhc.2019.02.003
UN. (2020). World Fertility and Family Planning 2020: Highlights. In United Nations
https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd
/files/files/documents/2020/Jan/
un_2020_worldfertilityfamilyplanning_highlights.pdf
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Appendices
Appendix I: Questionnaire
Dear Respondent,
award of the Master’s Degree in Public Health of Accord University. I kindly request
you, to fill in blank boxes and spaces as provided. All the information provided will
be used purposely for academics only and all information will be treated
confidentially.
…………………………………………
4. Occupation
4 - Business woman
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5. Number of children
A. 1 – 2
B. 3 – 4
C. 5 and above
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SECTION B: Prevalence of Family planning methods
7. Which of the following family planning method are you currently using? (Please
write the correct number, Using: 1= Yes, 2 = No)
Family planning method 1(Yes), 2(No)
1- Inject able
2- Pills (Oral contraceptives)
3- IUD
4- Male condoms
5- Implants
6- Female condoms
7- Female sterilization
8- Rhythm method
9- Withdraw
10- Emergency contraceptives
11- Male sterilization
12- Lactation amenorrhea
13- Spermicides
9. Do you ever discuss matters regarding infant feeding with your spouse/partner?
1- We discuss
2- We never discuss
10. Do you get support from any of your family members in regard to infant feeding?
1- Yes
2- No
11. Which of the following describes the nature of your family?
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1- Nuclear
2- Extended
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