Review articleUptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators
Introduction
Family planning through contraceptive use is a critical component of reproductive healthcare; it allows women and their families to have the desired number of children and also to control the timing of pregnancies [1]. The ability to limit and space pregnancies has a significant impact on a woman’s wellbeing, child survival, and economic growth and development [1], [2], [3], [4], [5]. Despite the benefits of contraceptive use, it is estimated that approximately 21% of women in sub-Saharan Africa have an unmet need for modern contraception [6]. This gap is largely responsible for the high proportion of unintended pregnancies in the region [6], estimated at 38% of the annual total of 51 million pregnancies in sub-Saharan Africa [7]. A substantial number of maternal deaths in this region could be averted if unintended pregnancies were prevented with the use of effective, less user-dependent modern contraception such as permanent contraception [8].
Permanent contraception includes vasectomy for men and tubal procedures for women, which are highly effective, with failure rates of less than one percent [9]. The approach to permanent contraception among women involves blocking or cutting the fallopian tubes through surgical or nonsurgical means (tubal ligation or occlusion) [10], [11]. Permanent contraception offers a number of benefits compared to other contraception methods. It eliminates the recurrent direct and indirect costs associated with reversible methods [12]. In addition, it eliminates problems associated with other methods such as compliance, side-effects, availability and inconvenience [13]. Also, for women, evidence suggests that tubal ligation has non-contraceptive benefits such as reducing the risk of ovarian cancer [14]. Lastly, studies have shown that tubal ligation in sub-Saharan Africa is safe, with a low rate of complications or failure when performed according to standard practice [15], [16], [17]. Reported complications include pain, infections, and bladder and bowel injuries [16], [17], [18].
In spite of the encouraging data and increasing desire among women to limit childbearing, the uptake of permanent contraception among women remains low in sub-Saharan Africa [19], [20]. The prevalence of permanent contraception among married or in-union women of reproductive age in Africa is estimated at 1.6%, compared to Latin American and the Caribbean (25.7%), Asia (23.7%), Northern America (20.6%), and Europe (3.7%) [21]. Factors that likely contribute to this low uptake of permanent contraception include weak health systems and limited access to surgical procedures [22], [23], lack of information, misconceptions, and religious beliefs [24], [25], [26].
To date, studies examining barriers and facilitators to the uptake of permanent contraception in sub-Saharan Africa have either grouped a range of contraceptive methods (not focused exclusively on permanent contraception) [27], [28], or included both male and female permanent contraception [29]. The purpose of this study is to synthesize the literature on barriers and facilitators to uptake of permanent contraception-specifically, tubal ligation-among women in sub-Saharan Africa in order to inform female reproductive health policy and services in the region.
Section snippets
Material and Methods
This paper presents a literature review of available evidence on barriers to, and facilitators of permanent contraception among women in sub-Saharan Africa.
Study characteristics
The electronic search yielded 672 records from the four databases, while an additional six studies were identified from bibliographic and grey literature searches (Fig. 1). Two hundred and thirty-one (231) duplicates were removed, and 394 articles were subsequently excluded. The 48 studies ultimately reviewed included 34 quantitative studies, five qualitative studies, and nine mixed-methods studies.
Twenty-two (23) of the included studies were conducted in East Africa: Ethiopia (n=13), Kenya (n
Discussion
In this literature review, we identified and organized evidence on barriers to and facilitators of permanent contraception via tubal ligation among women in sub-Saharan Africa using a framework based on the social ecological model. We found uptake of tubal ligation to be influenced by individual-, interpersonal-, and organizational-level factors such as myths and misconceptions, fear of surgery, irreversibility of procedure, religious beliefs, lack of expertise and equipment factors,
Conclusions
Uptake of permanent contraception among women in sub-Saharan Africa is relatively low. Improving uptake will require multipronged social-behavioral and educational interventions to modulate negative individual- and interpersonal level perceptions, especially among women and their male partners. Health systems strengthening and policy changes are needed to narrow the gaps identified at organizational level. Women who desire it, and for whom tubal ligation is expected to provide better health and
Acknowledgements
The authors thank Xan Goodman for her assistance in conducting the electronic search for the review.
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