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Barriers and enablers of contraceptive use among

adolescent girls and women under 30 years of age
in Cambodia: a qualitative study

Farwa Rizvi, Elizabeth Hoban & Joanne Williams

To cite this article: Farwa Rizvi, Elizabeth Hoban & Joanne Williams (2021): Barriers and enablers
of contraceptive use among adolescent girls and women under 30 years of age in Cambodia:
a qualitative study, The European Journal of Contraception & Reproductive Health Care, DOI:
10.1080/13625187.2021.1884220

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THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
https://doi.org/10.1080/13625187.2021.1884220

RESEARCH ARTICLE

Barriers and enablers of contraceptive use among adolescent girls and

women under 30 years of age in Cambodia: a qualitative study
Farwa Rizvia , Elizabeth Hobana and Joanne Williamsb
a
School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, Australia; bDepartment of Health Sciences
and Biostatistics, Faculty of Health, Arts and Design, Swinburne University of Technology, Melbourne, Australia

ABSTRACT ARTICLE HISTORY

Objective: Unintended pregnancy and an unmet need for modern contraception remain high Received 12 September 2020
among adolescent girls and women in Cambodia. Qualitative descriptive research was conducted Revised 12 January 2021
to explore the barriers to contraceptive use among young women in urban Cambodia. Accepted 20 January 2021
Methods: Semi-structured interviews were conducted among 30 adolescent girls and women
KEYWORDS
aged 16–27 years, using purposive and snowball sampling strategies until data saturation was Adolescents; contraception;
achieved. The audio-recorded interviews were transcribed verbatim and quality-checked. Inductive family planning; sexual and
thematic data analysis was conducted. The results are presented using Bronfenbrenner’s theoretical reproductive health;
social ecological model. unintended pregnancy
Results: The emerging major and minor themes indicate misconceptions about hormonal contra-
ception as well as women’s preference for using oral contraceptive pills for family planning after
an unintended pregnancy. Women had low autonomy in choosing a contraceptive method, as
their partners or husbands tended to prefer the withdrawal method. Young women faced cultural
and supply chain barriers in accessing short- and long-acting reversible modern contraceptive
methods at health centres.
Conclusion: Cambodian women aged 16–27 years are a vulnerable group who have low autonomy
and sexual and reproductive health literacy and also face gender inequality.

Introduction 5.6 of SDG 5 to ensure universal access to family planning

Adolescent Cambodian girls and women under 30 years of
age face many sexual and reproductive health (SRH) issues:
an increased unmet need for modern contraception leads
to unintended pregnancy and unsafe induced abortion,
contributing to maternal morbidity and mortality [1,2].
These health concerns are exacerbated by a lack of SRH lit-
eracy and youth-friendly SRH services as well as rural to
urban migration for employment [3]. Low levels of SRH lit-
eracy and formal education lead to earlier sexual debut,
non-use of condoms and unsafe sex [4]. Pregnancies
among adolescents in Cambodia have increased from 8%
in 2010 to 12% in 2014, with the highest prevalence (37%)
in girls with no formal education [5].
In Cambodia, fertility regulation programmes for sexually
active, unmarried young women are limited; the focus has
mostly been on providing safe obstetrics and birth spacing
programmes for married women of childbearing age
(15–49 years) in the Safe Motherhood programme [6,7]. Our
study focussed on adolescent girls and women aged
16–27 years living in Phnom Penh and urban areas of Siem
Reap Province. It draws on previous research on factors
influencing unintended pregnancy in this group which
reported a significantly increased likelihood of unintended
pregnancy among urban Cambodian girls and women
aged between 15 and 29 years (16.3%) compared with their
rural counterparts (11%) [1]. Our study aim supports target
3.7 of Sustainable Development Goal (SDG) 3 and target
services, universal SRH rights and gender equality [8]. The
end goal is to explore the barriers and enablers of contra-
ceptive use, switching or discontinuation among urban
adolescent Cambodian girls and women aged 16–27 years
living in Phnom Penh (capital city) and Siem Reap
Province.
Methods
Face-to-face semi-structured interviews that incorporated
the photo-elicitation method were used to explore the per-
sonal, social and cultural factors that affect young
Cambodian women’s perceptions of their SRH issues and
barriers to the use of modern contraception [9–11]. This
study used a qualitative, descriptive design and adhered to
the 32 item checklist of the consolidated criteria for report-
ing qualitative research guidelines [12]. Data were collected
between January and April 2019 by the first author (FR)
with help from a bilingual female research assistant and
two local Cambodian transcriptionists.
Purposive sampling [13] and snowball sampling [14]
were used to select the 30 participants from different back-
grounds and with different characteristics to maintain a
maximum variation sample. The research assistant gave the
participants or their guardians a plain language statement
and consent (PLSC) form in the Khmer language. The PLSC
form was read to the participants on request owing to
their varying levels of formal literacy. Informed verbal

CONTACT Farwa Rizvi rizvifa@deakin.edu.au School of Health and Social Development, Faculty of Health, Deakin University, 221 Burwood Highway,
Burwood, 3125, VIC, Australia
ß 2021 The European Society of Contraception and Reproductive Health
2 F. RIZVI ET AL.
consent was obtained from the participants prior to com-
mencing the interviews and was digitally recorded [11].
The participants received details of appropriate psycho-
logical and SRH counselling services before the start of the
interviews.
An interview guide was used because it allowed the
researchers to cover the major topics in the interviews [15];
the photo-elicitation method facilitates conversations about
topics that are challenging to discuss [9] and provides an
opportunity to obtain information from participants with
low levels of literacy [10]. The interview guide was devel-
oped and pilot-tested, and necessary changes were made
[16]. It included questions related to the participants’
knowledge and perceptions of the barriers and enablers of
modern contraceptive use, discontinuation and switching.
During the photo-elicitation activity, preselected images of
different contraceptive methods were shown one by one
to each participant, followed by the same basic prompts
that were used for each image: ‘Do you know about this
type of contraception?’ Follow-up questions were: ‘Are you
currently using any contraceptive method?’ and ‘Why do
you prefer this type of contraceptive method (modern/trad-
itional)?’ We also followed the participant’s lead as she
talked about the images and gently asked questions and
used probes, always following the interview guide. The
selected images were deemed to be culturally and ethically
appropriate and no brand names were included [5,9,10].
Information about the withdrawal method, a traditional
contraceptive method, was explored using the Khmer word
for this method.
The photo-elicitation interviews were one-off and lasted
for 45–60 min. Thirty adolescent girls aged 16–19 years and
women aged 20–27 years participated in the interviews.
The participants were given a code to maintain their ano-
nymity. Interviews were conducted until data saturation
was achieved [11]. All participants were given an opportun-
ity for member checking so that they could inspect the
final interview transcript before the researchers began for-
mal qualitative data analyses [17]; however, only three
women requested their transcript be sent to them for
member checking.
Rigour was ensured by pilot testing the interview guide,
integrating the photo-elicitation method into the interview
and using a maximum variation purposeful sampling strat-
egy to select adolescent girls and women who were single,
married or sexually active in a union [16,17]. A quality con-
trol check was conducted on six (20%) randomly selected
interview transcripts by back translation of the six English
language transcripts into Khmer and checking the tran-
scription quality by listening to the audiotapes by an inde-
pendent senior female Cambodian transcriptionist.
After the interviews were transcribed and translated into
English, the first author read the transcriptions several
times and classified the data into various categories and
codes [17,18]. The researchers performed an inductive the-
matic analysis of the data manually using the reduction
and transformation of data technique, which included tar-
geted selection and transformation of data in the interview
transcriptions [17,18]. Bronfenbrenner’s social ecological
model was adapted as the theoretical framework to cat-
egorise the themes that emerged at the three levels (indi-
vidual, microenvironment and macroenvironment) affecting
women’s contraceptive use patterns [1,19]. Categories were
assigned and codes were used as labels to allocate compo-
nents of meaning to the transcriptions [17,18]. Major and
minor themes were then identified and placed under one
of the three levels of the model [17–19].
Ethics approval was obtained from the Deakin University
Human Research Ethics Committee (DUHREC 2018-218) in
September 2018 and from the Cambodian National Ethics
Committee for Health Research (NECHR 313), Ministry of
Health, in December 2018.
Results
Of the 30 participants, eight were single and not sexually
active; of the 22 who were sexually active, 12 were married
and 10 were unmarried and in a sexual relationship.
Seventeen participants were rural to urban migrants, 16 of
whom lived in Phnom Penh and one lived in Siem Reap
City. One participant had impaired vision, so we asked
about her knowledge of the different modern contracep-
tive methods instead of showing her the pictures. Another
participant had a physical disability and she used crutches
for mobility support. Table 1 shows participants’ sociode-
mographic characteristics.
Individual level of social ecological model
Misconceptions about modern contraception
The participants had concerns about perceived health side
effects, including headaches, vomiting and weight gain,
with the use of hormonal contraception such as oral
contraceptive pills (OCPs), or heavy menstrual bleeding
associated with the use of an intrauterine contraception
device (IUCD).
My friend told me some people had headaches after they used
pills. I will choose the natural way. My boyfriend uses pull out
[withdrawal method] and it is ok.
P12, 20 years, sexually active
My cousin told me if I use the pill wrongly I would have some
complications.
P17, 23 years, married
If I use the coil [IUCD] it would also have some complications.
For example, if it does not work well with me, I would
experience pain and bleeding … and get thinner. These are
the problems.
P17, 23 years, married
Some women believed that the IUCD was a ‘foreign
object’ that caused injuries inside women’s bodies or it
floated inside their abdomen. These fears were reinforced
by the negative experiences of a friend or family member.
I don’t like the coil [IUCD] inside me. [I’m] not interested
because I am afraid it is unsafe. It can get out in my body. It
will go out in my stomach and I will not be able to eat, [I will]
get thin and it will make holes in my stomach, so I don’t want
to use it.
P16, 22 years, married
Fear of infertility. Participants feared the loss of fertility,
which was explicitly associated with hormonal contracep-
tion including OCPs and injections.
Table 1. Participants’ sociodemographic characteristics.
Age Place of Migrant from Current contraceptive method used/desire for
Participant no. (years) residence province Education status Job description Relationship status future contraception
P1–P5 19 Phnom Penh No 1st year university Full-time student Single Subdermal implant in future, if in a steady
17 Year 11 relationship, or condoms
18 Year 12 (part-time
beautician)
16 Year 10
18 Year 11
P6 23 Phnom Penh No Bachelor’s degree Junior manager Sexually active since 14 years Withdrawal method (fear of using OCPs)
of age
P7 26 Phnom Penh Kratie Year 6 Garment factory Married (1 month) Not using any contraception
worker
P8 24 Phnom Penh Prey Veng Year 5 Shopkeeper Married (3 years) OCPs after an unintended pregnancy
1 child aged 2 years
P9 25 Phnom Penh Kandal Year 6 Garment factory Married (6 years) Withdrawal method
worker 1 child aged 5 years OCPs started after first baby (unintended
pregnancy)
P10 19 Phnom Penh Kampong Cham 1st year university Full-time student Sexual partner for 4-6 months Withdrawal method
Subdermal implant in future
P11 17 Phnom Penh Prey Vihear 1st year university Full-time student Single Subdermal implant in future
P12 20 Phnom Penh Kampong Cham 2nd year university Full-time student Sexually active for 3-4 months Withdrawal method
P13 25 Phnom Penh Kratie Year 12 Housewife Married (7 years) Withdrawal method
1 child aged 5 years Subdermal implant not available
P14 20 Phnom Penh Takeo 2nd year university Part-time shop Single –
worker
P15 27 Phnom Penh Kratie Year 12 Part-time shop Married (8 years) Withdrawal method
worker 2 children aged 6 and OCPs started after second baby (unintended
3.5 years pregnancy)
P16 22 Phnom Penh Preah Vihear Bachelor’s degree Administrative Married (1 month) Withdrawal method and calendar method
assistant
P17 23 Siem Reap No Year 8 Housewife Married (4 years) Withdrawal method
Province 1 child aged 1 year
P18 24 Siem Reap Preah Vihear Year 7 Housewife Married (5 years) OCPs started after second baby (unintended
Province 2 children aged 4 and pregnancy)
1.5 years
P19 26 Phnom Penh No Year 7 Part-time shop Married (7 years) Withdrawal method
worker 2 children aged 6 and 2 years OCPs started after second baby (unintended
pregnancy)
P20 25 Phnom Penh Kandal Bachelor’s degree Government Married (2 months) Withdrawal method
Visual impairment officer
(blindness)
P21 24 Phnom Penh Kandal Bachelor’s degree Disability Married (2 years) OCPs
Physical disability (uses services
crutches) officer
P22 23 Siem Reap No Bachelor’ degree Teacher Married (1 month) Withdrawal method
P23 22 Phnom Penh Takeo Year 5 Garment factory Widow Withdrawal method
worker Now engaged and sexually
active
P24 20 Phnom Penh Preah Vihear Year 10 Shop worker Sexually active Withdrawal method
P25 21 Phnom Penh No Year 12 Family business Single –
worker
THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE

P26 25 Phnom Penh No Master’s degree Sexually active Condoms

Subdermal implant in future
3

(continued)
 4 F. RIZVI ET AL.

Some of my friends … use it [OCPs]. I can see how their body

Modern contraception includes SARC methods: OCPs for continued monthly use, progestin-only pills, emergency contraception pill (morning-after pill), hormonal injectables and condoms; LARC methods: IUCDs and subdermal implants;
Current contraceptive method used/desire for changes. They tell me women cannot have a baby afterwards. I
already decided not to use it.
P6, 23 years, sexually active

Subdermal implant not available

Subdermal implant not available

future contraception

Withdrawal method previously

Modern contraception after an unintended pregnancy.

Now using condoms

Five participants had had an unintended pregnancy while
Withdrawal method

Withdrawal method

Withdrawal method their husbands were using the withdrawal method. These
women had already heard about OCPs from the health
care staff at their pre- and postnatal visits to the health
centres.
My husband told me about it [withdrawal method]. He wants
Traditional contraception includes behavioural methods (such as withdrawal or coitus interruptus, abstinence and the calendar rhythm method) and other folk methods (including herbs). this. My second baby was born early … [I] did not want it
then. After my second baby, I got information about OCPs and
now I am using pills.

P15, 27 years, married

Relationship status

Microenvironment level of social ecological model

Sexually active

Sexually active

Sexually active

Sexually active

Low autonomy in choosing a contraceptive method

The partners or husbands of 13 of the 22 sexually active
participants preferred to use the withdrawal method.
Information about the withdrawal method mostly came
from the women’s sexual partners or husbands, who them-
Full-time student
Job description

Cold drinks cart

selves received the information from less reliable sources

Beauty salon
specialist

manager
Programme

such as friends and colleagues. The 14 participants who

product

worker
Telecoms

seller

had migrated to Phnom Penh and one to Siem Reap from

rural provinces did so in search of better paid work and
study opportunities, or they migrated to the city with their
husband after marriage.
My boyfriend wants the natural way [withdrawal method]. It is
Education status

Currently completing

not 100% effective, but you have to really trust your partner.
master’s degree

1st year university

What can I say?

P6, 23 years, sexually active

Some husbands did not believe in using condoms in a

Year 2

Year 5

and non-reversible, permanent modern contraceptive methods: female and male sterilisation.

marriage, and some partners did not like the sensation of

wearing a condom, so they used the withdrawal method.
Firstly, if we use a condom, my husband could not have the
Kampong Cham
Migrant from

feeling. He would not have it.

province

Prey Veng

P17, 23 years, married

No

No

No steady relationship among unmarried women

These women did not want to use OCPs or contraceptive
residence

injections for months or years in the absence of a steady

Phnom Penh

Phnom Penh

Phnom Penh

Phnom Penh
Place of

sexual relationship with a boyfriend.

For myself, I will want to be sure that my partner is the one
… then maybe use the coil or the [subdermal] implant for a
long time, but not right now.
(years)

P26, 25 years, sexually active

Age

25

18

19

19

Accessibility issues for modern contraceptive methods

All the unmarried, sexually active participants reported that
Table 1. Continued.

they were shy or embarrassed to access the modern

contraceptive methods provided at health centres, shops
Participant no.

or pharmacies.
Related to unmarried women, it is shameful to buy, because if
P27

P28

P29

P30

a young girl buys [a modern contraceptive], it is a bad view

 THE EUROPEAN JOURNAL OF CONTRACEPTION & REPRODUCTIVE HEALTH CARE
[judgement] from the pharmacy. They will think badly of her.
But, if they [women] are married, it is normal to buy it.
P1, 19 years, single
Influence of health care workers. Five women received
information about modern contraception during their preg-
nancy when they attended pre- and postnatal check-ups.
This reassurance by health care personnel motivated them
to begin using OCPs for contraception.
I used to be afraid of it [OCPs] too, but after asking for advice
from [the] health centre, they said there are no bad effects to
our health at all. I went to see the doctor after [having] my baby.
P9, 25 years, married
Macroenvironment level of social ecological model
SRH knowledge
All participants reported not receiving any formal informa-
tion or counselling about SRH and contraception while at
school or university, by staff in health centres or from their
mother or another female family member.
They don’t have enough education about that … In school
the teachers just don’t educate us about it because they are
shy. And women themselves feel ashamed of getting all this
information and education, so they don’t have it.
P22, 23 years, married
Sources of information about contraceptive methods.
Study participants who had completed at least years 10–12
of high school were quite familiar with accessing social
media and all had smart phones with internet connections.
I searched for all this information from newspapers, magazines,
TV and social media, because they use this to increase
information [about contraception] to people.
P2, 17 years, single
I don’t think they [young women] would go to a pharmacist,
because they are really embarrassed. They would absolutely go
online [and] try to search for the information.
P5, 18 years, single
Desire to use subdermal implants
Nine participants (four single, four sexually active in a
union, one married) expressed a desire to use subdermal
implants as a long-acting reversible contraceptive (LARC)
method in the future because of the implants’ longevity
(3–5 years) and hormonal dose.
I checked for it [subdermal implant], but they were not
[available] at the pharmacy.
P27, 25 years, sexually active
There [are] a lot of pills. Anything you take there’s going to be
a side effect. But I checked online for it [subdermal implant]. I
wanted to have it [so that] I [would] not need to ask [my]
boyfriend to use condoms, but it is not [available] anywhere.
P30, 19 years, sexually active
Discussion
Findings and interpretation
The main themes that emerged from the data include: fear
of the side effects of modern contraceptives; low personal
5
autonomy to make choices about SRH and contraception;
culturally restricted access to modern contraception, espe-
cially among unmarried, sexually active women; absence of
SRH education in schools; and non-availability of subdermal
implants at health centres.
There were three main reasons why some participants
did not want to use modern contraception: poor SRH liter-
acy associated with the utility and efficacy of modern
contraceptive methods; limited access to modern contra-
ceptive methods due to social and cultural barriers and
taboos; and the short-term nature of sexual relationships,
especially among unmarried women.
Five participants switched from the withdrawal method
to OCPs after having an unintended pregnancy which
served as a wake-up call. This switch might also point
towards their husband’s belated support for modern
contraceptive use in order to avoid another unintended
pregnancy. Previous research indicated that Cambodian
women aged 15-29 years were significantly more likely to
use modern contraceptive methods after having an unin-
tended pregnancy [1].
Withdrawal is a traditional contraceptive method that
has a high failure rate, resulting in unintended pregnancy,
unsafe abortion or sexually transmitted infection [20–25].
Most women in our study knew that the withdrawal
method was not 100% effective in preventing pregnancy,
but they were not involved in the decision-making process
in choosing a contraceptive method; instead their husband
or partner made the decision. Two studies in Cambodia
reported a threefold increased likelihood of Cambodian
women using effective, modern contraception if their hus-
bands wanted a smaller family [26,27].
Differences and similarities in relation to other studies
Almost half of the participants in our study were migrants
who had moved to Phnom Penh and Siem Reap Province
with their husband after marriage. These women had lim-
ited access to nearby SRH services and effective counselling
by health care personnel about modern contraception.
Thus, young Cambodian women face a number of per-
sonal, social and financial challenges accessing SRH services
owing to the rapid rural to urban migration and industrial-
isation [3,7,27]. Cultural barriers also play a significant role
in limiting a young woman’s access to modern contracep-
tive methods, especially if she is unmarried [6,7].
Previous studies have pointed towards young
Cambodian women’s limited autonomy to insist on safe
sex and condom use from their male partner or husband
[26,28]. Our findings are consistent with the existing litera-
ture that there is a dearth of person-centred SRH and
contraceptive counselling for the many modern methods
of contraception (both short-acting [SARC] and LARC meth-
ods) available to women in Cambodia. In Cambodia, ado-
lescent girls and women under 30 years of age are a
vulnerable group when they become sexually active.
Relevance of the findings: implications for clinicians
and policy-makers/health care providers
We recommend a multipronged national SRH literacy pro-
gramme in Cambodia to educate men and women, with a
6 F. RIZVI ET AL.
focus on empowering young women by enhancing their
ability to make informed decisions about their overall
health, SRH and well-being, since most participants could
not access accurate information about modern contracep-
tion and were too shy to ask health providers about effect-
ive SARC methods; furthermore, subdermal implants were
not available at health centres.
Strengths and limitations
A strength of our research is that with the use of purposive
and snowball sampling techniques, a maximum variation
sample and data saturation were achieved while quality
control was maintained. Our study adds to evidence also
provided by others [29] of the need to empower women
with SRH literacy in order to enable them to take control
of their reproductive function and to make informed deci-
sions about using modern contraception. A weakness of
our study is the small number of participants recruited
from only two industrialised cities in Cambodia.
Unanswered questions and future research
Future large-scale mixed methods research using the
photo-elicitation method, with a larger study sample of
young women and young men from different geographical
locations, are recommended to derive more representative
national data.
Conclusion
Cambodian women face multiple barriers to accessing
modern contraception: a low level of literacy (cognitive
barriers); accessibility (physical barriers); opposition from
partners and low SRH autonomy (psychological barriers);
non-availability or limited choice of modern contraceptive
methods (supply chain barriers); and difficulty in accessing
modern contraception, especially among sexually active
unmarried women (cultural barriers).
Author contributions
All authors made substantial contributions to the conception and
design, data acquisition or data analysis and interpretation, and draft-
ing the article or critically revising it for important intellectual content.
All authors gave final approval of the version to be published and
agree to be accountable for all aspects of the work in ensuring that
questions related to its accuracy or integrity are appropriately investi-
gated and resolved.
Disclosure statement
The authors declare no conflict of interest associated with this study.
ORCID
Farwa Rizvi http://orcid.org/0000-0002-0485-8683
Data availability statement
The data are available as interview transcriptions on request from the
authors.
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