CHAPTER ONE

INTRODUCTION

1.1. Background to the Study

At the end of 2015, the sustainable development goals (SDGs) replaced the Millennium

development goals (MDGs) that aim at promoting universal access to 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, Norton, and Marcus, 2016). However,

implementation of family planning interventions is context dependent and the countries with

stable sociopolitical infrastructure may be better suited to successfully implement the

interventions and 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

support provision of comprehensive SRH. In a bid to improve the implementation of 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 study, study objectives, research questions, study

hypotheses, significance of the study, study scope, limitations of the study, theoretical

framework, conceptual framework, and operational definitions.

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 2019 (United

Nations, Department of Economic and Social Affairs, Population Division, 2020). 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 women die as a result of

pregnancy related causes (WHO, 2017).

In sub-Saharan Africa, the contraceptive prevalence rate is estimated at 21.8%, of this 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 to health facilities and inadequate information (UNFPA, 2012). In addition, studies

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 of access to information or services to lack of support

from their partners or communities (Aviisah et al, 2017). This threatens their ability to build a

better future for themselves, their families and their communities.

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 studies 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 modern family planning remains unclear whether especially in regard to the

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.

1.2. Problem statement

The global fertility rate declined from 3.2 live births per woman in 1990 to 2.5 in 2019 (UN,

2020). In sub-Saharan Africa, the region with the highest fertility levels, total fertility fell from

6.3 births per woman in 1990 to 4.6 in 2019. (UN, 2020).

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 14.9% of women in Somalia currently use

contraceptive methods (United Nations - Department of Economic and Social Affairs, 2019).

The estimates are presented for female and male sterilization, intrauterine device (IUD), implant,

injectable, pill, male condom, withdrawal, rhythm and other methods combined (United Nations

- Department of Economic and Social Affairs, 2019).

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 mortality. (L, 2016)
Coupled with the consequences of political instabilities, Somalia is a developing country with

limited resources to sustain the ever-growing population. 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

women of reproductive age (18-45years) in Mogadishu-Somalia.

1.3. Research questions

1. What is the prevalence of family planning utilization among women of reproductive age (18-

45 years) in Wadajir District, Mogadishu – Somalia?

2. What are the personal related factors affecting utilization of family planning methods among

women of reproductive age (18-45 years) in Wadajir District, Mogadishu – Somalia?

3. What are the family specific factors affecting utilization of family planning methods among

women of reproductive age (18-45 years) in Wadajir District, Mogadishu - Somalia?

4. What are the health facility related factors affecting utilization of family planning methods

among women of reproductive age (18-45 years) in Wadajir District, Mogadishu – Somalia?

1.4. Objectives of the Study

1.4.1.General Objective
The purpose of the study is to examine the factors associated with utilization of family planning

methods among women of reproductive age (18-45years) in Wadajir District, Mogadishu –

Somalia. It is therefore strongly recommended that family planning provision on the dimension

of service quality and coverage so as to promote and educate advantage of utilization of family

planning to achieve the goal.

1.4.2. Specific objectives
1. To determine the prevalence of family planning utilization among women of reproductive

age (18-45 years) in Wadajir District, Mogadishu – Somalia?

2. To investigate the personal related factors affecting utilization of family planning methods

among women of reproductive age (18-45 years) in Wadajir District, Mogadishu - Somalia

3. To examine the family specific factors affecting utilization of family planning methods

among women of reproductive age (18-45 years) in Wadajir District, Mogadishu - Somalia

4. To establish the health facility related factors affecting utilization of family planning methods

among women of reproductive age (18-45 years) in Wadajir District, Mogadishu - Somalia

1.5. Hypothesis of the Study

H01: Personal, family, and health facility factors are not associated with the utilization of family

planning methods among women of reproductive age (18-45 years) in Wadajir District,

Mogadishu in Somalia

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 District,

Mogadishu in Somalia.

1.6. Significance of the study

Women of reproductive age

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 with women’s and

girls’ use of FP.

Health practitioners

The study will help health practitioners to understand the inherent factors which significantly

influence family planning use among women of reproductive age in 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 and Quran interpretations by different Muslim

scholars.

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 and, consequently,

find ways to address the existing problems.

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 women to seek and access FP

services.

Researchers

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 national

strategies and provide evidence to support program implementation.

1.7. Study scope

Research is going to be conducted in Wadajir District, Mogadishu in Somalia. 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 3 years, that is from 2018 to 2021.

1.8. Conceptual framework

Personal factors
 Age
 Level of education
 Personal level of income
 Occupation
Utilization of Family planning
 Number of children
methods
 Attitudes
 Pills
 IUD
Family factors  Injections
 Decision making powers
 Spousal communication  Implants/Norplant
 Family support  Female condom
 Nature of family
 Female sterilization
Health system factors  Lactational amenorrhea
 Attitudes of FP (LAM)
service providers
 Privacy of service
provision
 Affordability of
services
 Counseling
 Waiting time
 Capacity of health
workers to offer FP
services
1.9. Operational definition of key terms
Demographic Factors: In this study, demographic factors will include; age, marital status,

education level, income levels, number of living children, and experience of child loss and will

be operationalized as below.

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

Education level: Refers to the respondent’s highest level of educational attainment. It will be

measured using an ordinal scale; 1 = No formal education, 2 = Primary, 3 = Secondary, 4 =

Diploma, 5 = Certificate/vocational training, and 6 = Degree.

Income levels: In this study refers to the respondent’s monthly income. It will be measured

nominally as 1 = high, 2 = Medium, and 3 = Low

Number of living children: Refers to the number of biological children respondent 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 either

positively or negatively. It will measure nominally as 1 = Positive and 2 = Negative.

Family factors: In This study will refer to decision making powers, spousal communication,

family support, and nature of family and will be operationalized as 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 alone, and 4 = someone else.

Spousal communication: In this study refers to whether the respondent communicates with her

partner on issues related to family planning. It will be measured nominally as; 1 = Yes, and 2 =

No

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.

Nature of family: Will refer as to the family is nuclear or extended, It will be measured

nominally as; 1 = nuclear, and 2 = extended

Service provider factors: In this study will include; attitudes of FP service providers, design of

service provision which includes; privacy of service provision, affordability of service,

counseling, waiting time, capacity of health workers to offer FP services. These will be

operationalized as below.

Attitudes of FP service providers: In this study refers to the positive or negative perception

clients have towards service provider’s interest in providing FP services for instance; service

providers refusing to provide FP services to women of 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 respondent has about the service provider as; 1 = Welcoming,

2 = Listening, 3 = Friendly, 4 = Rude, 5 = Respectful.

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 medical personnel. It will

be measured nominally as; 1 = Available, 2 = Not available

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

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, and 3 = sometimes among

others.

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 waiting time), and 2 = >1

hour (Long waiting time)

Capacity of health workers to offer FP services: Refers to whether the health services

providers are knowledgeable enough to offers FP services. It will be measured nominally as; 1 =

Knowledgeable, 2 = Not knowledgeable

Uptake of family planning services: In this study refers to whether a respondent is currently

using any family planning services or not during the time of the study. It will be measured on a

nominal scale as; 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, and 13 =

Spermicides