FACTORS ASSOCIATED WITH UTILISATION OF FAMILY PLANNING

SERVICES AMONG WOMEN OF REPRODUCTIVE AGE (18-45 YEARS) IN

WADAJIR DISTRICT, MOGADISHU- SOMALIA

Mohamed Hassan Barow

MASTER OF PUBLIC HEALTH

September 2023

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FACTORS ASSOCIATED WITH UTILISATION OF FAMILY PLANNING

SERVICES AMONG WOMEN OF REPRODUCTIVE AGE (18-45 YEARS) IN

WADAJIR DISTRICT, MOGADISHU- SOMALIA

Mohamed Hassan Barrow

A Proposal submitted to the department of public health in partial

fulfillment of the requirements for the award of the degree of

Masters of Public Health,

SEBTEMBER, 2023

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Table of Contents

Table of Contents............................................................................................................i

CHAPTER ONE...........................................................................................................1

INTRODUCTION........................................................................................................1

1.1. Background to the Study.................................................................................1

1.2. Problem statement..............................................................................................3

1.3. Research questions..................................................................................................4

1.4. Objectives of the Study......................................................................................5

1.4.1. General Objective............................................................................................5

1.4.2. Specific objectives...............................................................................................5

1.5. Hypothesis of the Study.....................................................................................5

1.6. Significance of the study....................................................................................6

1.7. Study scope........................................................................................................7

1.9. Operational definition of key terms....................................................................8

CHAPTER TWO..........................................................................................................12

2.0. LITERATURE REVIEW......................................................................................12

2.1. Personal factors Influencing Family Planning Methods among Women of

Reproductive Age.........................................................................................................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

2.1. Research Design....................................................................................................21

2.2. Location of the Study...........................................................................................21

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2.3. Study Population and Target Population of the Study..........................................22

2.4. Sample Size...........................................................................................................22

2.5. Sampling Procedure..............................................................................................22

2.6. Data Collection and Study Instruments.................................................................23

2.7. Validity and Reliability.........................................................................................23

2.8. Data Collection Procedure.....................................................................................24

2.9. Data Analysis........................................................................................................25

References....................................................................................................................26

Appendices...................................................................................................................30

Appendix I: Questionnaire...........................................................................................30

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 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).

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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

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

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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 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

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

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

vicinity inside the international, sub-Saharan Africa, noticed a decline in TF

from 6.three births according to female in 1990 to 4.6 in 2019.

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 -

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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?

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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.

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

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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

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

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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

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 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

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

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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

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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.

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

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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,

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

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CHAPTER TWO

2.0. LITERATURE REVIEW

This chapter provides the related literature on the factors influencing family planning

methods among women of reproductive age.

2.1. Personal factors Influencing Family Planning Methods among Women of

Reproductive Age

2.1.1. Age and family planning service

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

of contraceptive use as many reproductive health providers’ declines to serve young

women (less than 18 years) or on the other hand young women are afraid or ashamed

of going to seek these services from hospitals or clinics. Lakew et al.,(2013) in an

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

scenario takes place among women of reproductive age in Somalia.

2.1.2. Women’s level of education and family planning service

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

12
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

planning (Gordon et al., 2011).

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

formal school is an important factor for FP use.

In addition, Mona, (2013) mentioned that female education has been seen as a key

determinant of contraceptive use in that, better educated women have more

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

greater likelihood of rejecting a fatalistic attitude towards life.

2.1.3. Religion and family planning service

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

as compared to other religion. This is because the discouragement of FP use in

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

association was statistically significant (Tengia-Kessy & Rwabudongo 2006). Though

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

13
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.

2.1.4. Occupation and family planning service

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

unemployed and those with less education.

2.1.5. Women’s level of income

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).

2.1.6. Number of children

In a study which analyzed influencing factors Women's Intention to Limit Child

bearing in Ethiopia, in older women as the number of surviving children increases,

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

no children (Gizaw & Regassa 2011).

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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).

2.1.7. Perceptions and attitudes and family planning service

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

those with negative attitude.

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2.2. Family factors Influencing Family Planning Methods among Married

Women of Reproductive Age

2.2.1. Partner discussion and approval and family planning service

In one study of FP practice and related factors of married women in Ethiopia, the

result demonstrated that partner/husband discussion had association with FP use.

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

Ethiopia (Stephenson et al. 2014).

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).

2.2.2. Spousal communication on FP and family planning service

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

16
the achievement of reproductive goals is beneficial to the family (Meekers &

Oladosu, 1996; Salway, 2013Female autonomy and seclusion, equality between

spouses linked with spousal communication, influence contraceptive use (Narzary,

2012).

Shrestha (2014) found in a study in Nepal that spousal communication on family

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

among married women in Somalia.

2.2.2. Nature of a family and family planning service

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).

2.3. Health Facility Related Factors Influencing Family Planning Methods

among Married Women of Reproductive Age

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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

from attending FP services. Similarly, Tesfahun et al (2014) found that majority of

mothers who did not attend FP complained of limited availability of health services

including drugs and equipment

2.3.2. Distance to health facility and family planning service

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

association was not statistically significant (Tengia-Kessy & Rwabudongo, 2006).

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

services live in a community with at least one government-run source of family

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)

contraceptives with one woman in two accessing the facility.

18
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.

2.3.4. Health providers’ attitude and family planning service

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 &

Mburu 2011b). So negative attitude of HCW discourages the use of FP as a result

unwanted pregnancy and unsafe abortion will follows.

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

19
South Africa- Kwazulu Natal, observed heavy workload, long hours, inadequate

equipment or facilities, and personal danger causing demoralization and traumatized of

staff and lead them to take their frustration out on patients hence compromising the

quality of healthcare (Ruminjo & Hiza, 2014).

20
 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

considerations. The operational structures are to be placed of high interest in this

section.

2.1. Research Design

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

participants in a numerical form to investigate the factors associated with family

planning utilization in Wadajir district, in Mogadishu, Somalia. The study design

selection of a cross-sectional to be used is based on its cost effectiveness in terms of

time and finance.

2.2. Location of the Study

This study will be carried out in Wadajir district of Banadir region in Somalia.

Wadajir district is 1of 17 districts in Banadir region Mogadishu Somalia is the 2 nd

largest district in Banadir region. Geographically it lies in South-Eastern 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

facilities offering family planning methods. This offers an opportunity to examine

why women of reproductive age are using or not using family planning methods.

21
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.

2.4. Sample Size

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:

The formula n = Zα ² * p*(1-p)

e²

Where: Z = 1.96 at 95% confidence level

P = Prevalence of women in reproductive age using family planning = 0.291

n = 1.96 ² * 0.291*(1-0.291)
0.05²

n = 317.038

n ≈ 317

The final sample size will be 317 women of reproductive age.

2.5. Sampling Procedure

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.

22
2.6. Data Collection and Study Instruments

Being a quantitative study, the survey method will be used to collect data. The data

collection instrument will be a self-administered questionnaire which will contain

closed-ended questions.

2.6.1. Questionnaire

Data will collect using a researcher administered standard self-administered

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

income, occupation number of children and perceptions

Section B will capture data on family factors like Decision making powers, spousal

communication, family support, and nature of family

Section C will capture data on health system factors like attitudes of FP service

providers, privacy of service provision, affordability of services, counseling, waiting

time and capacity of health workers to offer FP services

2.7. Validity and Reliability

The data quality control will be achieved by ensuring the validity and reliability of the

data collection instruments.

2.7.1. Reliability

Reliability refers to the consistency of the instrument in measuring whatever it is

intended to measure. Sekaran, (2000) argues that reliability of an instrument indicates

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
23
the SPSS computer software, to compute the Cronbach’s alpha for reliability testing.

An alpha of >0.7 will be used to measure the reliability of the tools.

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

of the theoretical concept it is designed to measure (Amin, 2014). He further states

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;

Content Validity Index (CVI) = No. of items declared valid

Total no. of items

Again, a CVI of >0.7 will be taken as valid.

2.8. Data Collection Procedure

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

to the administration of Wadajir district.

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

24
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.

The researcher will ensure voluntary participation and confidentiality of the

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

be warranted by the investigator.

2.9. Data Analysis

Simple proportions will be used to describe categorical data at univariate level and

presented in frequency, percentage distributions, Means (M), and Standard Deviation

(SD). At bivariate level, Pearson’s Chi-Square will be used to determine the

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%

confidence interval. A relationship between the independent and dependent variable

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

will be included in a logistic regression model to determine the relationship between

the variables and the dependent variable.

25
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Appendices

Appendix I: Questionnaire

Dear Respondent,

I am by the names of Mohamed Hassan Barow a student pursuing a Master’s Degree

in Public Health of Accord University. I am conducting a research on “FACTORS

ASSOCIATED WITH UTILISATION OF FAMILY PLANNING SERVICES

AMONG WOMEN OF REPRODUCTIVE AGE (18-45 YEARS) IN WADAJIR

DISTRICT, MOGADISHU- SOMALIA” which is part of the requirement of the

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.

SECTION A: PERSONAL FACTORS

Please tick where applicable)

1. What is your age? (In complete years)

…………………………………………

2. What is your highest level of education?

1- No formal education 2 - Primary 3 - Secondary

4 - Diploma 5 - Certificate/vocational training 6 = Degree

3. What is your level of income?

1 - High level 2 - Medium level 3 - Low level

4. Occupation

1 - Civil servant 2 - Full time House wife 3 - Casual Laborer

4 - Business woman

30
5. Number of children

A. 1 – 2

B. 3 – 4

C. 5 and above

6. Please choose/tick ONE of the following statements that BEST DESCRIBES

your attitude towards use of family planning

1- Use of family planning is very important to my health because am able to

decide when to produce
2- Use of contraceptive for family planning can lead to loss of libido thus causing
marital breakdowns
3- Using of family planning contraception while young can lead to loss of
fertility resulting in divorce
4- Family planning methods interfere with their menstruation cycles and cause
excusive bleeding
5- Children born with disability is because of using family planning
contraception

31
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

SECTION C: Family factors

8. Who makes the decisions regarding infant feeding?

1- I make the decisions
2- My partner makes the decisions
3- We make the decision together

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?

32
 1- Nuclear
2- Extended

SECTION D: Health system factors

12. Attitudes of FP service providers

1- Welcoming
2- Listening
3- Friendly
4- Rude
3- Respectful
13. There is a private room where you receive birth control methods in the presence of
only the medical personnel
1- Available
2- Not available
14. Are you able 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?
1- Yes
2- No
15. Are you counseled on issues concerning all available methods for limiting, space
children, their related effects and which one is most effective for them?
1- Yes
2- No
16. How long do you take in the health facility while receiving FP services?
1- < 1 Hour (Short waiting time),
2- > 1 hour (Long waiting time)
17. The health services providers you visit are knowledgeable enough to offers FP
services
1- Knowledgeable
2- Not knowledgeable

33