Abstract

Introduction: The goal of the study is to assess the determinants of the choice of family planning method among women on family planning at Chawama Level One Hospital. The choice of a family planning method among women is influenced by a combination of personal, cultural, social, and medical factors. These determinants can vary from one individual to another. However, little is known about the research study that assessed the determinants of the choice of family planning method among women on family planning in Chawama Level One Hospital, hence this study. Methods: This was an analytical cross-sectional study where 400 respondents aged 15 years and above participated in the study. Participants were randomly selected. A questionnaire was used to collect data. Statistics Package for Social Sciences computer software package version 26.0 was used to analyze data. Chi square and fisher’s exact tests were used to test the significance of the association between knowledge on FP, attitude towards FP, choice of FP among women. A 95% confidence interval and P value of 0.05 were used to ascertain the degree of significance. Multivariate binary logistic regression model to determine predictors of choice of FP method was also used. Results: On analyzing the dependent variables, most women (337, 84.3%) chose an appropriate family planning (FP) method, while only a few (63, 15.7%) did not. Majority of respondents, 333 (83.3%) had high knowledge levels while 67 (16.7%) had low knowledge levels and majority 338 (84.5%) had a positive attitude towards FP while 62 (15.5%) had a negative attitude. Significant associations were found (P < 0.05) between, parity, and knowledge on choice of FP method. Thus, women who had children with odds ratio more than 1 (1.489) Confidence Interval (95%), (OR: 1.489, CI: 1.050 - 2.110, P: < 0.028) and Women who had high knowledge levels odds ratio (14.538) Confidence Interval (95%) (OR = 14.538, 95% CI: 6.956 - 36.849, p < 0.001) were more likely to make a correct choice of FP (Table 4). Conclusion: Negative attitude and low knowledge levels were the main reasons associated with wrong choices of FP method. Particular attention should therefore be given to ensuring that women are given adequate information on FP methods order to improve the quality of life.

Keywords

Choice of FP Method, Knowledge, Attitude, Availability

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1. Introduction

Family planning is described as the ability of individuals and couples to have the desired number of children while also planning the spacing and timing of their deliveries using contraceptive treatments [1]. The provision of a wide range of contraceptive methods increases the opportunity for individual couples to obtain a method that suits their needs. Therefore, family planning empowers women by giving them control over their reproductive choices. When women can decide when and how many children to have, they are more likely to pursue education, participate in the workforce, and engage in their communities [2]. Therefore, family planning choice is a critical component of quality of care in the delivery of family planning services [3].

Globally, the use of contraceptives has been increasing, with the World Health Organization (WHO) reporting that about 65% of women of reproductive age (15 - 49 years) worldwide were using some form of contraception as of 2020 [4]. In Sub-Saharan Africa, however, contraceptive use remains comparatively lower, with modern contraceptive prevalence estimated at around 33%. In Zambia, progress has been made in expanding access to family planning services, but challenges remain. According to the 2018 Zambia Demographic and Health Survey (ZDHS), the contraceptive prevalence rate (CPR) among married women was 48%, with modern methods accounting for 45%. Despite this, the unmet need for family planning stood at 21%, indicating that many women still want to delay or prevent pregnancy but are not using any method Zambia Statistics Agency, [5]. Barriers such as myths and misconceptions, limited knowledge, cultural and religious beliefs, partner influence, and health system constraints continue to hinder optimal uptake.

The determinants of the choice of family planning method choice involve individual, cultural, fertility, and contextual factors including family planning program efforts [6]. Previous studies conducted by Lasong et al. [6]; Mukanga et al. [2]; reported that choosing the method of contraception relies on the availability, affordability, and accessibility of the methods as well as couples’ education level, traditions, religion, culture, health status, number of children, and socio-economic status.

In Nigeria, women’s choice of contraceptives is hindered by traditional and cultural beliefs [7]. The findings revealed that the men’s level of contraceptive knowledge and their attitude to modern contraceptives was high in this area. These findings indicated that women in skilled occupations had a positive attitude towards modern contraceptives of males, a high level of knowledge on contraceptive methods of males, approval of family planning by males, and current living children had significantly more positive effects on using modern contraceptives by the couple. It was also found that couples who desired more children were less likely to use modern contraceptives. Alternatively, the education level of the husband and the desired number of additional children harmed the use of traditional methods while media exposure, a high level of knowledge on contraceptives, and an approval of family planning had positive impacts on the use of traditional contraceptives over not using any method.

Mukanga et al. [2] argued that the selection of contraceptive methods depends on psychological, social, and cultural factors such as perceptions of contraception and existing social norms about this culture. Moreover, the use of contraception is largely dependent on the knowledge and attitudes of males towards modern contraception such as contraceptive pills, implants, injectable, intrauterine devices, male and female condoms, vasectomy, or tubal ligation. The partner’s disapproval of contraceptive use is associated with more use of traditional methods such as coitus interrupters and periodic abstinence [6]. The study also stated that cultural norms directly impact contraceptive choice among women. Hence, there is a gap in the literature on determinants of the choice of family planning methods among women from the catchment area of Chawama Level One Hospital. It is against this background the study endeavors to assess the determinants of the choice of family planning method among women on family planning at Chawama Level One Hospital.

2. Materials and Methods

2.1. Study Design, Setting, and Participants

A descriptive cross-sectional design was used to assess the determinants of the choice of family planning method, knowledge, attitude and accessibility of FP services among women of child bearing age. The study was conducted at Chawama level one hospital in Chawama Township of Lusaka Province. It is an urban area with people of different characteristics and education levels. It is densely populated with lots of women. Chawama level one hospital in Chawama Township was chosen on the basis that its location has a high population volume of women of child bearing age in Lusaka and on physical checkup; it has a high population of adolescent women. It is also a hospital proving FP services as well as other maternal and child health services and medical surgical services.

They were considered eligible if they were on FP (continuous acceptors) at Chawama level one hospital, aged 15 to 45 years and consent to participate. The study excluded women on FP who were mentally ill at the time of data collection and women on FP who were not residents of Chawama level one catchment population. The study was conducted from January 2024 to April 2026. A sampling frame was created using the daily FP clinic attendance register, which listed all eligible women present on each clinic day. Over the 8-week data collection period, a total of 800 eligible women attended the clinic. Based on the family planning (FP) clinic attendance register, an average of approximately 20 eligible women attended the clinic per day. Therefore, the sampling frame consisted of approximately 800 eligible women, from which a sample of 400 participants was selected using simple random sampling. Simple random sampling was applied using the lottery method. Each eligible woman was assigned a unique number based on the attendance register. These numbers were written on equal-sized pieces of paper, mixed thoroughly in a container, and randomly drawn without replacement until the required sample size for the day was reached.

2.2. Data Collection Procedure

The data was collected over a period of 8 weeks from 1st June to 31st July, 2024. Participants were assured of anonymity and confidentiality by allowing them to answer questions in privacy individually after consenting to participate with their signature. The researcher administered a questionnaire in face-to-face interviews that lasted about 30 minutes.

2.3. Instruments

Data was collected using a questionnaire on the knowledge, attitude and Choice of FP method. The questionnaire was developed based on the Choice of Contraceptives among Women of Reproductive Age Questionnaire which was validated by Maitanmi, et al. [7]. It was a reliable and valid instrument with the Cronbach’s alpha values of 0.76, 0. 82 and 0.77 for each section of the questionnaire. The questionnaire was pretested on a small group of respondents in a similar setting, and necessary adjustments were made to improve clarity and consistency. The structured questionnaire contained questions under six sections; Section A: Demographic Characteristics (age, marital status, parity, employment status, education level and income), Section B: Choice of FP. The outcome variable, “choice of family planning (FP)” method, classified as either correct or wrong. A correct choice was defined as selection of FP method that was medically appropriate, aligned with the woman’s reproductive intentions, supported by adequate knowledge, and available at the health facility. A wrong choice referred to selection of a method that did not meet one or more of these criteria. Each respondent was assessed on four criteria: suitability of the choice of FP, reproductive intention, knowledge, and attitude. Each correct criterion scored 1 point with a maximum of 4. Scores of 3 - 4 were classified as a correct choice while scores of 0 - 2 were classified as a wrong choice. Section C: Knowledge on FP among women of child bearing age. Each correct response was scored 1, and incorrect responses scored 0. Total scores were summed and converted to percentages. Scores of ≥50% were classified as high knowledge, while <50% indicated low knowledge. Section D: Attitude towards Choice of FP among women of child bearing age. Attitude was measured using Likert-scale statements. Responses were scored from 1 to 5, with higher scores indicating a more positive attitude. The total attitude score was calculated, and respondents scoring at or above the mean were classified as having a positive attitude, while those below the mean were classified as having a negative attitude.

2.4. Data Analysis

Data were analyzed using the IBM® Statistical Package for Social Sciences (SPSS®) for Windows version 28.0. The Chi-square test was used to determine an association between predictor variables (demographic factors, knowledge of women on choice of FP, Attitude of women towards choice of FP) and the outcome variable (Choice of FP among women). For the categorical variables, a Chi-square test was used. The Confidence Interval (CI) of (95%) was set and set level of significance at 5%. The binary logistic regression analysis was used to determine the true predictor of choice of FP.

3. Results

The interview was conducted with 400 participants of whom more than half 268 (67%) were aged between 15 to 29 years. Majority 315 (78.8%) were married, and almost all the respondents, 384 (96%), were Christians with only 16 (4%), being Islam. Most of the respondents, 257 (64.3%) were multi-parity and more than half of the respondents, 232 (58%), had attained tertiary education (Table 1). Table 2 the majority of participants, 337 (84.3%), made a correct choice of family planning (FP) method, while 63 (15.7%) made an incorrect choice. This corresponds to a mean proportion of 0.843 with a standard deviation (SD) of approximately 0.36, indicating relatively low variability with most respondents making correct choices. Regarding knowledge levels, 333 (83.3%) of respondents had high knowledge, whereas 67 (16.7%) had low knowledge. The mean proportion of high knowledge was 0.833 with an SD of about 0.37, again suggesting that most participants were knowledgeable about FP. In terms of attitudes toward FP, 338 (84.5%) of women demonstrated a positive attitude, while 62 (15.5%) had a negative attitude. This corresponds to a mean proportion of 0.845 with an SD of approximately 0.36, reflecting that positive attitudes were predominant among respondents (Table 2).

Overall, the findings show consistently high proportions, with relatively small dispersion, indicating that correct FP choice, high knowledge, and positive attitudes were common in the study population.

Table 1. Demographic characteristics of nursing students (n = 400).

Table 2. Overall knowledge levels on choice of FP (n = 400).

Table 3 shows that there were statistically significant associations between knowledge levels, number of children of a respondent and choice of FP among women. Therefore, results obtained from a test between parity and choice of FP showed that majority of multi-parity respondents, 212 (63.3%) made a correct choice of FP compared to 45 (72.6%) who made a wrong choice. Chi-square test on parity and choice of FP, (P-value 0.028), P < 0.05 indicates that there is an association between parity and choice of FP among respondents. From 400 participants, majority 324 (96.1%) who demonstrated high knowledge levels on FP made a correct choice of FP compared to 9 (14.3%) who had high knowledge levels but made a wrong choice. Chi-square test on knowledge and choice of FP, (P-value 0.001), P < 0.05 indicates that there is an association between knowledge levels and choice of FP among women. Regarding attitude, out of 400 participants, more than half 285 (84.6%) participants with a positive attitude towards FP made a correct choice of FP compared to 53 (84.1%) with a positive attitude but made a wrong choice. Chi-square test on attitude and choice of FP, (P-value 0.929), P < 0.05 indicates that there is no association between attitude and choice of FP among women.

Table 3. The relationship between variables (n = 400).

Table 4 shows the binary logistic regression model was tested for multicollinearity, Hosmer and Lemeshow test of fitness for data, and omnibus test of model coefficients and classification accuracy. The dependent variable was choice of FP: Correct (1) and Wrong (0). The results of the binary logistic regression analysis showed that holding other variables constant, thus, women who had children with odds ratio more than 1 (1.489) Confidence Interval (95%) (OR: 1.489, CI: 1.050 - 2.110, P: < 0.028) were more likely to make a correct choice of FP. Women who had high knowledge levels odds ratio (14.538) Confidence Interval (95%) (OR = 14.538, 95% CI: 6.956 - 36.849, p < 0.001) were more likely to make a correct choice of FP (Table 4).

Table 4. Binary logistic regression analysis of choice of FP by knowledge, attitude and parity.

4. Discussion of Findings

4.1. Characteristics of the Study Sample

The important demographic variables in this study included age, level of education, marital status and parity. These were included in the study to assist the researcher understand how they may influence choice of FP among women. Results revealed that less than half 116 (29%) were aged between 20 to 24 years. The age group of the sample characteristics in the current study is almost similar to that of a study conducted by Asif et al. [8] aimed at exploring the knowledge, attitude and practices of family planning methods. Awareness was lowest among the adolescents (92.3%), and best among 20 - 34 years’ age group (96.9%). The age group of 20 to 24 and 20 to 34 years mainly comprises young adult women who are more likely to be engaged in sexual activities but much more cautious of the consequences such as unwanted pregnancies. Therefore, the demand for FP is higher among this age group. Results of the current study are almost similar to the study results by Demissie et al. [9], whose study comprised of married women. Demissie et al. focused on factors associated with decision-making power of married women to use family planning in sub-Saharan Africa. In addition, the Demographic and Health Surveys (DHSs) in Zambia has evidently shown an increasing trend in the percentage of married women using contraceptives in the last three decades. As of 2018, this percentage increased from 34.2% in 2001 to 40.8% in 2007 and from 45% in 2013 to 48% in 2018 [10]. The similarity in a higher number of married women leading the consumers of FP among all, could also be that, married women tend to be on FP through the medical care settings where records are kept compared to those that are not married who prefer the over the counter morning FP on whom, records are not kept.

4.2. Choice of FP

In this study, most women (337, 84.3%) chose an appropriate family planning (FP) method, while only a few (63, 15.7%) did not. Among those who made a correct choice, many selected injectable contraceptives as a long-term method and could also correctly identify their situation such as whether they were spacing births, delaying, limiting, breastfeeding, or had multiple partners. The current study findings are similar to Gage et al. [11], who also reported that most women choose and use FP correctly. However, a study by Ochako et al. [12] in Nairobi found that both short and long term methods were used less frequently among women living in slum and non-slum areas. This difference may be due to the different characteristics of the populations being studied. For example, in our study and in Gage et al. [11], most women were Christian (96%) and only a few were Muslim (4%), while the Nairobi study included women from several different communities and living conditions, which may influence FP use differently.

Other studies also show that women’s contraceptive choices are strongly influenced by their background and environment. According to Owusu and Muhammad [13], factors such as age, religion, culture, access to FP services and awareness of different methods all play a role in determining which method a woman chooses. They suggest that efforts to increase FP use should include community education, support from religious and traditional leaders, and ensuring that health facilities offer different contraceptive options. In addition, addressing partner disapproval and fears about side effects is important for improving FP use in many communities.

4.3. Knowledge on FP

In relation to knowledge levels of respondents on FP, majority of respondents, 333 (83.3%) had high knowledge levels while 67 (16.7%) had low knowledge levels. Of the respondents who had high knowledge, the specific areas where respondents had high knowledge included, respondents being familiar with FP, respondents knowing different types of FP, respondents source of information on FP, respondent currently using FP, importance of FP for women. One possible reason for the high levels of knowledge demonstrated by most respondents in this study could be that, more than half, 232 (58%) of respondents had attained tertiary education. FP being one of the most important aspects of maternal health demands women to seek vast information about it. Furthermore, Chawama sharing both the urban and peri-urban aspects, is more likely to have respondents with good knowledge level on FP as they have access to social media, and internet on which vast information is shared and taught by various specialists compared to patients from rural areas. The low knowledge levels exhibited by respondents on FP could have been associated with lack of adequate information provided by the health care workers. Low knowledge levels could also be associated with the negative attitude of some respondents towards FP.

The current study results do not agree with the study results conducted by Bekele et al. [14], that reported a significant number of women with poor knowledge on FP and multiple socio-demographic factors contributed to knowledge on FP. Semachew et al. [15], also reported relatively low knowledge level on family planning utilization. Results from another study conducted by Jalu et al. [16] are in disagreement with the current study results. Jalu et al. reported that most of reproductive age women know little or incorrect information about family planning methods. Different research studies have shown that there is highest awareness but low utilization of contraceptives making the situation a serious challenge [17] [18]. Even when they know some names of contraceptives, they don’t know where to get them or how to use it. Urban and rural disparities persist in awareness levels, with urban women often having better access to information through healthcare facilities and media. Bridging these gaps requires targeted interventions that consider the unique challenges faced by women populations according to their geographical location. Therefore, the health sectors of the regions and other stakeholders should strengthen the health extension program to disseminate messages related to FP to improve the knowledge of women.

4.4. Attitude of Women towards the Choice of FP

With regards to attitude, majority 338 (84.5%) had a positive attitude towards FP while 62 (15.5%) had a negative attitude. Of the respondents who had a positive attitude the specific areas where respondents had positive attitude included, respondents thought of FP use by women, respondents thought of using FP every time being important, respondents thought of using FP every time they have sexual intercourse.

Contrary to the current study results, Bekele et al. [14] reported a significant number of women having a poor attitude towards FP and multiple socio-demographic factors contributed to attitude of FP. Therefore, the health sectors of the regions and other stakeholders should strengthen the health extension program to disseminate messages related to FP to improve the attitude of women. Similarly, Kasa et al. [15], indicated that the level of attitude towards family planning was relatively low and the level of family planning utilization was quite low among women in a study to assess the knowledge and attitude regarding family planning and the practice of family planning among the women of reproductive age group in South Achefer District, Northwest Ethiopia. Furthermore, the study showed that the level of knowledge and attitude towards family planning was relatively low and the level of family planning utilization was quite low in comparison with many studies. Every health worker should teach the community on family planning holistically to increase the awareness so that family planning utilization will be enhanced. Besides, more studies are needed in a thorough investigation of the different reasons affecting the non-utilizing of family planning and how these can be addressed are necessary. The different results from similar studies could be due to study setting differences; study conducted in Chawama a peri-urban area of Lusaka while the study conducted in Ethiopia was from the urban setting. Additionally, the study sample in the current study is smaller compared to the other studies done in Ethiopia and Uganda with bigger study samples.

4.5. Relationship between Variables

Analysis of associations between age, parity, education level and choice of FP was done. Pearson’s Chi square tests was used to test for significance with the P-value set at 0.05. According to the results obtained on age and choice of FP from 400 participants, 105 (31.4%), respondents aged between 20 to 24 made a correct choice of FP compared to 22 (24.4%) aged between 25 to 29 who made a wrong choice. Chi-square test on age and choice of FP (P-value 0.508), P > 0.05 indicates that there is no association between age and choice of FP. Similarly, majority 196 (58.3%) of respondents who attained tertiary education made a correct choice of FP compared to 36 (58.1%) at the same level of education who made a wrong choice of FP. Results obtained from a test between parity and choice of FP showed that majority of multi-parity respondents, 212 (63.3%) made a correct choice of FP compared to 45 (72.6%) who made a wrong choice. Chi-square test on parity and choice of FP, (P-value 0.028), P < 0.05 indicates that there is an association between parity and choice of FP among respondents.

Furthermore, an association between knowledge and choice of FP was analyzed. Pearson’s Chi square tests as well as Fisher’s exact tests were used to test for significance with the P-value set at 0.05. In this study, it was revealed that there was a strong association between knowledge on FP and choice of FP among women. Therefore, in this study, respondents with high knowledge also made a correct choice of FP method. Hassan et al. [19] indicated that knowledge and awareness are critical determinants that significantly influence the choices of family planning methods among women. A well-informed and aware population is more likely to make decisions that align with their reproductive health goals. Women’s knowledge and awareness of available family planning methods significantly influence their choices Hassan et al. [19]. Adequate information empowers women to make informed decisions based on their preferences and health needs. The study highlights the importance of targeted educational campaigns in increasing awareness and knowledge Hassan et al. [19]. Therefore, having vast knowledge about various family planning methods allows women to understand the range of options available to them.

The binary logistic regression model was tested for multicollinearity, Hosmer and Lemeshow test of fitness for data, and omnibus test of model coefficients and classification accuracy. The dependent variable was choice of FP: Correct (1) and Wrong (0). The results of the binary logistic regression analysis to predict whether the variables age, parity, education level, attitude, knowledge and availability predicted choice of FP showed that, parity and knowledge predicted the choice of FP among women. Thus, women who had children with odds ratio more than 1 (1.489) Confidence Interval (95%). The current study results are similar to a study conducted by Ogundana A.E., and Adetumi A.S. [20], who reported the uptake of family planning being influenced by the number of children the women already has or the family size. Thus, family planning program strategies and family planning messages targeting women who have large family sizes should be created. This will likely provide more knowledge and understanding among women and enhance the correctness in making a choice of FP method.

With regard to knowledge, women who had high knowledge levels odds ratio (14.538) Confidence Interval (95%) were more likely to make a correct choice of FP (Table 4). Similar to a study conducted by Gage et al. [11], to assess the effect of the Momentum project on contraceptive choice among first-time mothers (FTMs) age 15 - 24 who were six-months pregnant at baseline in Kinshasa, knowledge was one of the positive predictors of the choice of long acting reversible contraception (LARC) use. This entails that having adequate information on FP methods increases the chances of making a correct choice. It is therefore encouraged to give as much health education as possible to women on FP in order to facilitate good decision making.

Similar to the current study results, Owusu M.O. and Muhammad A. [13], reported socio-demographic factors, cultural and religious beliefs, and awareness levels being predictors of choice of FP method. Efforts to improve contraceptive uptake should focus on community-based education, engaging religious and traditional leaders, and ensuring the availability of diverse contraceptive options in healthcare facilities. Addressing spousal disapproval and misconceptions about side effects will also be crucial in promoting family planning in the region.

4.6. Conclusion

The study has established presence of making a correct choice of FP among women. The findings have also reported high knowledge levels on FP among respondents. The specific attributes that were revealed as being predictors of choice of FP methods were knowledge, parity and education level. It has therefore been shown in this study that there is need to improve the knowledge levels among women so as to improve the level of understanding of FP and making a correct of FP. Continued provision of health information to the women on the methods of FP appropriately suited for them should be done to prevent the possible negative outcomes of choosing wrong FP methods. Particular attention should therefore be given to ensuring that women are given vast health advice and help improve their understanding and make a correct choice of FP as well as maternal and child health.

5. Recommendations

1) The Ministry of Health should ensure continued attention on FP as a key component of women and child health and formulate guidelines on FP methods and profiling categories of women. Work place policies are disseminated and implemented with more focus at primary health care level.

2) Emphasis should be made in the nurse training curriculum on the importance of providing information education and communication on FP among women to allow them graduate as nurse educators upon completion of training.

3) Members of staff managing women should intensify the provision of information Education and Communication (IEC) sessions during the follow-up visit to women. The IEC should include the importance of child spacing and making right choices of FP.

4) To have this study replicated using a larger sample in order to evaluate a large-scale representation of women’s choice of FP.

6. Limitations of the Study

The study sample size (n = 400) against the population of women of child bearing age was limited, thus generalization of results should be with caution as it only represented views of women who accessed maternal and child health services from Chawama Level One Hospital. The sample size comprised of women from the rural and peri-urban settings hence the result may not be generalized for the rest of Zambia. The case may be different from women in urban towns, as urban hospitals have availability of specialized health professionals to provide sufficient information on FP. The data collecting tool used comprised closed ended questions and this could have limited the respondents from giving more required information.

Acknowledgements

Foremost, I would like to express my sincere gratitude to my supervisor Doctor Maureen Masumo for the continuous support of my Master of Science in Midwifery, women’s and child health and research for her patience, motivation, enthusiasm, and immense knowledge. Her guidance helped me in all the time of research and writing the proposal. I could not have imagined having a better advisor and mentor for my MSc study programme. Besides my advisor, I would like to thank the rest of my fellow MSc students for the support and contributions they have made towards my research proposal development.

Statement

Ethical clearance and permission were sought from the University of Zambia Biomedical Research Ethics Committee (UNZABREC REF. No. 1662-2021).

Conflicts of Interest

The authors declare no conflicts of interest.

References