The economic capital city of Côte d’Ivoire, Abidjan, is inhabited by approximately five million people, i.e., 21% of the country’s total population. It has three regions and thirteen health districts and is home to almost all the reference health establishments, including four University Hospital Centers, a tenth General Hospitals (GH), a plethora of health centers and private clinics. It concentrates the largest number of health activities at national level.

We have decided to conduct the present study in two randomly selected health centers, given our financial difficulties and our intention to keep the work concise. The study was conducted at the General Hospital (GH) of Yopougon Attié in the Yopougon-East health district and the Adjamé 220-unit urban health center in the Adjamé-Plateau-Attécoubé health district (Figure 1).

The suburb of Yopougon has 1,071,543 inhabitants (2014 General Census of Population and Housing) on 153.06 km² or 7004 inhab/km². It is known for its warm and popular ambiance that attracts residents from other municipalities. The GH of Yopougon Attié was created in 2013 to support the University Hospital Center of Yopougon. It has an obstetrical unit and carries out about 26 deliveries per day. It treats an average of 80 - 100 children per day. Each doctor sees at least 20 patients per day. The FP service saw 1510 patients in 2018 of which 725 (48%) are put on MCM (Figure 1).

The suburb of Adjamé, located in central Abidjan, north of Plateau, has 372,978 inhabitants living on (2014 General Census of Population and Housing) 12.10 km², i.e. 21,016 inhabitants/km². As buses, mini-buses, and trains central stations, as well as the biggest day market location, Adjamé sees more than a million people passing through its center every day. As such, it is the place where migrants and local populations cross meet (Figure 1).

The Urban Health Unit of 220 dwellings in Adjamé was created in 2006. The FP Service received 7524 women of childbearing age in 2019, of whom 5098 (67.7%) were advised on contraceptive methods, of which 485 (6%) were put on modern contraceptive methods. The center cared for a total of 19,741 women in 2017, 26,323 women in 2018 and 13164 women in 2019 (all consultations combined).

We conducted a cross-sectional study with descriptive and analytical purposes through the collection of quantitative data. This study took place over a 10-month period from December 2018 to September 2019.

The study population consisted of all women of childbearing age, sexually active and at risk of pregnancy, attending the two health centers selected for the study.

Inclusion criteria: All FP, maternity, and gynecology clients of reproductive age, sexually active, and at risk of pregnancy who agreed to participate in the study.

Exclusion criteria: Clients who were not of childbearing age, those who were not sexually active, those who were not at risk of pregnancy, and those who refused to participate in the study.

The sample size for quantitative data collection was determined by using the Schwartz formula

n = t 2 ⋅ p ⋅ ( 1 − p ) e 2

- n = The sample size.

- t = The reduced deviation = 1.96 for a risk of error of 5%.

- P = Prevalence of the phenomenon in the population = 50%.

- q = 1 − P = 0.5.

-e = The precision of the result required = 5%.

n = 384.33.

We have adjusted our sample size (n) to 423 women of childbearing age at risk of pregnancy (i.e., a 10% increase) to ensure sufficient representativity at the level of the sample subgroups. Women were recruited by non-probability sampling until our sample size was obtained.

The investigators, health workers (physicians and nurses, public health specialists, second and third authors), were briefed on the study and trained on developed survey sheets. The collection materials were pre-tested before the survey began to ensure their validity and reliability. Information was collected from participants in a face-to-face interview, using an individual structured questionnaire containing closed and semi-open questions.

The dependent variable was women’s use of MCM based on the question, “Are you currently using a modern contraceptive method?”

The independent variables were socio-demographic and reproductive characteristics. Other areas covered by the questionnaire included knowledge and perceptions of FP methods, acceptability of MCM by male partners and close contacts, and communication about FP methods.

Data collection took place from January to May 2019. The questionnaire was administered in French in most cases or in local languages in some cases when necessary. Some data were verified by the interviewers.

Before the study was conducted, an awareness and information session were held in the selected health centers to obtain the support of health workers, women, and their partners (secondary target) to facilitate the survey. At each collection session, the interviewer explains the purpose of the survey to the respondent and reassures them that the data collected is confidential. The interviewer checks that the forms are filled out correctly before thanking the respondent for her cooperation at the end of each interview.

The data collected were entered using Epi-Data software and then analyzed using SPSS 16 software. Descriptive analysis determined means for quantitative variables and then frequencies and percentages for qualitative variables. Interpretation of results was done at the significance level (α = 5%, 95% CI).

Ethical approval was obtained from the National Ethics Committee for Life Sciences and Health of Côte d’Ivoire (N/Ref: IRB000111917). Other approvals were obtained from the Ministry of Health, particularly from the directors of the health centers. Ethical considerations included confidentiality and anonymity of responses. Participants were given autonomy, time, and information about the purpose, objectives, methods, and use of the results to decide to participate voluntarily, freely, and without pressure. Informed consent was obtained from all subjects and/or their legal guardian. Confidentiality was guaranteed by making the questionnaire anonymous.

Among a total of 423 women of childbearing age and at risk of pregnancy recruited in the two selected health centers, only 37% were using a modern contraceptive method at the time of the study. Injectable contraceptive methods (36%) were the most used, followed by the pill (32%) and implants (26%) (Figure 2). However, almost all these women had already heard of FP (94%) and MCMs (99%), the best known of which were the pill (43%), injectable contraceptives (33%) and implants (17%). They knew that contraception was intended for women of childbearing age (88%) to avoid unwanted pregnancies (96%) and knew the supply sites (97%), including health centers.

MCM use was significant among women aged 15 - 25 years (39%) and 25 - 35 years (44%), with high school (44%) and higher education (30%), managers (18%), and students (29%), single (42%), Catholic (30%) Protestant (19%), and evangelical (31%) religious denominations. Thus, age, education, being single, and Christianitý favored MCM use. Furthermore, this use increased with the age of the women (Table 1).

Indeed, the Muslim women in the study were predominantly uneducated (52%), most Catholic (38%) and Evangelical (37%) women had tertiary education, while Protestant women had more of a secondary education (Table 2).

Among the respondents who had a current contraceptive method, the majority stated that they were able to demand a condom during sex (76%) and to take the initiative to start a modern contraceptive method in their relationship (80%). These two acts express the decision-making power of the woman in the couple (Table 3). A large proportion of the respondents believed that the use of contraception should be a joint decision of the couple (96%) and that condoms effectively protect against pregnancy/STI/HIV/AIDS (96%). In addition, these women did not need to go to the health center to obtain information on FP methods (93%). They wanted condoms to be used by married people (87%) and discussed family planning (54%) with their partners. In contrast, women who experienced peer pressure (18%) and those who did not discuss sexual issues with their partners (43%) used MCMs (Table 3).

In sum, factors such as the woman’s decision-making power, communication about FP within the couple, and positive ideas about the effectiveness of FP methods favored the use of MCM. However, opposition from close family and friends, the taboo nature of sex in the couple, and the fact that they did not go to the health center to obtain information on FP did not prevent the use of MCM (Table 3).

MCM use was high among women who wanted only two children (49%) and those who had an average of two living children (64%). This contraceptive use was also important among women who had had unwanted pregnancies (15%). Thus, the number of children desired, the number of living children and the occurrence of unwanted pregnancies favored the use of contraceptive methods (15%) (Table 4).

The MCM use rate was estimated at 37% in our study population. This rate is higher than the national contraceptive prevalence estimated at 21% according to the 2018 FP report. Compared to previous studies, our result remains largely below that of Keita, estimated at 64% among women at the Center of Health Reference of Municipality VI of the District of Bamako in Mali [10]. The use rate of HIV-infected women followed as outpatients at Treichville University Hospital was estimated at 62.9% by N’Guessan et al. [16].

High contraceptive prevalence in hospitals in big cities are not exceptional and can be explained by the nature of the study population. These are people who are followed by health workers and received accurate and timely information that improves their knowledge. These women are supposed to be more receptive to health offers and do not reflect the health behavior of the general population. The weakness of our results could be explained by missed opportunities for information and communication in the health centers. Indeed, only 51% of the clients had received information/counseling on FP. However, this result may be related to the value placed on fertility in our country. Thus, the use of MCMs remains a challenge in African countries despite years of awareness raising and strategic interventions supported by visible political leadership. The women in our study preferred injectable contraceptives (36%), the pill (32%) and implants (26%). This result could be explained by the ease and discretion of using these methods, which are often used without the knowledge of the partner [18]. Injectable progestins, implants and intrauterine devices were the methods of choice for women in the N’guessan study population in Abidjan [16] and Keita in Bamako [10]. The pill was the safe method for young French women under the age of 30 [19]. Although the male condom was in use in the health zones of Dibindi and Mumbunda in the Democratic Republic of Congo [4] [20].

MCM use was high among young women aged 15 - 35, especially those aged 25 - 35 (44%). Young women are first concerned with completing their studies and then, once they are in a household, they are faced with the problems of spacing and limiting births. Our results are consistent with previous studies that have estimated the contraceptive use rate at 35.7% among women aged 25 - 29 in the DRC [20] and to 49% - 53% among Nigerian women aged 25 - 39 [21].

Education improves knowledge and removes one of the major barriers to the use of MCMs, which is misinformation about their side effects and undesirable consequences on the reproductive health of users. Therefore, several studies, like ours, have shown that education improves the use of MCM [4] [22] [23] [24] [25]. This explains the high use of MCM among women in managerial positions in society and among the Christian women in the study. Indeed, Catholic, Evangelical and Protestant women tended to have higher and secondary levels of education respectively, whereas Muslim women were mostly uneducated. However, this result found also by Matungulu CM (2015) and Ugal BD (2013), could highlight a superficial practice of the Christian faith through the non-respect of the fundamental biblical principles on the one hand and on the other hand the quest for certain temporal and worldly privileges [20] [21].

The educational advantage of our study population could explain the fact that 93% of the users of contraceptive methods did not need to go to the health center to obtain information on FP methods and the results showed that they had a good knowledge of MCMs. In fact, the users of MCMs had primary (22%), secondary (44%) and higher (30%) levels of education. They have the ability and the possibility to inform themselves through the mass media, the internet, social networks, books and magazines (Essis EML. 2021) [26]. Moreover, education increases women’s decision-making power as well as their ability to communicate and negotiate with their partners. This is why pressure from the immediate environment had no influence on the contraceptive practice of the majority of MCM users (18% vs. 1%), nor did the taboo nature of sex in couples’ communication.

Contraceptive use was high among single women (42%) and this result was found by Congo Z (2005) in Burkina Faso [27]. The single woman is very often schooling and on parental cover. She can also be a young servant with the concern of stabilizing herself on the matrimonial side. She cannot afford the luxury of having children who risk having different fathers or finding herself in a situation where the father refuses to assume the paternity of the children.

The woman’s decision-making power influences contraceptive use. In fact, contraceptive use was important for women who could make the decision or take the initiative to use MCMs, in this case condoms, in their relationship. Low contraceptive use is greatly affected by the woman’s lack of decision-making power. This result has similarities with previous studies [28] [29] [30] [31] [32]. Contraceptive use is better and even more effective if it is accompanied by good communication within the couple [28] [33] [34] [35] [36] and by positive ideas in favor of FP and MCM [6] [9] [22] [37] [38] [39]. Thus, contraceptive practice without the knowledge of the partner is the result of poor communication between partners [26] [31] [34].

The wish to have very few children leads to an early need for birth control. An unwanted pregnancy reflects an unmet need for FP [13] and is a signal to start contraception and avoid similar cases. Every birth is the responsibility of the parents, who will normally be responsible for the new human being with all its rights. For this reason, parents have the duty to assume a responsible paternity and maternity to avoid that their offspring are taken care of other persons or have their fundamental rights violated. For these reasons, people define an ideal number of children for which they can assume responsibility and then use contraception with reason.

The difficulties encountered were related to the availability of women. Indeed, the waiting time before the consultations is long and constitutes a waste of time for the women. They are therefore stressed and impatient to return to their occupations. In addition, our respondents found some of the questions difficult or too private and the length of the interviews too long. They were wary of confidentiality, and this was justified by the fear of indiscretion experienced by some users. Many women use contraceptive methods without the knowledge of those around them, including their spouses.

The main limitations of this study were financial restrictions that limited it to two health centers, non-response, and incomplete and even erroneous information from women.