The study was conducted in Yopougon, one of the ten municipalities of Abidjan. It is located between Banco Forest and the Ebrié Lagoon, in the western part of northern Abidjan. It has a population of 1,571,065 inhabitants, including 775,622 women (GPHC, 2021), spread over an area of 153.06 km², resulting in a population density of 10,264 inhabitants/km². Yopougon has 14 villages and is bordered to the north by the city of Anyama and the commune of Abobo, to the east by Attécoubé, to the south by the Atlantic Ocean, and to the west by Songon. Its infrastructures, mostly located in its industrial park, provide local employment opportunities. It also has residential neighborhoods with apartment buildings, middle-class low-rise housing, affordable rental areas, and numerous informal settlements. Yopougon is known for its vibrant and popular atmosphere, with over 1500 restaurants and nightclubs.

This is a qualitative, cross-sectional study that used semi-structured interviews to gather information on women’s knowledge, attitudes, and practices regarding traditional contraceptive methods. The study was conducted over a one-month period, from September 1^st to September 30^th, 2019.

Participants were recruited using two non-probability sampling techniques, namely, “accidental” and “snowball” samplings. The first technique involves selecting subjects based on their practical accessibility and proximity to the researcher. The second technique identifies participants through referrals, starting from a key informant within the researcher’s network. These approaches enabled the researchers to move from one user to another, following initial contact and interviews with three traditional healers and two herbalists and three of their patients who use PTCMs. This facilitated access to women using natural and popular traditional contraceptive methods. The sample size was determined by including participants until data saturation was reached, i.e., when no new information emerged with new participants.

A total of 22 informants were interviewed, including 2 women who sell medicinal plants and are known as healers, three traditional practitioners, two FP providers, and 15 women selected according to the following criteria:

Sexually active women with unmet family planning needs, i.e. woman at risk of becoming pregnant who wishes to delay pregnancy in order to space out her children or prevent pregnancy in order to stop having children, but does not wish to use any of the modern methods available.Women who have used popular traditional contraceptive methods.Willingness to participate in the study.

Approval of modern contraceptive methods.Current use of modern contraception because these women, who have never used PTCMs, cannot tell us anything reliable about them; at best, they will regale us with rumors.Refusal to participate in the study.

Data were collected through face-to-face individual interviews using a structured questionnaire covering the following thematic areas:

Reasons for choosing PTCMs.Traditional customs and practices used to prevent unwanted pregnancies.Medicinal plants employed.Participants’ wishes and suggestions for improving PTCM use.

The fieldwork was conducted in two phases. The first phase was a preliminary survey, which played a crucial role in facilitating access to and exploration of the study area. The National Program for Traditional Medicine helped establish contact with three traditional practitioners experienced in medicinal plants used for contraception. Individual interviews with these traditional practitioners focused on women’s motivations for using PTCMs, the medicinal plants involved, and associated cultural practices. Each traditional practitioner put us in touch with a patient who was using PTCMs, who in turn led us to another user within their circle of acquaintances or herbal supply network, until we reached our target sample size. Additionally, these users of PTCMs facilitated contact with two herbalists, who were also interviewed individually.

Two midwives providing family planning services were consulted to gather insights into why women abandon modern methods in favor of popular traditional ones. This phase lasted five days (September 1 - 5, 2019) and allowed the research team to identify the various types of popular traditional methods available and to gain familiarity with the field context.

The second phase involved the main survey, conducted over three weeks and four days (September 6 - 30, 2019) in Yopougon. These two phases enabled the researchers to meet all actors included in the sample. Interviews were conducted with users of popular traditional methods, family planning providers, and herbalists. The scheduling of interviews was adapted to participants’ availability, including evenings and weekends. Data collection was carried out by a sociologist trained in interview techniques and familiar with the data collection tool. All interviews were recorded using a digital voice recorder with an integrated microphone and transcribed in French.

The data collected were transcribed in French and reviewed several times by members of the research team. The interviews were coded by a coder, following a preliminary review to ensure they understood the study’s objectives, using Microsoft Word and Excel Windows 16. The first author verified the accuracy of the coded data.

Subsequently, relevant units of meaning were identified from the respondents’ verbatim comments and were manually coded. This involved assigning codes to recurring ideas, perceptions or experiences expressed in the transcripts.

Codes exhibiting similarities or conceptual links were grouped into categories, which enabled the identification of main themes and sub-themes reflecting the central elements of the participants’ discourse. The themes were progressively refined through comparative readings of the transcripts to ensure their consistency, relevance and representativeness in relation to the study’s objectives.

Finally, a thematic analysis was performed to code and process the information using Nvivo 15 software. This involved listing the collected data and transcribed audio recordings verbatim, preserving the original wording of participants’ responses. The data consisted of life stories and opinions, which were used to identify, describe, and categorize in detail the social factors influencing the non-use of modern contraception.

The study faced challenges related to data availability on patients using TCM. Specifically, there was a lack of detailed data on each method, and the limited available data were incomplete.

Another difficulty was participants’ mistrust regarding the confidentiality of their responses. This mistrust stemmed from fears among traditional healers, herbalists, and some users that their products developed through years of effort might be commercially exploited without their consent. They also feared that their ancestral knowledge of medicinal plants, passed down in secrecy, could be disclosed.

Additionally, some participants found certain questions difficult or too personal. Some respondents preferred that the interviews be conducted outside their homes, in women’s gathering places, or in public areas within the city. The duration of interviews conducted in their neighborhoods was generally shorter, often taking place during rest hours. Some individuals failed to attend scheduled appointments.

Among the 22 respondents in our sample were 2 midwives providing family planning services (aged 35 and 44), 2 herbalists (aged 48 and 54), 3 traditional practitioners (aged 69, 56 and 51) and 15 users of MCTP. The users were aged between 23 and 64, traders (60%) or housewives (27%), uneducated (20%) or with primary (47%) or secondary (33%) education, and mothers of between 1 and 7 children. They were married (80%) or single (20%). In total, 19 women (86%) and 3 men (14%) were interviewed.

3.2.1. Adverse Side Effects of MCMs

The main reasons for using TCMs, as listed by our respondents, included: the adverse effects of MCMs, prejudices and rumors, i.e., the supposed health problems caused by MCMs, the absence of side effects of TCMs on maternal health, cultural and religious beliefs, effectiveness over time and accessibility, etc.

According to the respondents, the most recurrent rumors regarding the side effects of MCMs were the cessation of menstruation, disruption of the menstrual cycle, early menopause, bothersome bleeding, the development of fibroids, and secondary infertility. These rumors about side effects, whether alleged or proven, seem to outweigh accurate information. This is reflected in the testimony of one respondent:

“…Iheardthatagirlusedthethree-monthinjectablecontraceptive, bledforfourmonths, anddied.WhenIusedcontraceptionmyself, Ibledfortwomonthsandbecamepale.Mymotherasked, ‘Whatisthis!?’ Shehadtotakemetoawomanwhogavemesomemedicine, Istartedpurgingandthenitstopped.There’salsoanauntiewhogotanimplant, andnowshecan’tsleepwithamananymore—theyruinedherlife!?” (Housewife, 25 yearsold, inacommon-lawrelationship, motheroftwochildren)

3.2.2. Rumors Spread about the MCM

In summary, the rumors surrounding modern contraceptives are often overwhelming and distressing. They create psychological barriers that hinder the use of modern contraceptive methods, as illustrated by another respondent:

“…therearewomenwhoarewillingtohaveabortionseveryday, everyyear—Yeah! Buttheydon’twantchemicalsintheirbodies; weseealotofsuchcases.” (Familyplanningprovider, 35 yearsold, motheroffivechildren)

This perceived risk associated with MCMs leads women to seek alternative contraceptive methods, particularly those based on plants, as explained by another respondent:

“Womenareincreasinglyabandoningmoderncontraceptionbecausetheyhavefoundothermethods.Theytrusttraditionalmethodsmore, believingthatwiththem, therearenoissueslikemissedperiodsorcycledisturbances.Whentheyaregiventraditionalmedicine, theyaretold, ‘Hereisthetotem, don’tdothis, don’tdothat’; andtheyseetheirperiodsreturntonormal!Whentheyfollowtheirmethod, wearingtheirtraditionalcordaroundtheirwaist, theirperiodscomeasbefore…andwhentheystop, theydon’thaveanyotherproblems…Also, theydon’twanttoqueueforconsultations.Theyprefertoexplaintheirproblemstonaturopathsandhealers, whoprescribemedicineimmediately.” (Family planning provider, 44 years old, mother of five children)

These views are echoed by a colleague who blames traditional healers for the low uptake of modern contraceptives:

“Sincenaturopathsstartedclaimingtheycanprovidenaturalcontraception, it’sbeenaproblemforus!They’resupposedtohelpus, buttheydon’t.Instead, theycreate problems forus.” (Family planning provider, 35 years old, mother of five children)

3.2.3. Challenge of Managing Adverse Effects of MCM

Thus, contraceptives derived from traditional medicine based on plants or environmental knowledge significantly influence the use of modern methods. Moreover, the quality of training among healthcare providers also contributes to the preference for traditional methods. In addition to their limited knowledge of MCMs, their handling of the supposed side effects of modern contraceptives is often inadequate, as reported by one respondent:

“Hmmm…whenyoufeelunwellafterusingamethod, orwhenundesirablesymptomsappearandyoureturntothehealthcentertoexplainyourproblem, theytellyouthemidwivesarebusy.Whenthey’redone, they’llbetootired, sotheyaskyoutogohomeandcomebackonyourappointmentdate.” (Trader, 28 years old, married, mother of three children)

The cost of treating side effects caused by MCMs is borne by the users themselves. These women often find themselves in situations where they must cover both direct and indirect costs alone. One respondent shared her experience while living in a rural area:

“WhenIwantedtohaveachild, Istoppedusingthemethod.Butitwasdifficultformetogetpregnant.IhadtogotoAbidjanfortreatment, whichlastedtwoyears.Beforethat, IhadalreadyreceivedcareinKorhogowithoutimprovement, theninBouaké, wherethetreatmentswereveryexpensive.That’swhyIbelieveit’simportantforthesideeffectsofMCMstobecovered.” (Schoolteacher, 30 years old, married, mother of one child)

3.2.4. Effects of Religion on Contraceptive Use

Paradoxically, although religion was mentioned by some respondents, it no longer appears to be a significant barrier to the use of modern contraceptives, according to other testimonies. One respondent stated:

“Accordingtomyfaith, itisforbidden.Butnowadays, wearefacedwithrealityteenpregnancies, younggirlswithchildrenwhichisnotgood.So, weareforcedtoreflectonthisissue.Eventhoughmybeliefsdon’tallowmetoacceptsuchthings, theonlymethodIfindacceptableismenstrualcycletracking.That, tome, isappropriate.” (Woman, 51 years old, mother of five children, trader)

Conversely, another respondent shared a different perspective:

“Religionisnolongeraproblem.Weevenraiseawarenessnowinreligiousgatherings…Theytellusthatifyouhaveachild, youcanuseamethodbecauseyourhusbandmightneedyouwhilethechildisstillbreastfeedingorhasn’tgrownenough.So, toavoidrefusinghimorgettingpregnantagain, youcanuseamethodforuptotwoyearsandthenstoptohaveanotherchild.” (Housewife, 32 years old, married, mother of four children)

According to our respondents, women engage in certain traditional practices aimed at preventing unwanted pregnancies. For instance, it is believed that a woman must immediately cleanse herself after sexual intercourse to expel semen and thereby avoid conception. One respondent explained:

“Thereisamethodwherethewomanpositionsherselftoexpelthesemen.Aftersexualintercourse, thewomandoesnotsayanythingtoherpartner; shepretendstogotothebathroom.Shesitsdown, focuses, pressesherabdomen, andthesemencomesoutimmediately.Assoonasthemanejaculatesandwithdraws, sheactsasifsheisgoingtourinatetoperformthispractice…” (Housewife, 31 years old, mother of three children)

Some respondents also mentioned the use of a specific “safety belt” that purportedly helps women avoid unwanted pregnancies. Similarly, wearing amulets prepared by traditional healers is believed to yield the same effect. One respondent stated:

“Whenwomenfollowtheirtraditionalmethod, thatis, wearingtheirtraditionalcordaroundtheirwaist, theyexperiencetheirmenstrualcyclesnormallyasbefore, butdonotbecomepregnant.” (Family Planning Provider, 44 years old, mother of five children)

A traditional practitioner provided further details about the so-called safety belt:

“Thesafetybeltisacottoncordspunusingaspindle, onwhichthehealertiesseveralknots…ItispracticedbynorthernIvorianethnicgroupssuchastheDjimini.Thewomanwearsthecordaroundherwaisttoavoidpregnancy.” (Traditional Practitioner, 69 years old, mother of five children)

Another traditional practitioner echoes this sentiment, describing an ancestral practice passed down through generations that he personally experimented with and found effective:

“ThereisasomewhatspiritualmethodthatIevenpracticedonmywife.Aftershegavebirth, Itooksomeofherpubichair, placeditinasmallpieceofpaper, andwenttothosewhoworkwithleatherandanimalskins.Theymadeasmalltalismanintowhichthepapercontainingthehairwasinserted, buttheydidnotknowwhatitwas.Iplacedthetalismanaroundthechild’sneck.Aslongasthechildwearsthetalisman, themothercannotbecomepregnant.Butifitisremoved, shecanconceive.Myfather, whowasahealer, passedthisknowledgetome, havingreceiveditfromhisownfather.Itisancestralknowledge…” (Traditional Practitioner, 56 years old, father of four children)

Some respondents also revealed other popular practices based on their life experiences, confirming the existence of such methods:

“…Thereisonethatislikewood, asmallpieceofwoodthatisinsertedintothevagina…” (Healer, 48 years old, mother of five children)

“Aftersexualintercourse, youmustdrinkalargecupofwater.Sometimes, youalsoneedtodrinklemonjuicetopreventapossiblepregnancy.” (User, 23 years old, mother of one child)

Users also disclosed that they sometimes resort to the calendar method, withdrawal, or abstinence during their fertile period:

“Before, whenwehadtotakemedication, wewouldn’ttellanyone.Andwhenwegavebirth, aslongasthechildwasn’tthreeyearsold, wewouldn’tsleepwithourhusbands.” (Housewife, 64 years old, mother of five children and grandmother)

Various parts of medicinal plants are used, including root and stem bark, whole roots, entire plants, leaves, flowers, fruits, and seeds. These components are used to prepare different medicinal formulations. These are administered to women of reproductive age who are sexually active and at risk of pregnancy through various routes: dermal (application), vaginal (vaginal baths, purges), oral (drinks, instillations), and rectal. Respondents shared their experiences with using medicinal plants for vaginal douches and purges to prevent unwanted pregnancies:

“Igetthemedicinefromtheoldwomanwhosellsundertheshelteritcosts100or200CFAfrancs.Shenevershowstheplantorsaysitsname.Shepoundstheleavesandsellsthem.That’swhatwecallthe‘secret’ youtakeiteveryday.Ifyouskipaday, yougetpregnant.Hertotemisthatyoumustnotskipaday.” (Respondent, 27 years old, mother of two children)

Some traditional healers and herbalists shared specific techniques and secrets of their practices. One respondent explained:

“Youtakethesefreshleavesrightaftersex.Youheatthemabit, chewthem, anditneutralizeseverything.Ifyouwanttohaveachild, youdon’ttakeit.Butifyoudon’twantachild, youtakeit.Thisisespeciallyusefulwhenyou’reabouttotravel.” (Female healer, 54 years old, mother of six children)

Another respondent revealed:

“Therearecertainnutsthreeinashellyoutakeonetoprotectyourselffromunwantedpregnancyforayear…Itworksabitlikeimplants.Therearealsoleavesthatyoupoundandmixwithkaolin, thendryandstore.Youuseitforpurginganddrinkingtoavoidpregnancy…” (Traditional healer, 69 years old, mother of five children)

In the same vein, another respondent shared this knowledge:

“…youtakeanunripepineapple, crushthepulptoextractthejuice, thenpoundtheleavestogettheirjuice, mixbothjuices, drinkit, anduseitforavaginalpurgeaftereachsexualencountertopreventunwantedpregnancies…” (Traditional healer, 56 years old, father of five children)

Additionally, some medicinal plants are used to produce contraceptive products, such as capsules, as described by this traditional healer:

“IdevelopedcapsulesfromthefruitsoftheMomordicacharantiaplant.Awomantakesonecapsuleperdayfortendaysafterhermenstruationtoavoidpregnancy.” (Traditional healer, 56 years old, father of five children)

However, according to the traditional practitioners and healers interviewed, many natural products used as traditional contraceptives are also said to have cleansing or abortive properties. They stated that the use of these products could lead to permanent infertility in the user in the event of an incorrect dosage or malpractice on the part of the practitioner. Furthermore, it is possible that products with non-contraceptive effects may be deliberately administered to women to make them more fertile.

In summary, the rumors surrounding modern contraceptive methods (MCMs), compounded by the reality of certain confirmed side effects, are often overwhelming and discouraging. These factors lead many women to abandon modern contraception. Moreover, the difficulties and painful experiences associated with MCMs create psychological barriers and unmet needs in family planning. In response to this situation, some women turn to popular traditional methods to meet their reproductive health needs.