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• Published: 09 February 2021

A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya

• Susan Ontiri   ORCID: orcid.org/0000-0001-7622-5714 1 , 2 ,
• Lilian Mutea 3 ,
• Violet Naanyu 4 ,
• Mark Kabue 5 ,
• Regien Biesma 2 &
• Jelle Stekelenburg 2 , 6  

Reproductive Health volume  18 , Article number:  33 ( 2021 ) Cite this article

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Addressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives.

Qualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach.

Use of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods.

This study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users.

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Use of contraceptive methods allows spacing of pregnancies or limiting family size, enabling individuals and couples to fulfill their fertility desire by choosing if and when to become pregnant. Contraceptive use not only has positive effects on health-related outcomes, such as improved maternal and child health [ 1 ] but also improves schooling and economic outcomes for girls and women [ 2 ]. Global trends have shown an increase in contraceptive uptake, however, many women, approximately one out of three, discontinue their method within a year [ 3 , 4 ]. Contraceptive discontinuation is an important determinant of contraceptive prevalence, as well as unintended pregnancies, and other demographic impacts as it increases the unmet need for family planning (FP). Several studies have found that contraceptive abandonment and failure contribute substantially to the total fertility rate, unwanted pregnancies, and induced abortions [ 3 , 4 , 5 ]. Analysis of data from 36 developing countries revealed that over one-third of unintended pregnancies resulted from women who had discontinued the use of contraception [ 5 ]. Unintended pregnancies have negative consequences on the health and well-being of women and their families as they can lead to maternal morbidities and even death. Besides, it is documented that children born from unintended pregnancies are: less likely to be breastfed, more likely to be stunted, at risk of a lack of parental love, and at higher risk of child mortality than children from wanted pregnancies [ 6 ].

An analysis of Demographic and Health Surveys conducted by Curtis et al. demonstrated that women’s socio-demographic characteristics—age, education, place of residence, and economic status—are the determinants associated with contraceptive discontinuation [ 7 ]. Even though studies indicate that women with higher levels of education and those residing in urban residences are more likely to discontinue their initial method, additional analyses reveal that these women are more likely to switch than stop after discontinuing a method [ 7 , 8 , 9 ]. This could be because they are enlightened on their contraceptive choices and will discontinue and switch if a particular method does not suit them since they can also easily access the contraceptive services due to shorter distances to health facilities.

Researchers continue to investigate why a woman or a couple would discontinue the use of modern contraception while still in need. Past studies show side effects and health concerns have been the main causes of contraceptive discontinuation [ 3 , 4 , 10 ]. Indeed, side effects account for more than half of the reasons for discontinuing contraceptives while still in need [ 9 , 11 ].

Kenya has implemented a strong national family planning (FP) program since it was launched in 1967 [ 12 ]. Over the past five decades, the country has developed FP/reproductive health policies, strategies, and guidelines and implemented programs aimed at increasing access and utilization of modern contraceptive methods among women of reproductive age and supporting men's involvement. These efforts have borne fruit; the current data estimates a contraceptive prevalence rate of 62.8%, which is mostly driven by the use of modern methods at 60.7% [ 13 ]. However, more than one-third of all pregnancies in Kenya are unintended and one in three women discontinue use of contraceptives by 12 months [ 14 ]. Like other countries, the main reason cited in Kenya for discontinuation is side effects, predominantly side effects associated with hormonal contraception [ 14 ]. Studies have linked poor quality of care, particularly inadequate counseling on side effects with contraceptive discontinuation [ 4 , 15 ]. For instance, data from round 5 to round 7 of Kenya’s Performance Monitoring and Accountability 2020 surveys indicate a glaring gap in the quality of FP services provided in health facilities. Only two-thirds of women were informed about side effects by service providers, with slightly more than half being informed about what to do in case of side effects [ 13 , 16 , 17 ].

Whereas the predictors of contraceptive counseling have been established by several quantitative studies [ 3 , 4 , 18 ], there is a paucity of information to understand the lived-in experiences of women who discontinue the use of contraceptives while still in need. This paper reports qualitative results from in-depth interviews and focus group discussions with discontinuers. The interviews and discussions explored experiences with previous use of modern contraceptives, reasons for discontinuation, and future intention to use contraceptives among discontinuers.

Study design and setting

A cross-sectional qualitative study was conducted as part of a formative assessment in a 24-month longitudinal study on evaluating the dynamics of contraceptive use, discontinuation, and switching in Kenya. The longitudinal study is being conducted in Kitui and Migori, rural counties in Kenya. The two counties have a diverse method mix; Migori’s mCPR is mostly driven by long-acting reversible contraceptives, at 72% while in Kitui, short-term methods are more popular, at 64% [ 14 ]. Details of the longitudinal study, including the study setting, have been published elsewhere [ 19 ]. Ten public health facilities, five in each county were purposively selected based on high FP caseload. The 10 facilities were located in 10 different sub-counties. Routine service statistics revealed that these facilities provided the highest number of contraceptive services in their respective sub-counties. Out of the ten facilities, 2 were county hospitals, 5 sub-county hospitals, 2 health centers, and 1 dispensary. The consolidated criteria for reporting qualitative research (COREQ) was used in this paper [ 20 ]. The completed checklist is available in Additional file 1 .

Study participants

Since the main objective of this study was to explore the experience with contraceptive use and discontinuation among discontinuers, participants who met the following inclusion criteria were selected: women of reproductive age between 15 and 49 years of age, who were sexually active, did not desire pregnancy, and had been but were currently not using modern contraception. The men who were interviewed to explore their perspective on contraceptive discontinuation were purposively selected since they were spouses of the women who met the inclusion criteria. Data collection included FGDs with adolescent mothers aged 15–19 years and women over 20 years and IDIs with couples and adolescent girls. Recruitment of study participants stopped once data saturation was achieved, that is when no new information was derived from the interviews and focus group discussions. In total, 42 data collection sessions (12 FGDs and 30 IDIs) were conducted with 135 study participants-105 in FGDs and 30 in IDIs. (Table 1 ).

Recruitment strategy

The study team selected community health volunteers (CHVs) who were providing health information including family planning to households within the catchment area of the study facilities. The CHVs were trained on the inclusion criteria and thereafter, mobilized and screened community members within their catchment area before referring them to the study staff who contacted, further screened, and recruited those eligible into the study. For couples, the CHV would approach the woman first to establish eligibility, before contacting the spouse. Both partners had to agree to participate before inclusion in the study.

Data collection

Data collection was conducted from May to July 2019. The data collection team was comprised of 10 research assistants, (seven females and three males) who had undergraduate training in Anthropology or Sociology. The team was selected based on their experience conducting qualitative studies. They further received an additional 5-day refresher training before data collection. They worked under the supervision of the lead author. Respondents were not known to the interviewers before the data collection sessions. Written consent was obtained from the participants to conduct and audio-record the data collection sessions. The time and place of the interviews were determined based on the convenience of the participants. The venue for the FGD data collection sessions was community halls while the IDIs were conducted at the participants’ homes. All participants were aware that the study was being conducted to explore their perspective and experience with contraceptive use and discontinuation as part of a formative assessment to improve the quality of family planning services provided.

Semi-structured topic guides covering FP topics for the various audiences were developed and piloted before use. The FGD guide included open-ended prompts related to knowledge and perception of contraceptives, use of FP with their community, and reasons for contraceptive discontinuation, including influencers. The study had IDI guides for the adolescent girls (15–19 years) and for married couples (18–49 years), husbands and wives were interviewed separately. The former group was asked about their knowledge and perceptions around sexual and reproductive health and contraceptive use, experience using contraceptives, and contraceptive discontinuation. The married couples shared their knowledge, perception, and decision-making experiences using contraceptives; FP use and discontinuation; and couple involvement in contraceptive use and discontinuation. The file showing the topic guides used in this study is provided in Additional file 2 .

Two trained interviewers were present at each FGD—one as a session moderator and the other as a note-taker. For the IDIs, only one trained moderator was present for the conversation. No observer was present during data collection. The FGDs and interviews were conducted in local dialect (Kamba and Dholuo) and Swahili. All the interviews were audio-recorded, and field notes were taken for each focus group session. The interview sessions lasted between 30 and 90 min. The data collection team debriefed after the end of each session. Interim findings were discussed weekly by the team and interview guides were modified and revised as needed. At the end of data collection, no new themes were emerging and data saturation had been achieved.

Data analysis

The digital recordings of IDIs and FGDs were transcribed verbatim, translated into English, and analyzed using NVivo 11. Data were analyzed thematically following the approach of Braun and Clarke to identify, analyze, and report patterns within the data [ 21 ]. Coding and theme development were directed by the content of the data (inductively) [ 21 ]. A final agreed thematic framework was applied to all interviews. Transcripts were not returned to participants in advance of coding. Data analyses were performed by two researchers (VN and SO) with in-depth knowledge of qualitative analysis who were supported by two analysts to ensure timely coding and validation of the coding frame. The team identified themes from reading and rereading the transcripts, noting any similarities and differences between and within participants’ accounts. The preliminary findings were shared with some of the study participants for validation.

Ethical considerations

This study was guided by a protocol that was approved by the Kenya Medical Research Institute Institutional Review Board and the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Participants gave informed written consent/assent to participate in the study. Protection and confidentiality of participants was ensured through conducting data collection sessions in private settings, maintaining confidentiality, and limiting access to study information to only authorized personnel.

The demographic characteristics of the 135 study participants are shown in Table 2 . The majority of the participants were adolescents and youth aged 15–24 years at 51%, had primary education 53%, were farmers 32%, and had one to two children (Table 2 ). The findings from the two study sites were comparable, with no major differences.

Study findings are provided in four themes below: (1) motivation for modern contraceptive use; (2) sources and decision-making for previous contraceptive used; (3) barriers to sustained use of contraceptives; and (4) future intention to use contraceptives.

Motivation for modern contraceptive use

The study explored the participant’s motivation for use of a contraceptive prior to discontinuation. Generally, there was strong consensus among all the study participants that the reasons for using contraceptives were to plan for the number of children they wished to have, and prevent pregnancy. Adolescent participants further noted that the greatest motivation for using contraceptives was to prevent pregnancy so as to pursue studies; they wanted to avoid unplanned pregnancies that might result in having to drop out of school and take on parental responsibilities they had not envisioned.

Economic reasons appeared to be the major impetus for use of contraceptives by adolescent mothers, older women, and married couples, as most participants shared similar sentiments on the need to have children they can manage to raise as illustrated by the following quote:

“We are able to space out the children and able to provide the right foods to the children so that they can be healthy because our incomes are low.” (FGD, Female).

Many participants reported that their motivation for use of contraceptives was to space their pregnancies to allow the healthy growth of children so they could get enough attention, nutrition, and care from their parents. A few married women noted, where couples were experiencing marital conflict, women used contraceptives to avoid getting additional children that they would need to support on their own.

Sources and decision-making for previous contraceptive used

The majority of participants interviewed indicated that they got their contraceptive method from public health facilities. Some, especially adolescents, got their contraceptive methods from private facilities, specifically chemists or pharmacists. Most older respondents indicated that they had opted for injectables and implants, while use of pills was mainly mentioned by adolescents.

“I bought my pills from the pharmacy shop in town” (IDI, Adolescent, Female).

The study findings revealed that before using contraception, most women sought the opinions of partners, peers, or family friends. For adolescent mothers, their mothers were mentioned as helpful in decision-making and accessing contraceptives. Most partners were involved in decision-making about uptake of FP before initiation of a method, while some were engaged after the FP method was started. However, some female participants stated that they had used contraception covertly due to non-supportive spouses or relatives, particularly the in-laws who threatened to report them to their partners.

Barriers to sustained use of contraception

The study further explored the reasons why women did not continue using a contraceptive method yet they still had a need for contraception. Reasons for discontinued use of contraceptives were manifold; five main sub-themes emerged: side effects, method efficacy, peer influence, gender-based violence, and health system factors.

Side effects of contraceptives

Across all the study groups, side effects resulting from use of contraception were repeatedly mentioned among the reasons for discontinuation. The leading side effect was irregular bleeding patterns presenting as menorrhagia (heavy menstrual bleeding) or amenorrhea (absence of menstrual bleeding). This was mainly experienced from the use of hormonal methods, and in particular injectables and implants. For example:

“When I used the three-months injection, I was bleeding excessively. Sometimes I would feel dizzy while walking. The bleeding would even continue for a month without stopping. So, I decided to stop using it.” (IDI, Female).

Heavy bleeding was cited to interfere with the participants’ social and economic lifestyle. The majority of the female participants who reported increased bleeding indicated that they were unable to carry out their economic activities since they were weak as a result of the increased menstrual flow. Another recurrent consequence of the increased bleeding was the interference with their sexual life:

“The reason I chose to stop using depo is for one reason. Sometimes my husband may have the desire to get intimate with you but you cannot, because of the bleeding. Whenever I want us to get intimate he declines because it is so much blood that is why he told me to try quitting it.” (IDI, Female).

On the contrary, some respondents reported that the absence of menstrual bleeding was what triggered discontinuation since they did not know whether they were still fertile or were pregnant.

“When I started using implants, my periods did not come for eight months, then it came back only for two days and disappeared again. I decided to stop using a contraceptive since I was always wondering whether I was pregnant.” (FGD, Adolescent).

Other side effects that led to discontinuation, albeit less frequently mentioned across the various study groups, included weight changes, dizziness, and low sexual libido.

“ My friend who was using the one for three years told me she stopped because she didn’t have an appetite for having sex, so it was raising issues between her and her husband.” (FGD, Adolescent).

Some study participants observed that experiences from other women influenced contraceptive use or discontinuation. Several FGD participants indicated that women discontinued the use of contraceptive methods after learning about side effects experienced by their friends. This prompted even those who were not experiencing the same to discontinue out of fear.

Contraceptive method efficacy

Contraceptive efficacy was a concern mentioned mostly by married couples. Respondents reported method failure whereby women got pregnant unexpectedly while still on a contraceptive method:

“One year after using an implant, I started becoming sick. When I went back to the hospital, I was tested and the results came out that I was four months pregnant, and at the same time I still had the implant in my arm.” (FGD, Female).

“I have a friend; she was using the one for 3 months. After sometime, she was shocked that she was pregnant. So, she decided that she will not use it because even if you use it you still get pregnant.” (FGD, Adolescent).

Several participants revealed that they decided to discontinue use of contraceptives after learning about cases of method failure among women who were using similar methods. On several instances, inconsistent use of contraceptive, especially short-term methods, that resulted in pregnancies were reported as method failure by some participants:

“The one for three months confused her a lot, it came to end without her knowing and she forgot to go back to the clinic for another injection. She became pregnant and then it surprised her. We had tried using it for a long time and I told her that she was using a method of a shorter duration and when it ended she became pregnant without planning.” (IDI, Male).

Covert use of contraception resulting in gender-based violence

Covert use of contraception was common due to lack of spousal support for use of a modern method. Across all the study groups, the participants shared their experiences or cases of other women who discontinued contraceptive use because their partners learned that they were using it covertly. Cases of gender-based violence directed at women by their partner after learning their use of modern contraceptive methods, further solidified their resolve to discontinue as illustrated by this experience:

“Another woman in our village went and got an implant without her husband’s knowledge. When the husband learned of this, he took a knife and removed it from her arm. This made my friends and me afraid, so we decided to just remove it for fear of what our husbands would do if they find out.” (FGD, Female).

Health system factors as a barrier to continuation

Health care system factors were repeatedly mentioned as reasons for discontinuation. Stock-outs of preferred methods during contraceptive initiation or resupply prompted women to either take alternative methods or leave without one. Provider bias that resulted in women taking up methods that they did not approve of came up as a sub-theme particularly by younger women, as shown in the quote below:

“I told him [the provider] I wanted depo and he said that the government does not advise the use of injection, and he refused to put it on me. He convinced me to take up an implant, which I did, but I went to another facility to have it removed.” (FGD, Female).

There were mixed experiences regarding FP counseling, particularly on side effects. Several respondents noted that they got adequate counseling by the health care providers during the initiation of a method; however, some mentioned that they were not informed of any potential side effects that could result from use of contraception.

“When I started using them, the doctor explained to me about the advantages and disadvantages of the various methods of family planning, such that, I know the goodness and effects of the method I am using.” (FGD, Female).

Future intentionality to use contraception

The study explored whether the respondents would consider using modern contraceptives again. Several respondents indicated willingness to use at some time, but some were hesitant. Those who would consider using an FP method again said they would consult widely, select a method with fewer side effects, and one with a longer duration. For those who were doubtful and not considering using FP, five reasons were provided.

First, there were fears about negative side effects. Women indicated that the fear of experiencing another side effect after discontinuation led them to decide not to take up any other modern method despite the counseling that they got from health care workers who were advising them on method switching. One woman shared her experience:

“These medicines bring problems. I stayed with the one injection for a while and every time I would feel sickly, weak, back pains at all times, bleeding from Monday to Monday. I came to the hospital and asked them to remove it. They asked me what the problem was, that they will give me another one, but I did not want one. So that is why I stopped using.” (FGD, Female).

Second, cost was cited as a barrier for continued use. Respondents indicated that the direct and indirect costs associated with uptake of contraceptive services hindered their intention to use. The cost barrier was mainly mentioned for short-term methods that require frequent resupply at facilities, hence, women had to make multiple visits to the facility. Several concerns were also raised regarding the removal of intrauterine contraceptive devices or implants after experiencing side effects. An important issue that participants highlighted was the cost incurred for the removal of a method, which caused women to fear the selection of another method in case they experienced side effects with that method.

“If you go to the facility before the expiry date, you are asked to pay 200 shillings, regardless of the side effects experienced. I wonder why they charge for removal yet they gave it for free. After that one fears to take up another method.” (FGD, Female).

Lastly, FP use caused conflicts in families. Women indicated lack of support from their partners and relatives impeded their intention to use contraception. It was evident that even though the women felt a need to space or limit their family size, that decision was mainly made by their partners. Other women, who had previously used the method covertly and had been discovered by their spouses or relatives, mentioned they could not use the method for fear of gender-based violence. This quote buttresses the point:

“My husband threatened to beat me also if he ever found me using a method. This was after he had observed a disagreement between our neighbors (couple), over the discreet use of contraceptives that ended up with the lady being hit by her husband. I decided to stop using to avoid such an occurrence. ” (IDI, Female).

This qualitative study aimed to explore the dynamics of contraceptive use and discontinuation among women with unmet need for contraceptives in the rural counties of Migori and Kitui, Kenya. A large and diverse group of adolescents, women, and couples who reported contraceptive discontinuation while still in need of a method provided insights on their experiences, perspectives with contraceptive use and reasons for discontinuation. Direct quotes of study participants about their experiences with FP use that culminated in discontinuation have been presented to deepen understanding of participants’ experiences [ 22 ]. From the study findings, it is evident that all the respondents chose to use contraceptives with the conviction that by using a modern method, they would be able to prevent pregnancy or plan when to have children, determine how far apart they want their children to be, and when to stop having children. However, this desire was not fully realized as they discontinued use of the contraceptives while still in need, which added to the pool of women of reproductive age with unmet need for FP.

There were numerous challenges faced by women using contraceptives that prompted them to discontinue their use. As noted in prior studies, side effects play a major role in reported decisions to discontinue [ 4 , 23 , 24 ]. Our study revealed that the most common side effect leading to contraceptive discontinuation were changes in users’ bleeding patterns, findings which are consistent with studies conducted across different parts of the world [ 18 , 25 , 26 ]. Irregularity of bleeding negatively impacts the well-being of women, mainly due to the social consequences, which could explain the low tolerance with contraception when such side effects are encountered. Studies have revealed that women, especially in the sub-Saharan region, believe that menstrual bleeding is a sign of fertility, hence any change that leads to reduced or no bleeding is frowned upon [ 27 , 28 ]. Conversely, increased bleeding impacts women’s socio-economic activities and sexual relationship with their partners [ 28 , 29 ].

Our findings thus provide strong support for addressing side effects experienced by women through management when they occur or being provided options for method switching to ensure the women continue to harness the full benefits of contraception. This can be achieved by conducting client follow-up by service providers to periodically assess the level of satisfaction with the contraceptive method while addressing issues that might prompt clients to discontinue. Proper counseling of clients, and their partners, is crucial to promote continuation with use of modern contraceptive methods as the users are made aware of the contraceptive’s mechanism of action, possible side effects, and what to do when they experience side effects. Helping women understand typical bleeding changes associated with their contraceptive methods could lead to greater acceptance of the changes, increased method uptake, improved satisfaction, and higher continuation rates [ 30 ]. Therefore, capacity building of health care providers on contraceptives should not just focus on the technical skills on insertion and removal (particularly for long-term methods), but also on contraceptives’ mechanisms, how they work, to ensure that providers are well versed on the potential side effects for each method. This is supported by evidence from studies in Madagascar and Ghana that revealed providers were not well informed on the physiological effects of contraception and how to manage side effects [ 4 ]. This resulted in inadequate counseling of women experiencing the side effects; women were counseled to switch to another method instead of being reassured that side effects would settle down over time or being offered medication to control some side effects [ 4 ]. This could be attributed to inadequate training content on side effects. A recent review of FP counseling, training, and reference materials revealed that bleeding changes are insufficiently addressed in capacity building resources and counseling tools for health care providers [ 29 ]. This is alarming, considering that the leading reason for discontinuation has been changes in bleeding pattern. Skilled counseling for side effects, particularly bleeding irregularities, can only be achieved if training materials for health care providers incorporate this information, information that will improve the quality of counseling by health care providers.

Contraceptive method failure was one of the reasons for discontinuation in this study. Method failure is a factor of either failure of a method to work as expected or incorrect/inconsistent use of a method by the user. In low- and middle-income countries, 74 million unintended pregnancies occur annually, of which a sizable share, 30%, are due to contraceptive failure among women using some type of contraceptive method [ 31 ]. Each contraceptive method has a Pearl Index number that reflects pregnancy rates during perfect and typical use, with use of long-term method conferring higher efficacy than short-term methods [ 32 ]. Whereas all contraceptive methods have some degree of failure, even during perfect use, failure rates can be reduced when individuals are sensitized on the proper use of contraception to ensure the method is used correctly and consistently. Provision of clear information about the risks and benefits of all available methods is crucial in facilitating informed contraceptive choice so women can make an educated choice for their preferred methods, which may reduce discontinuation.

Other reasons for contraceptive discontinuation, such as lack of support from partners and other social networks, are also corroborated in researches previously conducted in Kenya [ 28 , 33 ]. In our study, the decision to use or not use contraceptives was still primarily made by men. Although women made solo decisions on FP, they were heavily influenced by their spouses’ preference and would stop using if they thought it would bring marital conflicts. Opposition to contraceptive use by husbands appears to stem from the fear of side effects and the perception that women who use FP are more likely to be promiscuous. Additionally, Kenya being a highly patriarchal society, decision-making around the desired number of children mainly lies with the male partner. FP programs have mainly targeted women with information to promote uptake since they are the ones who face the risk of pregnancy and childbirth. Unfortunately, these programs have left out men, who are in most instances, the decision-makers in male-dominated societies, like most countries in the sub-Saharan region [ 34 ]. The findings from this study reveal the power dynamics when it comes to a couple’s decision to use contraception. This underscores the need to meaningfully involve men in FP programs by informing them of the health, economic, and social benefits realized from proper and consistent use of contraception so they can optimize use of FP services. Demand generation strategies that employ the use of positive deviants, satisfied users, and other key influencers, such as mothers-in-law, may lead to an increase in contraceptive uptake and enhance continuation.

This study indicates that the costs associated with consistent use of FP methods hinder their continued use. Promoting uptake of LARC methods will address the cost associated with the use of short-term method—LARCs have been shown to be more cost-effective and do not require frequent visits to facilities [ 35 ].

Our study also revealed punitive measures women faced, especially those on LARCs, when they wanted to switch to another method before its expiration. Allowing for method switching is indicative of strong FP programs that have an adequate range of methods and a flexible environment to meet women’s needs. Due to the health and social concerns that contraceptive use may confer on individuals, women may try different methods before settling for their preferred option. The health system should have a supportive policy environment that accommodates such needs of women by: instituting guidelines that prohibit penalization for method switching; addressing commodity stock-outs and ensuring sufficient method mix through increased financing of FP programs; and sensitizing providers on the importance of method switching by women who are not satisfied with their methods. Additional studies are needed to document the implications of frequent method switching on commodity security in countries that continue to face widespread stock-outs of contraceptive methods.

The study’s main strength was documenting the experiences of contraceptive use and discontinuation among discontinuers themselves. However, qualitative studies have limitations related to validity, subjectivity, and reliability. To address these issues, efforts were made to increase the rigor and trustworthiness of the findings through the selection of participants with a range of backgrounds and experiences with the guidance and supervision of experts, as well as external review. Information was not collected on the number of eligible participants who refused to participate in the study. Despite this, our study benefits from including a large number of participants, diverse in terms of age, gender, ethnicity, and location, and utilizing different data collection methodologies (FGDs and IDIs) to enrich the findings.

Conclusions

Our study, conducted in two rural counties in Kenya, revealed a number of important findings regarding factors influencing contraceptive use and discontinuation. The participants in this study had a common motivation for using contraception, to avoid pregnancies, however, side effects were a major hindrance in continued use of contraception. Covert use of contraception resulted in discontinuation when it was discovered and, in some instances, led to gender-based violence. Decision-making on contraception, method to use, and the number of children to have, was jointly done by couples or made by the husband. Reasons for discontinuation, specifically on side effects, were influenced by the husbands.

As contraceptive use in a population increases, success in avoiding unintended pregnancies depends less on initial contraceptive uptake and more on effective and persistent use. Enhanced efforts are needed to design and implement programs that focus on contraceptive discontinuation among women with unmet need for FP. Health care providers offering FP services should be well versed with the mechanism of action for the various contraceptive methods, and incorporate quality of care in the provision of contraceptive services. Additionally, contraception technological advancement is urgently needed to expand the method mix and to develop methods that have fewer side effects and side effects that can be more easily tolerated. This will go a long way in promoting continuation of contraceptive use, as indicated by a majority of our study participants who were willing to consider future use of contraception methods with fewer side effects. Findings from this study, as well as other studies, confirm the importance of engaging men and other social influencers in FP programs by educating them on the socio-economic and health benefits of family planning and dispelling any myths and misconceptions to create a social environment that supports use of modern contraception.

Availability of data and materials

The data used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Consolidated criteria for reporting qualitative studies

Community health volunteers

Focus group discussions

Family planning

In-depth interviews

Long-acting and reversible contraceptive

Total fertility rate

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Acknowledgements

The authors would like to acknowledge the generous contribution of time and expertise by those who participated in this study. We are grateful to Dr. Solomon Orero and Elizabeth Thompson from Jhpiego for reviewing the manuscript.

The study is funded by USAID Kenya and East Africa under Afya Halisi project, award number AID-615-A-17-00004. The funding institution did not play a role in the study design, implementation, in the writing of the manuscript, or in the decision to submit the article for publication.

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SO, LM, MK, RB and JS contributed to the design of the study. VN and SO performed data analysis. SO drafted the manuscript. All authors critically revised the manuscript and approved the final version. All authors read and approved the final manuscript.

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Ontiri, S., Mutea, L., Naanyu, V. et al. A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya. Reprod Health 18 , 33 (2021). https://doi.org/10.1186/s12978-021-01094-y

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Factors influencing the use of contraceptives through the lens of teenage women: a qualitative study in Iran

• Afrouz Mardi 1 , 2 ,
• Abbas Ebadi 3 ,
• Shirin Shahbazi 4 ,
• Sara Esmaelzade saeieh 5 &
• Zahra Behboodi Moghadam   ORCID: orcid.org/0000-0003-2889-802X 6  

BMC Public Health volume  18 , Article number:  202 ( 2018 ) Cite this article

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One out of seven teenage girls in developing countries marries before the age of 15. While the fertility rate of teenage girls is high, the rate of contraceptive use remains low; therefore, this group of teenagers needs reproductive healthcare. This study was undertaken to explore factors influencing the use of contraceptives from the perspective of teenage women living in the city of Ardabil in Iran.

This qualitative study was conducted with 14 married women aged 13–19 years who attended in urban-rural healthcare centers in Ardabil. Eligible women were recruited using purposive sampling and were invited to take part in individual in-depth semi-structured interviews. The duration of the interviews varied from 45 to 90 min with an average of 55 min. Sampling continued until data saturation was reached and no new data was collected. Each interview was tape-recorded after obtaining the participant’s permission, transcribed verbatim and analyzed for identifying categories and themes using conventional content analysis.

Three themes and eight subthemes were developed. The themes were as follows: “insufficient familiarity with contraceptive methods”, “pressure to become pregnant” and “misconceptions”.

Despite the high prevalence of early marriage in Iranian society, teenage women are not empowered or prepared for marriage and birth control. Sexual and reproductive healthcare services to teenage women should be improved to meet their needs.

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There are 580 million teenage girls worldwide and 88% live in low and middle income countries [ 1 ]. One out of seven girls in developing countries marries before the age of 15 [ 2 ]; hence, more than 39,000 girls become child brides every day worldwide [ 3 ].

Marriage patterns differ in Iran and regional countries and there continues to be pressure put on girls to marry [ 4 ]. In Iran, the legal minimum marriage age for girls is 13 years. More than 7.7% of girls living in Tehran marry before the age of 18. The rate of teenage marriage in rural areas is 19.6% [ 5 ]. According to the latest census, the highest rate of marriage was for the 20–24 year-old category for men and 15–19 year-old category for women [ 6 ]. Studies in Iran have shown that family structure, lack of autonomy in decision-making by teenage girls, the sexual, social and emotional needs of girls, low awareness of villagers and cultural poverty are the factors most strongly influencing early marriage. Villagers commonly believe that a girl should marry by the age of 15 or lose the opportunity of successful marriage. They believe that single girls have sexual or physical problems [ 7 , 8 ]. In other words, early marriage and parenthood is encouraged and childbearing is very desirable, as the failure to bear a child would likely lead to remarriage of the husband with or without divorcing the first wife [ 9 ]. Children are considered to be treasures of the home and help maintain and strengthen the integrity of the family [ 10 ].

It has been reported that about 2.5 million girls under the age of 16 give birth in low-income countries annually [ 11 ]. In accordance with the Iranian Strategic Government Plan to increase the population in Iran that went into effect on 20 May 2014, the rate of population growth should increase in the next decade [ 12 ]. In addition, the fertility rate of young adults should increase considerably by 2025 [ 13 ].

While the average rate of marriage for girls under the age of 15 years in most areas of Iran is 5%, this rate is higher in provinces such as Ardabil, at about 9% [ 14 ]. Ardabil province is located in northwestern Iran in the region of Azerbaijan. The majority of its residents are Azeri and speak a Azeri-Turkish dialect [ 15 ]. The early age of marriage (under 15 years of age) is one of the greatest challenges to women’s health in this province [ 14 ].

The consequences of the early marriage of girls, families, children and the community in terms of health, social and financial concerns have been previously studied [ 16 ]. As soon as a teenage girl is married, she must tolerate a great amount of pressure to prove her fertility and strengthen her position in the family through childbirth. Many teenagers are inclined to become pregnant immediately after marriage. Consequently, the responsibilities of pregnancy, motherhood and being a wife are imposed on teenage girls from a young age [ 16 ].

At times, contraceptive failure leads to pregnancy. While the fertility rate of teenage girls is high, the rate of contraceptive use has remained low, which makes these young women extremely vulnerable in terms of reproductive healthcare [ 17 , 18 ]. Teenage mothers and their children are at high risk for infantile and childhood mortality and morbidity, abortion, stillbirth, low birth weight, congenital anomalies, pre-eclampsia, anemia, hemorrhage, fistulas and dystocia [ 16 , 19 ]. The consequences of childbirth in girls under the age of 14 years are destructive and include puerperal endometritis, the possibility of episiotomy, postpartum hemorrhaging, operative vaginal delivery and anemia. In addition, the rate of maternal death in young girls is four times higher than for women aged 20 to 24 years [ 20 ]. The results of a survey of teenagers in southeastern Iran showed that preterm delivery, intra uterine growth retardation (IUGR) and placenta previa were higher in teenagers than in older mothers, despite improved prenatal care [ 21 ].

It has been reported that the use of contraceptives can reduce the maternal mortality rate by 44% [ 22 ]. The use of contraceptives helps reduce unplanned pregnancies and subsequent unsafe and illegal abortions [ 23 ]. The use of contraceptives or the prevention of teen-pregnancy is a major step toward achieving sustainable development goals, including healthy lives and the promotion of well-being for people of all ages, gender equality and empowerment of women, high quality education to all and the eradication of poverty [ 24 , 25 , 26 , 27 ].

Many women rely on myths and misconceptions about the side effects and negative consequences of contraceptive methods and this lack of knowledge is associated with the poor use of contraceptives [ 28 , 29 ]. Furthermore, the patterns of contraceptive use differs significantly between adolescent girls and adult women. Adolescents are less likely to use contraceptive methods than adult women. This difference is most likely due to insufficient knowledge and/or experience with regard to contraceptives and a lack of autonomy in decision-making by teenage women [ 18 ]. Moreover, the low educational levels and socio-cultural issues hinder their access to family planning methods immediately after marriage and limits the use of contraceptives in this age group [ 30 ].

Despite remarkable progress in maternal and child health in Iran, contraception and pregnancy in teenagers remain major problems in Iranian society [ 9 ]. Most studies conducted on teenagers in Iran have recruited unmarried girls who either are or are not sexually active. The needs, behaviors, practices, sexual health and use of contraceptives are quite different among teenagers who have married and live with their spouses and children. The results of studies carried out in other countries also cannot be generalized to the Iranian cultural context because of cultural differences. Some qualitative studies, however, have been conducted to improve understanding of the causes for the high rate of teenage pregnancies, such as the experiences of teenage women with the use of contraceptives.

The first author of this article was a resident of Ardabil province with over 20 years of educational and practical clinical experience in maternal and child health care. Because early marriage and pregnancy is prevalent in Ardabil [ 14 ], this study, which is part of a PhD dissertation, was conducted to explore factors influencing the use of contraceptives from the perspective of teenage women in Iran and in particular in Ardabil.

This was a qualitative study using a conventional content analysis conducted by the first author. Content analysis is a qualitative descriptive method for the interpretation and classification of textual data through consideration of cultural and contextual aspects influencing the study phenomenon. The final products of data analysis are categories and themes [ 31 ].

Participants

For the purpose of this study, 14 teenage married women were purposively sampled with maximum variation at urban-rural healthcare centers in Ardabil, Iran. For this purpose, the first author approached eligible participants. Each woman who met the inclusion criteria was provided with information about the study and encouraged to participate. The inclusion criteria were being a married woman of 13 to 19 years of age. In order to gain a variety of viewpoints, the women interviewed were of diverse demographic backgrounds in terms of age (early, mid and late adolescence), age at marriage, duration of marriage, urban or rural residence, educational level, parity and contraceptive method.

Although purposive criteria was applied, this was a convenience sample of whichever woman was asked and who agreed to participate in the study. In this group, the mean (±SD) age at marriage was 13.2 (±1.25) years and of the duration of marriage was 10 (±1.79) months. All were housewives and a majority of them were at junior high school.

Data collection

Data collection was conducted between May 2016 and Oct 2016. The interviewer was a PhD candidate in the field of sexual and reproductive healthcare and a faculty member in a medical sciences university in Iran. The interviewer had practical experience in qualitative research. The eligible women, who attended health centers to obtain health care services, were informed of the aim of the study and were invited to take part in in-depth semi-structured interviews. The interviews were conducted individually and face-to-face in a private room in the healthcare centers. The duration of the interview sessions varied from 45 to 90 min with an average of 55 min.

Sampling continued until data saturation was reached and no new data was obtained. The interviews were carried out in the Azeri-Turkish language and were then translated into Farsi and English for the purpose of publication of the findings. Each interview was tape-recorded with the participant’s permission, transcribed verbatim and then analyzed. The questions used in the interviews were as follows:

Please tell me about your experience with marriage.

Please tell me about your experience regarding fertility.

Can you describe your experiences with contraceptive use?

Can you tell me whether or not you intend to use contraception?

Data analysis

The data was analyzed based on the method suggested by Graneheim and Landman [ 32 ]. After each interview, they were transcribed verbatim and were read several times to get a sense of the whole. The transcriptions were then divided into meaning units, which were condensed and labeled with codes. The codes were sorted and divided into subcategories and categories given their similarities and differences and the hidden contents were developed as themes.

MAXQDA10 software was used for data management. The first author performed the data analysis and the other co-authors supervised this process. Discussions were held by the research team members to resolve disagreements.

Trustworthiness

Lincoln and Guba explained that credibility, reliability and data transmission abilities improved the accuracy of qualitative research [ 33 ]. In this study, purposeful sampling with maximum variation, immersion in the data, member checking and an audit trail helped validate the coding process and data analysis. Peer checking, long-term engagement with participants and maintaining ongoing relationships using notes and journals improved the depth of data analysis. Note that the translation of the interviews from Turkish to Farsi and English were performed by two translators separately and were ultimately checked by a third person.

Ethical considerations

This study was part of the first author’s doctoral dissertation and was conducted with the approval of the Ethics Committee affiliated with Tehran University of Medical Sciences (decree number = IR.TUMS.REC.1395.2576). The participants were informed of the aim and method of the study and gave the permission to tape-record their voices. Before the interviews, all participants signed written informed consent forms. The participants were assured that the study results would be completely confidential and anonymous. They were informed of the voluntary nature of participation in this study. They were also given the right to refuse to participate in the interviews at any time without being penalized.

The mean age of the teenage women was 14.9 (±1.62) years. Of the participants, four were pregnant, three had no children, six had one child having a mean age of 7.25 (±3.48) months, and one had undergone an abortion for medical reasons. It was determined that five people of the non-pregnant women were not using any contraceptive method. In this respect, three women used the rhythm method, one women used oral contraceptive pills and one woman used condoms, (Table  1 ). Data analysis led to the development of three themes and eight subthemes. The themes were: “insufficient familiarity with contraceptive methods”, “pressure to become pregnant” and “misconceptions” (Table  2 ).

Insufficient familiarity with contraceptive methods

The teenage women’s awareness of contraceptive methods was very low because of the poor quality of educational services and consultation in the healthcare system. They also did not receive the required information from their parents.

Low quality of education and counseling in healthcare system

Education about contraceptive methods was presented to couples on the day they registered to marry; however, lack of time, lack of concentration in the classes and lack mental readiness meant that the information presented was not useful. One young women referred to the healthcare system stated that no comprehensive education on the use of contraception was available because of the overcrowded conditions of the healthcare center.

A 13-year-old woman who had married 40 days earlier said about premarital counseling classes: “They said something that I cannot remember because I was preoccupied during those days. I was stressed out and did not know what I was doing. I was not relaxed. When I talked about it with my fiancée, I was worried. I could not comprehend anything at all.” (Participant 10).

A 15-year-old woman who was in her 28th week of pregnancy said: “In the healthcare center, I was told ‘try not to get pregnant for now’ , but they did not tell me how to do so.”

Lack of education by family

Talking about sexual issues and contraceptive methods in the family were primarily considered to be taboo. If the couple needed information, embarrassment, fear of being subjected to negative attitudes and lack of knowledge of the mothers of the women prevented proper communication between the young women and family members. A 15-year-old woman who recently had a miscarriage declared: “Before marriage, I was not taught anything about it [contraception]. At the beginning of my marriage, I asked my older sister some questions about it, but she said: ‘you are too young’. She was embarrassed to discuss such things.” (P 8).

Pressure to become pregnant

Most of the teenage women intended to become pregnant soon after marriage. Even if they personally wanted to delay motherhood in order to study or work or for other reasons, socio-cultural pressures did not allow them to do so.

Proving identity

Many of the teenage women try to prove their identity as adult women by becoming pregnant at an early age. Pregnancy signified health and fertility. In fact, Iranian society infuses a sense of confidence and self-esteem in pregnant women.

One participant said: “I was happy and thought that I had become an adult and was like my mother. I could conceive a child and grow it.” (P 13).

Another participant stated: “In my village, once a girl is married, she should have a child. If not, others will think that she is not healthy.” (P 10).

Consolidating one’s position in the husband’s family

Pregnancy for a young woman guaranteed security and comfort in the family.

A woman who does not succeed in giving birth to a child can be abused and neglected and even the continuation of her marital life can be compromised. For the women, pregnancy achieves a with a sense of power and peace of mind connected to their husband’s satisfaction and marital stability.

One participant said: “When the pregnancy test was positive, my husband promised me not to mistreat me again during our life and to meet my all needs. He had mistreated me before that.” (P 1).

A 14-year-old woman who married despite her family’s opposition said: “I was scared. If I did not get pregnant, my husband’s family would force my husband to marry another girl, even if he did not divorce me. Also, I thought that perhaps my husband’s family members would love me for the sake of the child.” (P 13).

Relieving loneliness

The findings of this study showed that the majority of the young women decided to immediately become pregnant because they had been forced to drop out of school, limit their social movement and stay at home. Having a child was a way to escape loneliness and providing a companion at home. Having a child , looking after it and providing for it gave new meaning and significance to life and brought hope and prosperity to marital life.

One of the participants stated: “I was alone so much. I had no relatives to talk to and was not allowed to leave the house. It is traditional here for a bride not to leave the house without her husband. I wanted a child to have someone to talk to.” (P 9).

Another participant who had experienced an unwanted pregnancy said: “I did not want to get pregnant so early. I had told this to my husband. When I found out I was pregnant, I wanted to have an abortion, but my husband said, ‘You are alone at home. Let’s have the child and I will help you with it.’” (P 3).

Lack of decision-making power

Almost all of the women lacked the power to make decisions because they were young and had no status in the family. They were unable to decide about the use of contraceptive methods. All decisions about childbearing, including the time, interval and number of children, were made by their husbands and family members. Some may suffer repeated pregnancies to finally give birth to a baby boy, because of the husband’s desire to have a son.

A 14-year-old participant who was in her 28th week of pregnancy and had been told that her child was a girl according to para-clinic tests said: “I don’t know. My husband should want it. I have no choice and if he wants a child, he wants it to be a boy. If he does not want to prevent pregnancy, I can do nothing.” (P 13).

Another participant answered the question of ‘Would you like to have a child?’ as follows: “I do not know. I should find out what the others [the husband and his family members] want.” (P 11).

Misconceptions

This theme was consisted of two subthemes: “fear of infertility” and “fear of possible side effects”. Many of the women had no inclination to use contraceptive methods due to misconceptions and inappropriate information provided by friends and relatives. Fear and concern were major barriers to the use of contraceptives. The most important concern mentioned by the participants was the fear of infertility caused by a particular method. In many cases, this was the main reason preventing them from using contraception.

Fear of infertility

Some participants believed that contraceptive methods led to infertility. A 16-year-old woman who became pregnant after 1 year of marriage said: “My mother told the relatives to ‘advise her to do not use contraceptives so she will not become pregnant in the future’”. (P 5).

Fear of possible side effects

One reason not to use contraceptives was fear of possible side effects. One participant, in response to the question “What do you know about contraceptive methods?” said: “I know nothing. I only know that they are harmful. For instance, I have heard that oral contraceptives may lead to the development of cysts.” (P 4).

This is the first qualitative study specifically aimed at exploring the factors influencing the use of contraceptives among teenage women in an Iranian setting . The study results reveal that, although most participants intended to postpone their pregnancy and motherhood, they had little inclination to use contraceptives. Factors such as insufficient familiarity with contraceptive methods, pressure to become pregnant and misconceptions affected their decisions not to use contraceptives.

The results show that the teenage women did not receive appropriate information about contraception from their family or the healthcare system. Other studies have reported that most teens have little awareness about their sexual and reproductive health and what knowledge they do have is incomplete and unreliable [ 34 ]. The reason for this could be that families and educational institutions do not empower and prepare girls for marriage and the acceptance of marital responsibilities such as family planning [ 35 ].

In the current study, most participants were dissatisfied with the time and quality of family planning education at pre-marital or healthcare centers and considered their training unhelpful. In addition, they had no appropriate access to relevant information from parents. It appears that this issue is more common among the Azeri people than in other regions of Iran and is cultural and religious in origin. A number of Iranian studies have confirmed these results and have shown that parents do not talk about sexual matters with their children. There is no appropriate interaction between mothers and daughters out of embarrassment, fear of being subjected to negative attitudes and lack of knowledge on the part of the mothers. Adolescents are also embarrassed to talk about sexual issues and taboos, beliefs and traditions also hinder young adolescent access to this required information [ 34 , 35 , 36 ].

Pressure to become pregnant was another finding of this study. The participants viewed pregnancy as a way to prove their identities and consolidate their position in the husband’s family. Nearly all of them had low autonomy in decision-making with regard to childbearing and the majority of teenage mothers decided on early pregnancy in order to escape from loneliness.

According to the literature, about 20% of young wives in developing countries (except China) attempt to have a child under the age of 18 [ 37 ] because becoming a mother is an important aspect of life and motherhood is considered to be the identity of a woman [ 38 ]. In the current study, it was found that teenage women thought that pregnancy would prove their identity and fertility. If a woman’s baby was a boy, she would become more popular in her husband’s family. This is in compliance with findings of a study in Mozambique which showed that having a child makes parents proud and helped them preserve their identities as males and females [ 38 ]. Another study in Iran showed that pregnancy makes young women feel that they have appropriately developed and are able to bear a child [ 13 ]. The social value of a teenage women increases when she bears a child, especially a boy [ 17 ]. In Iran, some families insist on having a male heir in the family; therefore, women in such families are forced to submit to repeated pregnancy in order to finally give birth to a male child [ 39 ].

The study results indicate that another reason for the pressure for immediate pregnancy was a woman’s limited decision-making power. The participants were not mature enough and had insufficient autonomy when it came to decision-making in married life. The study participants were too young to have learned essential life skills and were not empowered to make proper decisions about their reproductive health. Most were not able to anticipate the consequences of early pregnancy and motherhood and had insufficient autonomy in decision-making at home. They thus allowed others to decide for them on the use of contraception.

These findings are supported by those of other studies that report the decision to start or stop taking contraceptives is not primarily in the woman’s hands, but is influenced by others from their social network [ 28 , 40 ]. While most modern and traditional contraceptive devices are designed for women, it is traditionally the men who decide what contraceptives to use [ 38 ]. Sharma stated that social pressures about the “ideal woman” and proving fertility along with poor communication skills reduce a woman’s decision-making power about sexual and reproductive health [ 41 ].

The desire to escape loneliness and have a companion was another reason for not using contraceptives in this study. Teen mothers believed a child could distract and amuse them. It appears that this is a recent development among Iranian teenage. They experience isolation and loneliness at home after they are deprived of educational and social activities.

Beliefs about contraceptive methods tended to be in two forms: fear of possible side effects from contraceptives and fear of infertility. Fear was a major obstacle to the use of contraceptive methods and stemmed from inappropriate information gained from friends and relatives. The biggest concern for most participants was fear of infertility and this hindered the use of effective contraception. Many of these women had no inclination to use contraceptives because they feared the possible side effects, while they knew nothing about the risks of pregnancy for women under the age of 18 years. These results were in line with the results of similar studies [ 18 , 28 , 42 ].

Studies have reported that exaggerated beliefs about the side effects of contraceptive methods are rooted in myth and misconceptions [ 28 , 42 , 43 ]. Myths and rumors narrated by peers and partners affect the use of contraception [ 28 , 44 ]. In addition, those who want to delay pregnancy preferred traditional methods to modern methods from fear of infertility [ 23 ]. In Malawi, it was found that 40% of 19–12 year-old girls believed that if they had sexual relationships in a standing position, the probability of pregnancy would be low. More attention must be devoted to the education and health of teenage married women to reduce the consequences of early and high-risk pregnancies in this vulnerable group.

Limitations

Translation of the interviews from Turkish to Farsi and English were a limitation of the study. These were performed separately by two proficient translators and were ultimately checked by a third person. Furthermore, this study was conducted on a limited number of teenage women in one city in Iran; therefore, the results could not necessarily be generalized to all Iranian teenage women.

Suggestions for future studies

This population is very vulnerable and much more qualitative research is required to extend the insights and findings of this study to different parts of Iran and other developing countries. In addition, this study focused on women; therefore, it is recommended that future studies also consider the men experiences regarding contraceptive methods, because they have a significant effect on the demand and use of contraceptives.

The findings of the current study show that the majority of teenage women were reluctant to use contraceptive methods because they are insufficiently familiar with contraceptive methods, are under pressure to get pregnant and because they harbor misconceptions about contraceptives.

The poor quality of education offered by health practitioners and parents was an important factor limiting the use of contraceptive methods. Teenage women had little knowledge about contraceptives and little autonomy in decision-making about pregnancy. They felt that child-bearing proved their identities and consolidated their positions in their married life and provided an escape from loneliness. Of course, in these cases, incorrect beliefs had a significant impact.

These findings argue the need to develop culturally-sensitive programs and interventions that address the needs of this vulnerable group. This includes training for effective and friendly interaction between mothers and girls and special education for health practitioners. There is also a need for intersectional collaboration between policymakers, cultural and religious organizations and NGOs to improve the sexual and reproductive health of adolescent women.

Abbreviations

Intra uterine growth retardation

Qualitative data analysis software and Mac OS X

Non-governmental organization

Standard deviation

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Acknowledgments

This study was financially supported by the Tehran University of Medical Sciences. The authors extend their sincere thanks to healthcare centers staff members as well as the study participants for excellent contribution to the data collection.

This study was part of the first author’s doctoral dissertation and was financially supported by the Tehran University of Medical Sciences.

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Afrouz Mardi

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Abbas Ebadi

Shirin Shahbazi

School of Nursing and Midwifery, Alborz University of Medical Science, Alborz, Iran

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ZB participated in designing the study, conducting the data analysis and was a major contributor in writing the manuscript; AM participated in designing and managing the study, in data collection, in conducting the data analysis and in writing the manuscript; AE participated in designing and managing the study, conducting the data analysis and writing the manuscript; SS and SE participated in designing and managing the study and writing the manuscript. All authors read and approved the final manuscript.

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Mardi, A., Ebadi, A., Shahbazi, S. et al. Factors influencing the use of contraceptives through the lens of teenage women: a qualitative study in Iran. BMC Public Health 18 , 202 (2018). https://doi.org/10.1186/s12889-018-5116-3

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Received : 13 December 2016

Accepted : 23 January 2018

Published : 30 January 2018

DOI : https://doi.org/10.1186/s12889-018-5116-3

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