Barriers to Women’s Contraceptive Use in Benin

The Republic of Benin has made it a national priority to promote family planning as part of its efforts to reduce maternal and child mortality rates. In addition to preventing deaths, increased contraceptive use would help women and families achieve their desired number of children and have greater control over timing births. It would also help Benin meet its development goals, including reducing poverty and increasing women’s education and earning levels, children’s schooling and GDP per capita.

In 2013, Benin’s government set a goal of doubling modern contraceptive prevalence to 20% by 2018.¹ The government’s strategies for increasing modern method use have included mass information and sensitization campaigns and better integration of family planning into other reproductive health services. In addition, many civil society groups and international organizations have taken steps to promote family planning.²

Although Benin’s political environment supports increased use of family planning and surveys indicate that women increasingly want fewer children, fewer than one-tenth of reproductive-age women use modern methods.³ Among married women, 33% want to delay or limit their childbearing but are not using any contraception.⁴ Consequently, the proportion of births that are unintended is fairly high: 19% in 2007–2012.³

Understanding the reasons behind low contraceptive use is essential to achieving the government’s objective of 20% modern contraceptive prevalence by 2018. To that end, this report provides an overview of the contraceptive needs of women of reproductive age (15–49) in Benin. It draws on data from the 2011–2012* Benin Demographic and Health Survey (DHS) to understand women’s contraceptive needs, identify barriers to contraceptive use and provide recommendations on how to improve access to contraception. We also use data from the 2006 Benin DHS to examine trends in fertility and contraceptive use.

Women tend to have more children than they want, and method use is low

Benin has made substantial progress in reducing fertility. Between 2006 and 2012, the fertility rate declined from 5.7 to 4.9 children per woman.^3,5 However, the gap between actual and desired fertility has remained constant, at 0.9, indicating that women consistently have about one more child than they desire. Although the fertility rate is higher in rural areas than in urban areas (5.4 vs. 4.3), the gap between actual and desired fertility is similar in both, at 1.0 and 0.7, respectively (Figure 1).

 

Only 14% of reproductive-age women in Benin use any contraceptive method: About 5% use traditional methods and 9% use a modern method.^†3 While the proportion using a modern method represents an increase from 7% in 2006, overall contraceptive use has actually declined from 17%.⁵ Among modern contraceptive users, 38% use the male condom, 20% use injectables and 15% use the pill, while longer acting methods, particularly implants and IUDs, each accounts for less than 10% of use (Table 1). Long-acting reversible contraceptive (LARC) methods—IUDs and implants—are used by a total 14% of contraceptive users. Use of LARC methods is greatest among women residing in urban areas and among women from wealthier households.^‡ LARCs are more effective at preventing pregnancies and have significantly lower failure rates than other contraceptive methods, which are prone to inconsistent or incorrect use.⁶

 

Women’s varying needs for contraceptives are reflected in levels of method use

Levels of contraceptive use and types of methods used differ by marital status. As of 2012, 13% of married women report using any method.^§ The percentage of married women using modern contraceptives has remained fairly consistent in recent years: 6% in 2006 to 7% in 2012.^**4,7 The most popular modern methods used by married contraceptive users are injectables (27%), male condoms (25%) and the pill (18%). The proportion of married contraceptive users using LARC methods was 20% in 2006 and 21% in 2012.

In Benin, women are increasingly marrying at later ages. Among 25–49-year-olds, the median age at first marriage has increased from 18.6 in 2006 to 19.8 in 2012.^3,5 While the median age at first sexual intercourse has also increased, from 17.8 years to 18.4 years, the amount of time spent between first sexual intercourse and marriage has grown, indicating that women may be sexually active for an increased portion of their late teenage years.

Due to societal disapproval of childbearing outside of marriage, sexually active^†† unmarried women (most of whom are young) are typically more motivated than married women to avoid pregnancy. Thus, contraceptive use is much higher among unmarried sexually active women than married women. Indeed, 32% of unmarried sexually active women use some method of contraception, and 23% use a modern method.⁴ The proportion using modern methods was 26% in 2006.^4,7 Among unmarried sexually active women now using modern contraceptives, the vast majority use male condoms (64%), the pill (14%) and injectables (11%). Four percent of women in this group use LARC methods; 2% reported LARC use in 2006.

Women are not always the primary decision-makers about contraceptive use

Although most modern contraceptive methods are designed to be used by women, married women are not always primary or joint decision-makers when choosing whether to use contraceptives with their husband. Among married method users, 19% reported that their husband was the primary decision-maker about contraception in 2012, while 13% reported this in 2006.^4,7 Larger proportions of women report that their husbands are the primary decision-makers regarding contraceptive use in urban areas than in rural areas (22% vs. 16%) and in wealthier households than in poorer households (20% vs. 16%).⁴ Husband’s approval of family planning is a powerful determinant of contraceptive use.⁸

Unmet need is high

More than 47% of married Beninese women report that they do not want to become pregnant in the next two years or at all.³ Sexually active women who do not want to become pregnant but are not using any contraceptive method (modern or traditional) are described as having an unmet need for family planning. Unmet need among married women is high and has increased from 27% in 2006 to 33% in 2012 (Figure 2).^‡‡ Among married women, unmet need does not vary by age, residence or wealth.

 

Unmet need among sexually active unmarried women has increased from 35% in 2006 to 50% in 2012 and is substantially higher in this group than among their married counterparts. Unmet is higher among 15–24-year-olds in this category (54%) than among older women who are unmarried and sexually active (38%). These women’s unmet need for contraception is overwhelmingly related to the need to space births rather than to stop childbearing altogether. Similar to married women, sexually active unmarried women exhibit very little variation in unmet need by residence or wealth.

There are many reasons why unmet need is high, including differences in childbearing desires between women and men. Studies have shown that couples who share the goal of postponing or limiting childbearing are more likely than those with differing goals to use family planning.^9,10 In Benin, 27% of women report that their husband desires more children than they do, while 29% want the same number.⁴ Only 3% of women report that their husband wants fewer children than they do, and 40% report not knowing how many children their husband desires. The proportion of women who report that their husband desires more children is higher in rural areas (31%) than in urban areas (22%).⁴

Reasons for contraceptive nonuse vary by marital status

Beninese women have a range of reasons for not using contraceptives, and access problems account for only a minority of these reasons. Addressing unmet need will involve developing strategies for addressing specific concerns and targeting campaigns according to marital status subgroup.^§§

Married women with unmet need. Among married women with unmet need, the most commonly cited reasons for contraceptive nonuse are fear of side effects/health concerns (22%) and opposition to use (22%; Figure 3).⁴ Among those reporting opposition, one-quarter of women oppose contraception themselves, while 58% report opposition from their husband and 5% report opposition from other people. The remaining 12% of women reporting opposition give religious prohibition as a reason for nonuse. Much opposition likely stems from Catholic opposition to modern contraceptive use, as Catholics make up one-third of the population.⁴ Infrequent or no sex is reported as a reason by 16%, and postpartum amenorrhea and breast-feeding by 17%. While only 10% and 7% of married women with unmet need report having problems with cost and access, respectively, Benin nonetheless has one of the highest proportions globally of married women who cite these reasons for contraceptive nonuse.¹¹

 

Among married women with unmet need, the most common reasons for nonuse in urban areas are fear of side effects/health concerns (28%) and opposition (25%), while for those in rural areas, infrequent or no sex (20%), not knowing a method (11%) and access-related reasons (9%) account for the highest proportions of nonuse.⁴ Poorer women most commonly cite breast-feeding and being postpartum (20%) and opposition to contraception (20%) as reasons for nonuse, while those from wealthier households cite fear of side effects/health concerns (26%) and opposition (23%). Access poses a problem among a greater share of women from poorer households (9%) than of those from wealthier households (5%).

Never-married women with unmet need. Among never-married women with unmet need, not being married is the most prevalent reason for contraceptive nonuse, cited by 42%.⁴ This figure has increased dramatically from 2006, when only 12% of never-married women reported it as a reason for nonuse.⁷ Other reasons for nonuse include infrequent or no sex (21%), fear of side effects/health concerns (17%) and opposition (11%).⁴ Among women in this category, a total of 5% currently report access or cost as reasons for nonuse; 7% reported cost and 14% reported access as reasons in 2006.^4,7

Not being married and having infrequent or no sex are the two most commonly cited reasons for nonuse among never-married women with unmet need in both urban areas (44% and 18%, respectively) and in rural areas (38% and 27%).⁴ Poorer women also most commonly cite these two reasons (37% and 33%, respectively), while those from wealthier households report nonuse due to not being married (43%) and fear of side effects/health concerns (19%). Not surprisingly, access appears to be a problem among higher proportions of rural women than urban women (4% vs. 1%) and among higher proportions of poorer women than wealthier women (10% vs. 1%).

Women discontinue contraceptive use for many reasons

Some women stop practicing contraception despite their desires to delay or prevent a birth. The most common reasons for discontinuing modern use among former contraceptive users who do not want to become pregnant are side effects (22%), wanting a more effective method (11%), inconvenience of use (9%) and husband’s disapproval (8%).⁴ Overall, 3% of women who have stopped using their method cite cost, and 2% cite access, as reasons for doing so, but cost is cited by higher proportions of rural women (6%) and poorer women (7%) than by their urban (1%) and wealthier (2%) counterparts. Likewise, 4% of women from poorer households report lack of access as a reason for discontinuation, compared with 2% of women from wealthier households. Reasons for discontinuing modern contraceptive use related to access do not differ by place of residence.

Sources of family planning information differ by place of residence

The vast majority of women in Benin have ever heard of contraception, including modern methods (85%).³ Knowledge of contraceptive methods, however, is higher among unmarried sexually active women (94%) than married women (85%). Women learn about family planning from a wide variety of sources, and these differ by place of residence. A greater proportion of women in urban areas than in rural areas report recently having heard about family planning from all sources. For instance, the proportions who, in the months leading up to the survey, have heard of family planning from television are 56% for urban women and 21% for rural women; 61% and 49%, respectively, have heard of family planning from radio, and 25% and 7% have heard of it from newspapers and magazines.⁴ Overall, knowledge of family planning from these three sources (especially television) has increased over time. The percentage of women who heard about family planning from television jumped from 23% in 2006 to 37% in 2012, corresponding to an increase from 25% to 35% over the same period in the proportion of women with access to television.^4,7 Women also report recently having heard about family planning from leaflets and brochures (17%), cultural and educational presentations (23%), school (17%) and family planning posters (21%).⁴

Forty percent of women report not having heard of family planning from any mass media sources in the months before the survey.⁴ This proportion is much higher among women in rural areas than among those in urban areas (49% vs. 30%) and among women from poorer households than among those from wealthier households (56% vs. 32%).

Family planning is rarely discussed

Although the majority of women have heard about family planning messages from at least one source, only 14% report having discussed it with someone in the months before the survey; 18% reported having done so in 2006.^4,7 Higher proportions of women in urban areas and from wealthier households have recently discussed family planning, compared with rural and poorer women.⁴ Of those who have discussed family planning in the past few months, two-thirds discussed it with a friend or neighbor. Fewer than one-quarter discussed it with a spouse or partner—a substantial decline from nearly half in 2006.^4,7 The lack of discussions about family planning suggests that talking about family planning in public—and even in private—may not be socially acceptable.

Contraceptive service provision needs to strengthened

Given that fear of side effects is a common barrier to contraceptive use, it is important to assess whether women are informed about side effects and how to deal with them when seeking contraceptive services. Among current users of modern methods other than the condom, 57% were told about side effects when they picked their current method, and 88% of women told about side effects were given instructions on how to deal with them (Figure 4).⁴ Family planning service providers should also inform women about the full available range of contraceptive methods. Among women using modern methods other than the condom, 70% were informed of other methods by a health care provider.

 

For women with unmet need for contraception, each visit to a health facility represents an opportunity for a provider to offer sexual and reproductive health services. However, among sexually active women not using a method who visited a health facility in the last 12 months, only 34% discussed family planning with a health worker.⁴ Furthermore, only 38% of nonusers know a source of family planning. This percentage is particularly low among women in rural areas (31%) and those from poorer households (27%). These statistics reveal a high level of missed opportunities to integrate family planning services into primary health care and to educate women about sources of family planning. In Benin, family planning services are supposed to be offered at all health facilities that have a maternity ward; however, only about half to two-thirds of these health facilities offer these services.¹

Benin’s policies promote family planning

A number of recently implemented policies and plans indicate that Benin’s policy environment is conducive to promoting family planning.¹² As part of the National Plan for Health Development 2009–2018, the government incorporated measures to support reproductive health and family planning services.² Other important reproductive health policies include Policies, Norms, and Standards on Reproductive Health (1998), the National Policy for Reproductive Health 2011–2016 and the National Strategy for the Security of Reproductive Health Products (SNSPSR) 2011–2016. The SNSPSR, in particular, focuses on strategies to strengthen the provision of reproductive health products in Benin, which continues to be of poor quality. According to the Contraceptive Security Index—which measures the supply chain; the finance, health and social environment; and access to and use of family planning—Benin has a relatively low level of contraceptive security, suggesting that more needs to be done to increase the availability of family planning.¹³

Benin’s government has also pledged a regional commitment to increase the use of family planning services. In February 2011, the government of Benin and eight other francophone West African governments and their technical partners established the Ouagadougou Partnership with the aim of increasing the use of family planning services through political commitment, donor aid and an operational action plan.¹⁴ In September 2011, the Ouagadougou Partnership was expanded to include the participation of civil society organizations in its efforts.² Soon after, the Benin Ministry of Health’s Directorate of Maternal and Child Health, which coordinates the country’s family planning activities, created the Roadmap for Family Planning, a central framework for all state, donor and civil society stakeholders that outlines the interventions needed to promote family planning in Benin.

Benin’s government has implemented a number of measures to promote family planning. For example, all public health facilities are required to provide family planning services as part of their minimum package of services.¹⁵ Unfortunately, these services are not always available, particularly in rural and hard-to-reach areas, often due to a shortage of health service providers. Another way the government has shown its support for family planning is by exempting nongovernmental organizations from taxes on the importation of contraceptive products.² It has also pledged to provide adolescents and youth with free access to modern contraceptives in public health facilities by 2015.¹⁶

Improving contraceptive use depends on addressing barriers

Meeting the government’s target to increase use of modern contraceptive methods to 20% by 2018 will depend largely on the effectiveness of policies and programs that are implemented. Although Benin has made some progress in reducing fertility levels, more action is needed to remove the barriers that prevent women from exercising their rights to have the number of children they want, when they want to have them, and to do so using safe, voluntary family planning. The existing evidence on women’s contraceptive needs and the barriers to contraceptive use suggests numerous measures that can be taken to remove these barriers and to promote contraceptive use.

Improve availability and quality of contraceptive services. Beninese women report using a wide range of contraceptives, including short-term, long-term and permanent methods. The decision to use a particular method depends on a woman’s life circumstances and preferences, which may change over time. While a range of contraceptive methods are available in the country, it is not uncommon for poor forecasting of contraceptive needs and delays in shipments to result in stockouts of contraceptive supplies.¹⁷ Further, not all health centers and pharmacies are able to offer all types of methods, and limited offerings are especially common in rural areas. As of 2013, only 40% of health facilities report offering IUDs, and 39% offer implants.¹ Inadequate training in the provision of LARC methods in both public- and private-sector clinics means that these methods are unavailable to many women.¹⁸

Women seeking contraceptives should have the right to choose from a full spectrum of methods in order to find one that best fits their life circumstances and needs. During contraceptive counseling services, women should be fully informed about the different types of contraceptives available and methods’ advantages, disadvantages and failure rates. It is also important to adequately counsel women on potential side effects and how to deal with them if they occur, and to give them the opportunity to switch methods as needed.

The Association Béninoise pour le Marketing Social (ABMS) has developed a successful model for providing high-quality contraceptive services. Its ProFam network of 57 private-sector health clinics provides a wide range of health services, including family planning and a full spectrum of other reproductive health services.¹⁹ In addition, ABMS partners with 107 private clinics offering technical assistance and 51 public health centers to strengthen facilities’ capacity to provide a range of contraceptive methods, including LARCs. The organization trains health providers to insert IUDs and implants, provides contraceptive supplies, and monitors and evaluates the performance of health providers providing contraceptives. Creating more partnerships, such as the successful venture between ABMS and public health centers, is a potential strategy for increasing the availability of contraceptives and improving the quality of contraceptive counseling services.

Access problems continue to be a barrier to contraceptive use for close to one in 10 women residing in rural areas and those from poorer households, many of whom live in rural areas.⁴ Improved access, especially among rural and poorer women, is needed so that all women wishing to avoid unintended pregnancies are able to do so. In particular, ensuring the availability of LARC methods will allow women living in remote areas to make fewer trips to health facilities to restock on contraceptive supplies. One potential strategy for achieving greater coverage of contraceptive services is to use mobile family planning clinics to serve hard-to-reach areas. Through the use of mobile family planning clinics in Djougou health zone, the number of new family planning users has increased, and contraceptive prevalence has risen from 1% in 2009 to 12% in 2013.²⁰ Another strategy is to use community health workers to provide family planning services in hard-to-reach areas. In 2015, a pilot project to train community health workers, also known as aides-soignants, to provide injectables, condoms and pills, was launched in four boroughs of the Adja-Ouèrè commune.²¹ This project has since been successfully implemented in more than a dozen Sub-Saharan African countries and has received many positive evaluations.²²

Increase knowledge of family planning. Although the vast majority of women in Benin have heard of modern contraceptive methods, not all women have accurate and complete information about these methods, and some with unmet need report being unaware of contraception altogether. Thus there exists a need to increase awareness of family planning and ensure that all women have complete information about the types of contraceptive methods available and where to obtain them. Survey results showing that women frequently cite infrequent sex and breast-feeding as reasons for nonuse indicate possible misunderstandings about pregnancy risk and the return of fertility after a birth. Women also need better information about the times when they are at greatest risk of becoming pregnant.

Mass media is an effective strategy for transmitting family planning information to a large proportion of the population.²³ Campaigns targeting reproductive-age women, adolescents, and men with family planning messages are conducted regularly in Benin. However, rural and poor segments of the population may lack regular access to a media source, and alternative strategies are needed to reach these groups. Possible strategies include holding cultural and educational presentations, reaching women in schools and places of worship, and using social network interventions. The Tékponon Jikuagou Project, a five-year project funded by the U.S. Agency for International Development (USAID), has attempted to reduce unmet need for family planning by recruiting a small number of influential community leaders and groups to spread family planning messages via their social networks.²⁴ The project has succeeded in not only increasing communication about family planning within social networks but also increasing contraceptive prevalence.²⁵ Another strategy is to increase awareness of "la Verte Ligne 7344," a toll-free number created by ABMS that individuals using MTN, Moov and BBCOM phone numbers can call to speak to trained counselors about family planning, reproductive health issues and other health concerns.¹⁹ This service is available to individuals in rural and hard-to-reach areas. The success of this project is seen in the high volume of calls it fields: In 2014, la Verte Ligne 7344 responded to over 137,000 queries.

Needs for reproductive health information often vary by subgroup and thus need to be tailored appropriately. For example, unmarried women may be trying to avoid pregnancy while older married women may be trying to limit their fertility, and these two groups need access to different types of information. One strategy to address this is to use peer educators. For example, in 2011–2013, the Association Béninoise pour la Promotion de la Famille, with support from the RESPOND project, trained 100 youth peer educators and provided them with bicycles so that they could distribute condoms and promote family planning to their peers.²⁶ Previous research in 22 countries has shown that individuals are more likely to trust reproductive health information from peers than nonpeers.²⁷

Remove social and cultural barriers to contraception. Social and cultural barriers to contraception remain strong. Opposition to contraceptive use, primarily from women’s spouse or partner, has not decreased since 2006. Men’s approval for family planning is crucial for increasing contraceptive prevalence,⁸ yet as is the case in many African countries, Benin continues to have a pronatalist culture where many men place importance on having large families. Although campaigns have been conducted to encourage men to become involved in family planning, more needs to be done to promote discussion about and use of family planning among men and couples.² A 2007 study of 10 countries, including Benin, showed that women are more likely to use modern contraceptives if they have discussed family planning with their partner.²⁸

Among never-married women with unmet need, not being married is the most frequently cited reason for nonuse of contraceptives and likely points to social disapproval for sexual activity and contraceptive use among young and unmarried women. Family planning services should cater to the needs of all women, regardless of marital status or age. ABMS recently established a network of 15 Amour et Vie Youth Centers that provide youth-friendly sexual and reproductive health services throughout Benin.¹⁹ In 2014, more than 81,000 youth visited these centers, and in the centers’ first two years, contraceptive use has increased from 58% to 62% among unmarried sexually active adolescent women who attend schools or training centers in the centers’ intervention zones.²⁹

Religious leaders have the potential to influence their congregation’s views on family planning, and in Benin, it is not uncommon for religious leaders to harbor negative opinions of family planning.³⁰ Therefore, programs that seek to build approval for family planning among religious leaders can reduce the social and cultural barriers to contraception. For example, in September 2015, Health Policy Project (a USAID program) conducted a training for 26 religious leaders from all denominations on how to address family planning in their communities.¹⁷

Conclusion

Even though Benin has made noticeable progress in reducing fertility levels, greater action is needed to ensure that women who want to delay or limit their childbearing are able to do so. The greatest barriers to contraceptive use are method-related fears about side effects and health concerns that deter women from using contraceptives, as well as opposition to contraception. It is important to overcome these and other barriers so that progress can be made to reduce unmet need for family planning. Most importantly, helping women and couples achieve their desired family size will allow more Beninese the opportunity to live healthier and more productive lives; improve survival and well-being among their children; and contribute to economic and social development.

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