Use of modern contraceptive methods among women of childbearing age attending maternal and child health services in Abidjan and Agboville (Cote d’Ivoire)

Abstract

Introduction

Sub-Saharan Africa has the highest maternal mortality rate, with over 542 maternal deaths per 100,000 live births. This rate is estimated at 315 deaths per 100,000 live births in Côte d’Ivoire (EDS, 2021). Several factors, including low national contraceptive prevalence estimated at 13.9%, contribute to this situation. The aim of this study was to analyze the factors associated with the use of modern contraceptive methods (MCM) among women of childbearing age attending maternal and child health services.

Methodology

We conducted a cross-sectional study of 605 women of childbearing age attending maternal and child health services of five health centers in Abidjan and Agboville from December 2018 to September 2019. MCM use was defined as “being on modern contraception in the survey period”. Modified Poisson regression was applied to identify factors associated with MCM use using STATA version 15 software.

Results

A total of 605 women participated in our study, 45% of them aged 15–24 years. The rate of modern contraceptive use was 36%. Some 56% of clients had received family planning (FP) information at maternal and child health services . Marital status [(aPR): 0.80 (95%CI: 0.66–0.97)] and worship attendance [(aPR): 0.74 (95%CI: 0.62–0.87)] were associated with a decreased rate of MCM use. However, educational level [Primary level: (aPR): 1.86 (95%CI: 1.13–3.05); Secondary level: (aPR): 1.70 (95%CI: 1.04–2.79); Higher level: (aPR): 2.26 (95% CI: 1.38–3.71)] and information received about FP [(aPR): 8.05 (95% CI: 4.97–13.04)] were associated with an increased rate of MCM use.

Conclusion

FP programs should strengthen communication on FP, particularly through counseling sessions, and ensure that every opportunity for contact with health centers is seized to give women the right information on contraceptive methods. Measures should also be taken to increase girls’ school enrolment and keep them in school.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-25974-1.

Introduction

Family planning (FP) is an essential component of primary health care aimed at improving maternal, newborn and child health, by reducing morbidity and mortality in these categories, as well as the transmission of HIV/AIDS [1]. Of almost all maternal deaths worldwide, 99% occurred in developing countries, more than half of them in sub-Saharan Africa [2]. Moreover, this region has the highest maternal mortality ratio, at 542 deaths per 100,000 live births [3].

Several factors, including unmet need for family planning, explain this high rate of maternal death. Indeed, only 21% of African women in union use contraception, 29% of women have an unwanted pregnancy and 24% of women have an unmet need for FP [2]. Despite all the strategies and policies implemented, the prevalence of modern contraceptive use remains low in many low- and middle-income countries [4–6]. This situation is conducive to unwanted pregnancies and recourse to clandestine induced abortions which often cause maternal deaths [7–11]. Despite modernization and the political will to ensure the schooling of young girls, the integration of FP services into maternal and child healthcare, the nationwide dissemination of modern contraceptive methods (MCM) and awareness-raising campaigns, contraceptive prevalence remains low in developing countries [1, 12–14].

This is the case in Côte d’Ivoire, where unmet need for family planning is estimated at 22% among women of childbearing age, with a total fertility rate of 4.3 children per woman [15]. Contraceptive prevalence has changed only slightly among women in union, rising from 4% (1994) to 18% (2022), with significant regional disparities [15]. Accordingly, one of the strategies of Côte d’Ivoire’s national maternal health policy is to increase modern contraceptive prevalence to 40.5% and reduce unmet need to 13.3% by 2025 [16]. However, unmet needs in FP persist although their prevalence has been reduced by 5%, from 27% (2012) to 22% (2022) [15].

Information remains a key activity in all efforts to achieve FP objectives [17]. Implementing interventions to increase FP uptake requires a good understanding of the factors that influence uptake. Numerous studies have highlighted the key role of health workers in communication and information strategies, but above all the positive impact of information on contraceptive use [18–21]. Thanks to the training they have received, health workers have high-quality information on MCM. As a result, health facility is the safest place to receive the right information and advice on MCM. There is a lot of distorted and false information circulating in communities about MCM, and the situation seems to be getting worse with the advent of social networks/media. However, despite the proliferation of health centers and the availability of care, contraceptive use still seems to be low among the general population.

While population-based studies have long been the preferred method for investigating factors influencing FP and the use of MCMs, current studies focus on users of health facilities to estimate their contraceptive use and analyze associated factors [18–27]. The most incriminating factors are socio-demographic and cultural factors, factors linked to the health system and supply, and factors linked to contraceptive methods.

However, studies that have examined the contraceptive practices of women of childbearing age who use health services in West Africa have generally been descriptive [28–31]. To the best of our knowledge, none of them has analyzed the factors associated with the use of MCM by these women in the specific context of Côte d’Ivoire. Given the limited information available on this topic, this study aims to identify the factors associated with the use of modern contraceptives among women of childbearing age attending maternal and child health services in selected health facilities in Abidjan and Agboville. The results of this study could help policymakers and healthcare professionals develop strategies to improve the rate of modern contraceptive use in FP services.

Section 2: Methodology

Methodology

Study framework

A previous study conducted by Essis and collaborators (2019) revealed that the majority of women with unmet need for family planning were located in the south of the country [32]. These findings partly motivated the reasoned choice to conduct the present study in the cities of Abidjan and Agboville, located in the southern region of the country (Fig. 1).

Fig. 1.

Map showing study cities (Abidjan and Agboville)

all figure captions are captured and presented correctly. But, it will be necessary to put the titles under the figures.

Abidjan is the economic capital of Côte d’Ivoire. It lies on the shores of the Gulf of Guinea and is crossed by the Ébrié Lagoon (Fig. 1). It covers an area of 422 km2 and is home to 5,616,633 inhabitants, or 36% of the country’s total population according to Cote d’Ivoire’s General Census of Population and Housing (RGPH, 2022). It comprises ten communes and four sub-prefectures, three regions and thirteen health districts. It comprises 04 University Hospital Center (UHC), 09 General Hospitals and some 623 health centers and private clinics.

The Health District of Agboville was the chief town of the Agneby-Tiassa health region, which included the districts of Sikensi and Tiassalé. The town of Agboville is located in the southwest of the country, 80.2 km from the city of Abidjan (1h34mn by bus) (Fig. 1). It covers an area of 3850 km2 and has a population of around 384,340 (RGPH, 2022). It comprises 38 health facilities, including 19 rural dispensaries, 10 Rural Health Centers, 06 Urban Health Centers, 01 School and University Health Service, 01 Maternal and Child Protection Center and 01 Regional Hospital Center.

Our study took place by reasoned choice at the General Hospital of Yopougon Attié and the Formation Sanitaire Urbaine of Adjamé 220 housing units in Abidjan (Fig. 2) as well as at the Regional Hospital Center, the School and University Health Service and the Maternal and Infant Protection Center of Agboville (Fig. 3). This choice was guided by our financial constraints, on the one hand, and our desire to have centers serving representative populations, on the other.

Fig. 2.

Map of Abidjan showing study areas

Fig. 3.

Map of the town of Agboville showing the study areas

Yopougon, a middle-class suburb, is Abidjan’s most populous commune, with 1,571,065 inhabitants (RGPH, 2022). General hospital family planning service saw 1,510 patients last year, with a contraceptive use rate of 48%.

Adjamé is a trading center for nationals and migrants. It is home to over two million people during the day, with a high concentration of migrants living in “cours communes” (54%) and precarious housing (13%). The family planning service of the Formation Sanitaire Urbaine of Adjamé 220 housing units received 7524 women of childbearing age, with only 6% using contraception. In Agboville, we selected the two large centers offering FP services and one youth center.

More specifically, the study took place in the FP, maternity, prenatal consultation and vaccination units at Abidjan’s General Hospital and Formation Sanitaire Urbaine (Fig. 2), then in the gynecological consultation, FP, prenatal consultation and vaccination units at Agboville’s Regional Hospital (Fig. 3).

Type of study and duration

We conducted a cross-sectional study over a ten-month period, from December 2018 to September 2019.

Study population

The study population consisted of women attending the maternal and child health services of the five selected health facilities in Abidjan and Agboville.

Inclusion criteria

All women of childbearing age, sexually active and at risk of pregnancy, encountered in the said units, who agreed to be interviewed.

Non-inclusion criteria

All women whose state of health, as perceived by themselves, did not allow them to participate in the survey.

Sampling and sample size

The sample size was calculated using the following formula:

• n = Sample size.

• Z = Reduced deviation = 1.96 for a risk of error of 5%.

• P = Prevalence of the phenomenon in the population = 50% due to the scarcity of studies conducted in hospitals.

• q = 1 - P = 0.5.

• = Required result precision = 5%.

• deff: cluster effect of 1.5.

• a 5% non-response rate.

The minimum sample size was 605 women. We recruited women using a systematic random sampling method among users of mother-child health services of childbearing age who visited the selected health facilities during the data collection period. The first client from each health center was selected by random draw from among the women who met our inclusion criteria, and recruitment continued until the desired sample size was reached. We planned to recruit five women per day from the maternal and child health services we visited. The sampling interval was therefore calculated each day based on the number of women who arrived at these services.

Data collection

Before the survey was carried out, the research team held an awareness-raising and information session in the selected health centers to obtain the support of health workers, women and their partners (secondary target) in order to facilitate the survey. Regional and departmental directorates were informed and sensitized to obtain their support.

A data collection form was drawn up, with sections covering socio-demographic and reproductive data, knowledge, attitudes and practices relating to MCM and FP, and obstacles to the use of contraceptive methods. The interviewers, made up of health workers (doctors and nurses, public health specialists), were trained for two days to ensure understanding of the questions and harmonization of the data collection procedure in the field.

Data were collected from pre-tested anonymous individual questionnaires, administered to women by face-to-face interview in health facilities. The questionnaire was administered in French in most cases, and in local languages in some cases. At each collection session, the interviewer explained the purpose of the survey to the respondent, and reassured them that the data collected was confidential. At the end of each interview, the interviewer thanked the respondent for her cooperation. Data collection took place from January to May 2019.

Study variables

Dependent variable

Was current MCM use. Women were asked whether they were on MCM at the time of the study, whether they had used contraception in the past and whether they planned to use it in the future. Women who had used contraception in the past, those who had never used it and those considering using it were merged as “current non-users” to create a binary variable with women using MCM. Modern methods include female sterilization, male sterilization, the pill, the intrauterine device (IUD) or coil, injection, Norplant, vaginal methods (diaphragm, sponge, foam, jelly, cream and effervescent tablets), the male condom and the female condom in this study [33].

Independent variable

• Sociodemographic characteristics (age, level of education, marital status, religion, attendance, receipt of FP information/counseling at the health center).

• Reproductive characteristics (Desire for children, Number of living children, Adolescent FP approval, Unintended pregnancy, Peer pressure, Requiring condoms, Initiating contraception in the relationship).

Data analysis

Data from the survey were entered into Epi data, then analyzed using Stata 15 software. An initial descriptive stage described the population studied, using means for quantitative variables, and frequencies and percentages for categorical variables. Next, a bivariate analysis using the Chi2 test was used to measure the association between the dependent variable (MCM use) and the independent variables. Finally, a multivariate analysis was used to calculate the Adjusted Prevalence Ratio (aPR) to identify factors associated with MCM use. Only variables which were significant in the bivariate analysis were used for multivariate analysis. Collinearity was check using collin package of Stata. Variable with VIF greater than 4 was removed from the final model. Statistical tests were considered significant for a p < 5%.

Section 3: Results

Results

Socio-demographic and reproductive characteristics of the study population

A total of 605 sexually active women were recruited from maternal and child health services of five selected health centers, two in Abidjan and three in Agboville. The majority were aged under 25 (45%), educated (85%), married (51%) and Christian (74%) (Table 1).

Table 1.

Socio-demographic characteristics of participants, Côte d’Ivoire, 2019

Socio-demographic characteristics
	Frequency / Percentage (%)
Age (years)
[15-24]	272	45
[25-34]	241	40
[35-49]	92	15
Level of education
No schooling	89	15
Primary	127	21
Secondary	252	42
Superior	137	22
Marital status
Never married	214	35
Married	311	51
Divorced, widowed, separated	80	17
Religion
Muslim	159	26
Catholic	185	31
Protestant	261	43

While women overall wanted more than three children (59%), the majority had fewer than three living children (53%), and 32% were not yet mothers. Most had wanted pregnancies (88%) and were under no pressure to avoid contraceptive use (86%). They were able to insist on condom use during intercourse (62%) and to initiate contraception within their relationship (62%). They participated in Behavior Change Communication (BCC) sessions on FP (54%) and received information on MCM (56%) (Tables 2 ).

Table 2.

Reproductive characteristics of participants, Côte d’Ivoire, 2019

Reproductive factors	Frequency	Percentage (%)
Desired number of children
1-3	251	41
+ 4	354	59
Number of living children
None	194	32
1-3	322	53
+ 4	89	15
Unwanted pregnancy
No	535	88
Yes	70	12
Peer pressure against MCM
No	523	86
Yes	82	14
Be able to demand condom use
No	231	38
Yes	374	62
Be able to initiate contraception in the relationship
No	228	38
Yes	377	62
Behavior changes communication (BCC) sessions
No	281	46
Yes	324	54
Information received about MCM
No	267	44
Yes	338	56

Utilization of MCMs

Bivariate analysis showed an association between MCM use and education, religion, power to demand condom use during intercourse, power to initiate condom use within the relationship, negative peer pressure against MCM use, receipt of information and participation in FP BCC sessions.

Only 36% of women were on MCM at the time of the study.

Contraceptive use was lower among women with no schooling (16%; p < 0.001), married (30%; p < 0.001) or living alone (30%; p < 0.001), Muslim (24%; p < 0.001), Catholic (36%; p < 0.001), churchgoers (32%; p = 0.003), those unable to require condom use during intercourse (21%; p < 0.001) and initiate contraceptive use in their couple (19%; p < 0.001). Non-education, being married and divorced, widowed, or separated, Muslim and Catholic religions, church attendance, inability to demand a condom during sexual intercourse and initiating contraceptive use within the couple were all factors that hindered the use of MCM.

However, contraceptive use was higher among educated women at primary (38%, p < 0.001), secondary (37%; p < 0.001), Superior (46%; p < 0.001), single women (47%, P < 0.001), Protestant women (44%, P < 0.001), women who were not attending church regularly (45%, P < 0.001), women who were able to require condoms during sexual intercourse (45%, P < 0.001) and initiate condom use within the relationship (47%, p < 0.001) (Table 3). Thus, a higher level of education, not being married, Protestant religion, non-attendance at religious worship, power to require condom use and power to initiate its use within the relationship, favored MCM use.

Table 3.

Bivariate analysis of MCM use and covariates, Côte d’Ivoire, 2019

Using MCM
Socio-demographic characteristics	Frequency / Percentage (%)		Chi-Pearson / P-value
	No	Yes
Educational level
No schooling	75 (84)	14 (16)	<0.001
Primary	79 (62)	48 (38)
Secondary	158 (63)	94 (37)
Superior	74 (54)	63 (46)
Marital status			<0.001
Never married	113 (53)	101 (47)
Married	217 (70)	94 (30)
Divorced, widowed, separated	56 (70)	24 (30)
Religion			<0.001
Muslim	120 (76)	39 (24)
Catholic	119 (64)	66 (36)
Protestant	147 (56)	114 (44)
Worship attendance
No	101 (55)	83 (45)	0.003
Yes	285 (68)	136 (32)
Be able to require condom use			<0.001
No	182 (79)	49 (21)
Yes	204 (55)	170 (45)
Be able to initiate contraception in the relationship			<0.001
No	185 (81)	43 (19)
Yes	201 (53)	176 (47)

There was also a correlation between the use of modern contraceptive methods and reproductive factors. In fact, the use of MCMs was lower among women wanting more than 4 children (30%; p < 0.001), those with 1–3 (34%; p < 0.001) and 4 (33%; p < 0.001) living children, disapproving of contraceptive use in adolescents (16%; p < 0.001), not having had an unwanted pregnancy (35%; p < 0.001), not experiencing peer pressure against contraceptive use (33%; p < 0.001) and not having received information about MCM at the health center (7%; p < 0.001). Consequently, the desire to have and those having a large family, the disapproval of adolescent contraceptive use, the absence of unwanted pregnancy and peer pressure, and the absence of information on MCM limited contraceptive use.

On the other hand, MCM use was higher among women wishing to have 1 to 3 children (44%, p < 0.001), nulliparous women (42%), women approving of adolescent contraception use (48%, p < 0.001), those with unwanted pregnancies (46%, p < 0.001) and those who had received information on FP (59%, p < 0.001). Pressure from family and friends not to use MCM was not associated with decreased MCM use, rather it was associated with a higher share using MCM (49% vs. 33%, p < 0.001). (Table 4).

Table 4.

Bivariate analysis of MCM use and covariates Côte d’Ivoire, 2019 (continued)

Using MCM
Reproductive factors	Frequency / Percentage (%)		Chi-Pearson / P-value
	No	Yes
Childhood desire			<0.001
1-3	140 (56)	111 (44)
+ 4	246 (70)	108 (30)
Number of living children			<0.001
None	112 (58)	82 (42)
1-3	214 (66)	108 (34)
+ 4	60 (67)	29 (33)
FP* Approval at Adolescent			<0.001
No	190 (84)	35 (16)
Yes	196 (52)	184 (48)
Unwanted pregnancy			0.078
No	348 (65)	187 (35)
Yes	38 (54)	32 (46)
Peer pressure against MCM			<0.001
No	331 (67)	167 (33)
Yes	55 (51)	52 (49)
Information received about MCM at the center			<0.001
No	248 (93)	19 (7)
Yes	138 (41)	200 (59)

* Family planning

Consequently, the desire to have few children, nulliparity, unwanted pregnancies and information received on FP at the health center favored the use of MCM.

Factors influencing MCM utilization

The adjusted model showed that the main factors associated with a lower rate of MCM use were: marital status and worship attendance. Indeed, Married women were 20% less likely to use MCMs [(aPR): 0.80 (95% CI: 0.66–0.97)] compared to those who were never married. Women who attended worship regularly were 26% less likely to use MCMs [(aPR): 0.74 (95% CI: 0.62–0.87)] compared to those who did not (Table 5).

Table 5.

Factors associated with MCM use, multivariate analysis

Variables	cPR*	CI* 95%	p	aPR*	CI* 95%	P
Age groups
[15–24 years]	1
[25–34 years]	1.16	0.03–1.71	0.192
[35–49 years]	1.10	0.80–1.51	0.536
Education level
No schooling	1			1
Primary level	2.40	1.41–4.08	0.001	1.86	1.13–3.05	0.014
Secondary school	2.37	1.43–3.94	0.001	1.70	1.04–2.79	0.035
Superior level	2.92	1.75–4.89	< 0.001	2.26	1.38–3.71	0.001
Marital status
Never married	1			1
Married	0.64	0.51–0.79	< 0.001	0.80	0.66–0.97	0.023
Divorced, widowed, separated	0.63	0.44–0.91	0.015	1.02	0.76–1.37	0.875
Religion
Muslim	1			1
Catholic	1.45	1.04–2.03	0.028	0.75	0.54–1,04	0.085
Protestant	1.78	1.31–2.42	< 0.001	0.95	0.76–1.34	0.951
Worship attendance
Non-attendance	1			1
Worship attendance	0.72	0.58–0.88	0.002	0.74	0.62–0.87	< 0.001
Religious rigor
No religiosity	1
Religiosity	0.73	0.52–1.01	0.058
Condom use
Cannot require condom	1			1
Requires condom	2.14	1.63–2.81	< 0.001	1.18	0.86–1.62	0.307
Taking the initiative
Cannot take initiative	1			1
Takes initiative	2.47	1.85–3.31	< 0.001	0.97	0.69–1.38	0.889
Desire for pregnancy
No unwanted pregnancy	1
Unwanted pregnancy	1,31	0.99–1.73	0.061
Role of family and friends
No pressure	1			1
Pressure against MCM use	1.45	1.15–1.82	0.002	0.91	0.73–1.14	0.424
Receipt of information
No information on MCM	1			1
Information on MCM	8.32	5.34–12.94	< 0.001	8.05	4.97–13.04	< 0.001
Participation in BCC sessions
No BCC sessions	1
BCC sessions on FP	7.05	4.75–10.44	< 0.001
Desire for children
1 to 3 children	1
> 4 children	0.67	0.55–0.83	< 0.001	0.87	0.72–1.04	0.118
Number of living children
None	1
1 to 3	0.80	0.64–1	0.058
> 4	0.79	0.56–1.1	0.170

Only variables which were significant in the bivariate analysis were used for multivariate analysis

The variable “Participation in BCC sessions” was excluded from the adjusted model due to multicollinearity with “Receipt of information”

^* cPR: crude Prevalence Ratio

^* aPR: adjusted Prevalence Ratio

^* CI: confidence interval

When looking at factors associated with higher MCM rate, we noted that these factors were: the woman’s education level and receipt of information about FP. Indeed, educated women who attended primary school were 86% more likely to use MCM [Primary level: (aPR): 1.86 (95%CI: 1.13–3.05)] compared to those who were uneducated. Similarly, women with secondary and higher level of education had respective 64% [Secondary level: (aPR): 1.64 (95% CI: 0.95–2.64)] and twice [Higher level: (aPR): 2 (95% CI: 1.21–3.30)] more likely to use MCMs compared to uneducated women.

Women who had received information on FP were 8 times more likely to use MCMs [(aPR): 8.05 (95% CI: 4.97–13.04)] compared to women who had not received any information on FP.

Discussion

This study was conducted to analyze the factors associated with the use of modern contraceptive methods among 605 women aged 15 to 49 attending five health centers in Abidjan and Agboville. Modern contraceptive rate was estimated at 36%. Marital status and religious attendance were associated with decreased MCM use. In contrast, level of education and receipt of FP information at health centers were associated with increased MCM use in our study population.

This rate of 36% was well above the national modern contraceptive rate (18%) found by the 2021 DHS. Our rate measured in the hospital setting was simply in line with the reality that health service users, being better informed, are more receptive to the FP services offered. However, this result was well above that of Sylla (8.8%) found in health facilities in the Youwarou district of Mali [28].

This difference can be explained by the geographical location of the population concerned. In fact, Sylla’s study focused on rural women with low levels of education, who are prone to misinformation, whereas ours took place in urban areas. Studies conducted in government health facilities (37.8%) in the Wondo Genet district, hospitals (33.6%) in the southern zone of Wollo and public health facilities (36.7%) in the town of Bahir Dar, Ethiopia [19, 26, 34] had reported results similar to ours.

However, our results were lower than those of Arero WD et al. [18] in a study conducted at the Jimma University Medical Center in Ethiopia, with a rate of 53.2%, and those of Keita Mamadou et al. at the commune VI referral health center (64%) in the Bamako District of Mali [30]. In fact, Arero in Ethiopia [18] had focused on service users in the immediate post-partum period, who have a higher need for family planning than the general population of women of childbearing age with whom we worked. As a result, they are more inclined to delay the next birth until later, and to use the services offered for this purpose.

Keita Mamadou’s study in Mali [30] took place in a family planning unit, and even though the women in our study attended health services, they might receive less information about MCMs than users of a unit specifically dedicated to family planning.

Marital status and religious practice were associated with a lower rate of MCM use. In fact, married women and those who attended religious services used MCMs less than other women. This finding may point to a lack of autonomy in the use of modern contraception by married women. Indeed, married women need their spouse’s agreement to use MCM effectively and continuously. This could explain the high unmet need for FP in our countries, despite the availability of MCM [32, 35].

Consequently, strategies should be put in place to involve men in FP in order to improve the rate of contraceptive use.

The link between church attendance and low MCM use is consistent with the prohibitions of the Christian and Muslim religions. This result shows that women who are deeply rooted in these two religions and who strictly observe the prohibitions or commandments will have difficulty using MCMs [36–38]. It would therefore be appropriate to implement innovative strategies to overcome this obstacle, or to develop alternative solutions such as traditional contraceptive methods to help these women meet their FP needs.

On the other hand, level of education and receipt of FP information were positively associated with increased MCM use [39, 40]. This is due to the fact that the educated woman acquires knowledge that informs her responsible contraceptive use, as does the woman who has received useful information on MCM. Our findings are in line with those of some previous studies [19, 20, 27], which have noted better contraceptive use among women who have received information on FP. Useful, high-quality information improves beneficiaries’ knowledge and helps break the vicious circle of misinformation about rumors, myths, adverse effects and side-effects of MCM that hinder their effective use. As a result, educated women have a better perception of the benefits, efficacy and safety of contraception, thanks to their easy access to information. As a result, these women are more likely to make informed and sustainable contraceptive use decisions [41].

In short, the combination of instruction and information provides women with quality information on the different types of MCM available, including their action on the body’s functions, undesirable effects, indications and contraindications according to the woman’s medical conditions. Good information helps to avoid the contraceptive coercion practiced in some countries. Indeed, in ignorant and marginalized communities, providers may impose certain contraceptive methods on women, contrary to the objectives assigned or existing incentive policies [41–43].

Educated women have access to timely information through mass media, social networks [44] and even the most knowledgeable health workers. They have access to the latest scientific data. As a result, they are able to break out of the vicious circle of myths and misconceptions [44], which are real obstacles to the continued use of modern contraceptives. This result was also in line with that found by Animen S et al. (2018) in the Han health center in Ethiopia among IUD users [20].

Key strengths of the study

The key strength of this study lies in measuring contraceptive rate in maternal and child health services. Such rate data is extremely useful for assessing the effectiveness of maternal health services in our West African context. Indeed, women attending maternal health services provide opportunities to offer FP to women of childbearing age and help them acquire MCMs. It is therefore important to know whether contraceptive rate is high in this segment of the female population exposed to MCMs. Low rate of contraceptive use in this target population would indicate missed opportunities, prompting policy and technical decision-makers to review existing strategies in order to improve contraceptive use among women of reproductive age. This rate also reflects the effectiveness of maternal health services, which can be replicated in all other health services.

The main limitation of this study is the fact that it was conducted within the hospital. However, it is important to note that the rate in this study does not represent all women attending the health centers surveyed. It only reflects the rate among women who use maternal and child health services. It is likely that the overall hospital rate would be lower because women who attend maternal and child health services are more likely to be exposed to modern contraceptive methods than those attending other services. On the other hand, our approach could be a source of information bias, notably non-response, incomplete information and even social desirability or memory bias. In addition, this study is based on only 5 health centers. However, our results are useful and allow us to have an idea of the use of contraception in women of reproductive age.

Conclusion

The present study revealed a low use of modern contraceptives among women using health centers particularly maternal and child health services. Marital status and religious practice were associated with decreased MCM use. While educational level and receipt of FP information at health centers improved MCM use in our study population.

It would therefore be appropriate to recommend to policies and health service providers to:

• Encourage girls to stay in school and continue pursuing education.

• Use every opportunity to visit health centers to provide more informed FP counseling messages to women who use services.

• Implement strategies in health centers to avoid missed opportunities for behavior change communication associated with modern contraceptive use.

• Implement effective integration of FP services.

Future research, including qualitative studies should be conducted to identify additional and efficient strategies to improve the utilization of MCM in these sub-populations.

- Ethical approval

- Consent to participate

- Consent for publication

- Availability of data and materials

- Competing interest

- funding

- Authors' contributions

- Acknowledgements

- Authors information

Authors’ contributions

EMLE developed the study protocol and collected the data. KC analyzed and interpreted the data. EMLE wrote the first manuscript. DODK made critical revision of the manuscript for important intellectual content. EMLE, KC and DODK read, corrected, and approved the final manuscript. Therefore, all the authors mentioned in this article contributed to the production of the work we are submitting, and the contents of the manuscript have never been published.

Funding

No funding received.

Data availability

The datasets used and/or analyzed during the current study are available from the first author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by National Ethics Committee for Health and Life Science (CNESVS) of Côte d’Ivoire (N/Ref: IRB000111917).

Verbal and informed consent was obtained from the respondents, before proceeding with the interviews. For people with no formal education or illiteracy, consent was translated and obtained in the local language (Abbey, Dioula, etc.). If this was not possible, the participants’ legal guardian or an appropriate representative gave informed consent on their behalf.

Ethical approval and consent for participation were obtained from parents or legal guardians for participants under 16 years of age before their inclusion in the study. Indeed, those who were accompanied by a parent or legal guardian, gave their assent in addition to obtaining the informed consent of the accompanying person. Whereas those who were unaccompanied were asked to return with a parent or legal guardian for enrolment.

The questionnaire was only administered once consent had been obtained. Anonymity and confidentiality were respected, and initials were used instead of names. Interviews were conducted in French or the local language, and in private locations to ensure confidentiality.

Participation was voluntary and participants were informed of their right to withdraw from the study when they wished to do so. All the participants were aware of the study’s purpose, risks, and benefits. Data were collected, managed, and analyzed in a way to ensure the confidentiality of study participants. All procedures performed in this study involving human participants were in accordance with the ethical standards of the national ethic review committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.