Messages around contraceptive use and implications in rural Malawi

Abstract

The unmet need for contraception in Malawi remains high, despite progress increasing knowledge and access over the past two decades. Understanding the reasons for this unmet need is critical to programme planning and service delivery. In this study, we conducted 30 in-depth interviews and 13 focus group discussions with women and men in rural Malawi to understand social, cultural and relational barriers and facilitators to contraceptive use. We found that contraceptive decisions were influenced by complex, often conflicting messages with varying implications based on individual and contextual factors. Common factors that influence contraceptive use, such as spousal support, side effects and social norms that dictated acceptable users of contraception could act as both barriers and facilitators to use depending on context. While strides have been made in increasing access to contraception, findings indicate a need for public health programmes to take a nuanced approach to increasing contraceptive use that does not presume particular factors will be a barrier or facilitator across groups. Instead, programmes should seek to understand how social, cultural and relational factors influencing contraceptive use differ across groups.

Background

At the 1994 International Conference on Population and Development (ICPD), the United Nations Programme of Action agreed that ‘all countries should seek to identify and remove all the major remaining barriers to the utilisation of family-planning services’ (United Nations Population Fund 2014). In the 26 years since ICPD, major strides have been made in reducing barriers to contraception, especially with regards to increasing knowledge and access (Sedgh, Ashford, and Hussain 2016). Despite global progress, ambitious contraceptive prevalence targets have not been met: as of 2017, 214 million reproductive-age women in low- and middle-income countries (LMICs) who wanted to avoid pregnancy were not using a modern contraceptive method (Guttmacher Institute 2017).

To accomplish the public health aims of women and couples achieving their reproductive goals, there is a need to understand the nuanced and context-specific barriers to and facilitators of contraceptive use. While several studies since ICPD have documented women’s reasons for non-use and discontinuation of contraception (see for example Bradley, Schwandt, and Khan 2009; Sedgh and Hussain 2014), some barriers may change with time and social and economic progress, and others remain entrenched and in need of more clarification. For instance, while access to contraceptive services was a major barrier to family planning utilisation several years ago (and remains true for some), a relatively small proportion of women cite access-related reasons for nonuse in recent Demographic and Health Surveys (DHS) (Sedgh and Hussain 2014; Sedgh, Ashford, and Hussain 2016).

Malawi’s policies as a whole have been supportive of expanding access to contraception since ICPD. In 1994, the National Population Policy expanded access to family planning and allowed contraception for child-limiting. Since then, data from the Malawi DHS demonstrate a considerable increase in modern contraceptive prevalence: from 7% in 1992, to 26% in 2000, and to 59% in 2015-16 (National Statistical Office (NSO) Malawi and ICF 2017). Malawi has also witnessed a commensurate decline in total fertility: from 6.7 births per woman in 1992 to 4.4 in 2015-16 (NSO Office Malawi and ICF 2017), although disparities remain by region and socio-economic factors.

In Malawi, studies have focused on understanding the structural factors that have catalysed the increase in contraceptive use, such as pro-contraception policies and increase in access through the public health system (Heard, Larsen, and Hozumi 2004; Skiles et al. 2015). However, fewer studies have examined more nuanced barriers and facilitators to use of contraception. In this study, we sought to elicit and understand socially shared barriers and facilitators that shape individuals’ contraceptive decisions. To this end, in 2013 we conducted in-depth interviews (IDIs) and focus group discussions (FGDs) in rural Lilongwe district, Malawi that focused on fundamental reasons for contraceptive use and non-use that are unlikely to change with increased access alone (Goldberg 2014).

Barriers and facilitators to modern contraception

To use modern contraception, women must be aware that methods are available, know where to get them, and know how to use their chosen method effectively. Several studies in the 1980s and 1990s focused on knowledge and the relationship to contraceptive use, indicating that lack of knowledge of methods was associated with unmet need for contraception and non-use of a method (Bongaarts and Bruce 1995). However, more recent evidence suggests that knowledge has improved and may no longer be a significant barrier to contraceptive use (Khan et al. 2007; Sedgh, Ashford, and Hussain 2016).

More recently, health concerns and fear of side effects have emerged as powerful barriers to using modern contraception (Diamond-Smith, Campbell, and Madan 2012; John, Babalola, and Chipeta 2015; Sedgh, Ashford, and Hussain 2016). Several studies have found that fear of contraceptive side effects related to fertility is especially poignant in Malawi (Chipeta, Chimwaza, and Kalilani-Phiri 2010; Bornstein et al. 2020). Among women with unmet need for contraception in LMICs, about one in four have reported not using because they were concerned about side effects and health risks of methods (Sedgh and Hussain 2014).

Men can play a critical facilitating role in women’s contraceptive decisions. Male partner approval is associated with contraceptive use in a variety of LMICs, including Malawi (Campbell, Sahin-Hodoglugil, and Potts 2006; Shattuck et al. 2011; Diamond-Smith, Campbell, and Madan 2012). Women’s social networks – family members, friends and community members – may dissuade women from using contraception when they disapprove and when women openly discuss their negative perceptions or experiences with one another (Hindin, McGough, and Adanu 2014; Ochako et al. 2015).

Although it is often assumed that access-related factors, including availability, health centre distance and financial costs greatly influence women’s decisions, recent multinational studies show that women infrequently cite access-related barriers (Sedgh and Hussain 2014). Indeed, a recent study in Malawi suggested that addressing social norms around marriage and childbearing may have a more substantial impact on contraceptive use than addressing access-related barriers (Digitale et al. 2017).

Existing studies have identified socio-demographic correlates of contraceptive use in Malawi and other low-resource settings (e.g.age, education, marital status) (Wulifan et al. 2016; Mandiwa et al. 2018), and identified potential barriers to contraceptive use. A systematic review of barriers to contraceptive use in sub-Saharan Africa identified social and cultural factors as prominent barriers to contraceptive use (Haider and Sharma 2013). Other studies found that complex fertility desires may be associated with contraception non-use (Huber et al. 2017; Gibby and Luke 2019).

The present study focuses on the messages people receive and internalise about contraception, as well as contextual narratives that they associate with contraceptive users.

Methods

Study setting

Rural Lilongwe district in Central Malawi is about 50 km outside of Lilongwe city. The predominant language is Chichewa and primary ethnicity is Chewa. The area has high poverty rates, and many people are subsistence farmers. As compared to the Northern and Southern regions of Malawi, Central Malawi has the highest rates of modern contraceptive use (63%), but the highest rates of unmet need for contraception among unmarried women (42%) NSO Malawi and ICF 2017). Women in rural Malawi, such as this study setting, have an average of 1.7 more children than women in urban areas (NSO Malawi and ICF 2017). Overall, modern contraceptive use has risen in Malawi over the last five to ten years from 42% in 2010 to 58% in 2015-16. Unmet need for contraception has also declined in this time period (26% to 19%), but the gap between women’s totally fertility rate and desired family size has remained constant since 1992, such that women have approximately one more child than they desire NSO Malawi and ICF 2017).

Study design and data collection

This qualitative study was nested within the Umoyo wa Thanzi (UTHA) research programme on sexual and reproductive health decision making. In 2014, UTHA collaborated with a rural hospital to recruit 1,034 women and 441 of their male partners within the hospital’s 68 village catchment area (approximately 20,000 residents) for a prospective cohort study. We collected qualitative data, in June-August 2013 to inform the baseline survey. Thus, participants in this study were women and men residing within the research catchment area but not within villages randomly selected into the cohort study. FGDs were specifically used to elicit social norms and perceptions of contraceptive use; IDIs were conducted to understand participants’ personal experiences and narratives regarding family planning.

The UTHA research team developed field guides in English and then translated the guides into Chichewa. All IDIs and FGDs were conducted in Chichewa by trained, Malawian research assistants. Malawian colleagues and researchers verified translations and back-translated the guides to ensure content and semantic equivalence of each question, directed by Brislin’s (1970) guide to cross-cultural translation (Brislin 1970). In addition, we pre-tested the guides to assess question phrasing and sequencing and modified when necessary.

Participants were identified for FGDs and IDIs using purposeful sampling techniques (Padgett 2008). Regarding FGDs, the research team invited village headmen to propose community members with insights into sexual and reproductive health topics to join a focus group – i.e. women and men who would be interested in discussing these matters openly in a group forum. In this setting, it was culturally appropriate to include village headman in participant sampling and recruitment, as they often act as ‘gatekeepers’ to their communities and recruitment would be difficult without their support. The research team selected the final group of participants. Once participants had been recruited, the research team disaggregated participants based on marital status and gender (i.e.married and female, unmarried and female, married and male, and unmarried and male) with the aim of minimising gender- and power-inequities between participants. In total, 13 FGDs were held with approximately 10 participants in each group. FGDs lasted approximately 90 min each and were conducted in public locations near participants’ villages (e.g.in community centres).

To recruit participants for IDIs, the research team, with the assistance of village headmen and community health workers, identified women and men with insights on decision making about sexual health and contraception. In total, we carried out 30 IDIs, and whenever possible, interviewers were matched by sex with their interviewees as a means of establishing rapport and minimising social desirability bias (Padgett 2008). We held IDIs in or near participants’ homes, and interviews lasted approximately one hour. We determined our sample sizes for both IDIs and FGDs based on saturation in themes (Corbin and Strauss 2008).

Before each interview, trained Malawian interviewers asked participants to provide written consent to take part in the study. Participants who were unable to sign their names provided a thumbprint signature with a witness’s signature. The consent process was completed individually for each FGD participant, rather than as a group. All participants were given a copy of the consent form for his/her records. No personally identifying information was collected from participants. Participants were compensated 1000 MWK (approximately $2.50 USD) for their time.

Analytic strategy

We used NVivo (QSR International Pty Ltd. Version 11, 2015) for data management, coding and analysis. All IDIs and FGDs were audio recorded and transcribed from Chichewa to English for the purposes of analysis by bilingual, Malawian research assistants. We used a multi-stage analytical strategy to develop codebooks and identify key themes. At the first stage, we used open coding procedures to identify, name, categorise and describe the phenomena found in participant’s narratives (Corbin and Strauss 2008). From this, we developed an initial list of codes with definitions. We then sorted codes into broad themes, using an inductive and deductive approach, relying on both existing theory and building off of it based on prominent findings (Corbin and Strauss 2008). Then, we used selective codes to be primary categories, and all other codes were linked to the appropriate category through sub-coding (Corbin and Strauss 2008). In a second stage, we reviewed five transcripts line-by-line and applied the codes and sub-codes that were initially developed. We revised the codes and their definitions to develop a final codebook, which was then applied to the remaining transcripts. During coding, we used theoretical memos to summarise cases, draw comparisons, and identify emergent themes. We revisited the data throughout analysis to confirm the conclusions that we came to and discussed the final results as a team. All participants have been assigned pseudonyms to protect confidentiality and anonymity. In the findings that follow, participants’ comments are introduced or followed by one of these assigned pseudonyms.

Ethical approval

Ethical approval was obtained by the Institutional Review Boards of The Ohio State University and the Malawi College of Medicine.

Results

Participant characteristics

Most participants were married and very few had completed primary education (Table 1). Typical of the area, participants were primarily subsistence farmers. On average, about one-third of participants did not have any children, while a quarter had more than five children. The vast majority of female participants began childbearing at age 20 or younger, while men began childbearing at later ages (primarily 21 to 25). The majority of participants were between the ages of 14 and 25.

Table 1.

Selected participant characteristics as a percentage of the sample, Umoyo wa Thanzi research programme, 2013.

Characteristic	IDI Participants		FGD Participants
	Women (n = 24)	Men (n = 6)	Women (n = 93)	Men (n = 42)
Age
14 - 25	54.2	50.0	51.6	35.7
26 - 45	45.8	33.3	39.8	54.8
> 45	0.0	16.7	8.6	9.5
Marital Status
Unmarried	37.5	16.7	35.5	25.6
Married	29.2	83.3	40.9	61.9
Divorced	25.0	0.0	18.3	7.1
Widowed	8.3	0.0	5.4	0.0
Education
No education	4.2	16.7	18.3	11.9
Some primary	58.3	50.0	60.2	54.8
Primary	8.3	16.7	9.7	14.3
Some secondary	29.2	0.0	8.6	9.5
Secondary	0.0	16.7	3.2	9.5
Occupation
Home keeper	0.0	0.0	18.3	0.0
Farmer	54.2	83.3	50.5	83.3
Small business owner	8.3	16.7	10.8	7.1
Other (e.g. student)	37.5	0.0	20.4	9.5
Number of living children
0	37.5	33.3	20.4	28.6
1	12.5	16.7	21.5	23.8
2	16.7	0.0	10.8	9.5
3	4.2	0.0	10.8	19.0
4	16.7	33.3	10.8	7.1
5	12.5	0.0	10.8	2.4
> 5	0.0	16.7	14.0	9.5
Age at first birth
15–20	45.8	50.0	63.4	26.2
21–25	16.7	16.7	12.9	35.7
26–30	0.0	0.0	0.0	4.8
> 30	0.0	0.0	0.0	2.4
Not applicable or no response	37.5	33.3	23.7	30.1

Key themes

The two overarching themes that arose from the IDIs and FGDs concerned barriers and facilitators to contraceptive use. In many cases, barriers and facilitators were the same, and whether or not a specific factor acted as a barrier or facilitator depended on individual and contextual circumstances.

While participants were surrounded by a wealth of information about contraception, this information was often contradictory. We identified three sub-themes in the data and detail the messages and contexts where each theme could act as a barrier or facilitator of contraceptive use: (1) men believed that they were supportive of women’s contraceptive use, but women often perceived men’s attitudes as impediments; (2) some knowledge of contraceptive side effects was based on credible sources (such as women who experienced side effects), while other knowledge was the product of rumour or social myths; (3) married women with many children were supported, and even pressured, to use contraception, but unmarried women who used contraception were stigmatised.

We use the Chechewa word, kulera, to describe a specific set of family planning methods. Kulera refers to non-barrier, non-permanent methods of contraception (i.e. oral contraceptives, injectables, subdermal implants and intrauterine devices), not condoms or sterilisation.

Men’s support of kulera

Men often saw themselves as supportive of contraceptive use, while women frequently discussed men as barriers. Some men reported that they were involved in their female partner’s contraceptive use and showed concern for their partner’s and children’s health. Some men also reported that they, rather than their wives, began discussions about contraception. One man, whose wife recently took up contraception, described the process:

When I sat down with my wife, we saw that it is important that we should start kulera…Before we started using it, I did some investigation on the benefits of kulera and didn’t know that my wife was doing the same. So, when we started our discussions on kulera, everything went on smoothly. We [knew] the benefits of kulera from some people who had used it before. [Kulera] means that we have saved the life of the child and the mother.

(Patrick, male, married, age 20, 1 child IDI)

In addition to supporting contraceptive use, some men also reported that they played an important role in facilitating contraceptive uptake in their partnership. This was especially true when female partners lacked the motivation or resources to access contraceptive services.

We accept if [our wives] ask to use kulera… When she is not going for her regular appointments at the clinic, it is our duty to remind and encourage them to go to the clinic for [family planning].

(Samuel, male, married, age 26, 1 child FGD)

In contrast, many women perceived men as barriers. Further, men also recognised that male partner disapproval of contraceptive use was a barrier for women; although, no male participants said that they, themselves, disapproved. There was a general sense that men did not approve of contraception because of their own desires to continue childbearing. For instance, some participants indicated that a man might leave his wife or take an additional wife or female partner if he wanted to continue childbearing and his wife did not. These issues affected whether a woman used contraception, as some women might have to face the choice between maintaining their marriages and exercising their desire to limit childbearing. A divorced woman explained:

Sometimes it happens that a man can refuse his wife to use kulera, because the man says that if it is to do with the support for children, [he] will be able to support them… So, we tell the men that the support for children is not the only factor for starting kulera. The woman’s health is also one of the things which has to be looked into, because when you die in childbearing, your husband will not give you another life.

(Mercy, female, divorced, age 41, 2 children, IDI)

Another woman explained how men’s ability to engage in multiple marriages influenced family planning decision making:

Because men can have polygamy, some women just accept to continue having children when they would have used kulera… The husband becomes polygamous, because the woman has been using kulera and the husband still wants to have children.

(Faith, female, divorced, age 25, 1 child, IDI)

Women reported that men might sabotage their efforts to prevent pregnancy through condom use by tearing or puncturing holes in condoms before sex, leading to unplanned pregnancy and transmission of HIV/STIs. The motivation for men to conduct contraceptive sabotage was not always clear. However, because condoms were mostly viewed as something unmarried women used, most women believed that men wanted their partners to become pregnant with the aim of solidifying engagement and marriage.

Men tear the tip of the condom with the aim of convincing the woman that they have used the condom… They aim to impregnate the woman. It may be that the woman is refusing to get married… The woman says she does not want to get married at that particular time, but the man wants to marry her. The man plans to get the woman pregnant. In that way, he can easily marry the woman.

(Theresa, female, unmarried, age 19, 0 children, IDI)

Actual and perceived side effects of contraception

Participants overwhelmingly cited the side effects of contraception, both those they experienced and those experienced by others, as reasons for not using contraception. Side effects that caused the most concern was around fertility, menstruation, and sexual pleasure. Women’s concerns were not simply about the effects of contraception on their bodies but also about the impact of side effects on their relationships, daily functioning and ability to work.

The perceived negative impact of contraception on future fertility was of paramount importance to women. For younger women, maintaining fertility was especially important and, for that reason, were pressured to not use contraception before ‘knowing their fertility.’ Knowing one’s fertility could not be achieved until a woman had at least one child. Adolescent participants reported that it was typically their parents, teachers and community members who echoed the value of knowing your fertility and reiterated the dangers of using contraception. Myths about infertility caused younger participants to be afraid of using contraception. Even if they were not afraid, lack of support prevented young people from successfully seeking out family planning information or services.

I did not use kulera [during school], because they were saying that if you are still a girl (meaning you have not yet had children), and if you use kulera, you become barren… I heard it from older women, so you think what they are saying is true. Sometimes it is parents who say, “You girls do not start using kulera when you are at school. You will never see a child in your life.” So, when we hear about these things, we become afraid. Others say that we will have problems during delivery. I think coming from old women it could be true; maybe they experienced it.

(Gertrude, female, divorced, age 21, 2 children, IDI)

While most participants felt that reduced fertility could result from any method, a few participants mentioned that it was only a problem caused by particular methods, primarily IUDs and implants. Many women also believed that the side effects of contraception were the result of not knowing how fertile one was before utilising contraception.

Some get sick because they have not been examined to see if they are very fertile or not; and you find that after using the methods, they end up having back pains and other abdominal pains because of the methods which they are using.

(Rebecca, female, unmarried, age 24, 3 children, FDG)

Participants discussed the importance of childbearing and maintaining high fertility in this context. Family stability was largely achieved through childbearing within marriage. Infertile couples were highly stigmatised, as parenthood was seen as the primary marker of the transition to adulthood. Therefore, the safety of contraception was strongly linked to women’s stage in the life-course.

You can stay with the implant for a number of years and remove it when it expires. When you get married, it takes a long time for you to conceive. Your eggs have been burnt due to the implant… When you are infertile after using the implant, it will be hard for you to tell if you are infertile due to the implant or if you were born infertile. You get married; you are not conceiving. People will say that you burnt your eggs with implant usage.

(Joyce, female, unmarried, age 25, 0 children, IDI)

Nearly all participants suggested that married couples were expected to have their first child soon after marriage. Thus, the potential for contraception to interfere with a couple’s ability to adhere to socio-cultural norms of quick conception was often too great a risk. A couple actively avoiding pregnancy before having a first child was considered a foreign idea, as was the idea that contraception could be used by unmarried women or newlyweds.

[When a woman and man] have just been married, there is no reason for them to use family planning because they do not have a child. Why would they [use] kulera? When a person gets married the most important thing for them is to have a child.

(Theresa, female, unmarried, age 19, 0 children, IDI)

Another woman shared a similar view, clearly demonstrating the effect of socio-cultural norms on how and when contraception is to be used:

You don’t do family planning while you don’t have a child. How can you practice family planning as if you have a child? I don’t feel it’s proper for a girl to go for family planning when she doesn’t have a baby. Unless she has a baby, then she cannot go for family planning.

(Louisa, female, unmarried, age 23, 0 children, FGD)

Related to concerns about fertility, participants were also concerned about the impact of contraception on menstruation. Both women and men relied on regular, monthly menstruation as a sign of health and (future) fertility. In addition, the implications of prolonged menstruation or amenorrhoea extended beyond health concerns; irregular menstruation had negative social and relational implications, primarily for women. Participants reported that they could not have sex while a woman was menstruating, and extended periods of abstinence would be harmful to men’s health and negatively impact a couple’s relationship stability.

This weakens your relationship (in reference to prolonged menstruation from kulera). Before the woman started using family planning, there was strong relationship; the couple had sex. After she started using family planning, she is experiencing prolonged menstruation… Then, the husband has a sexual partner outside marriage. This means that family planning has weakened the relationship.

(Robert, male, married, age 18, 0 children, FGD)

In addition to fertility and menstruation related side effects, nearly all participants discussed the negative effects of contraception on sexual pleasure for both men and women. Participants believed that non-hormonal methods such as the copper IUD and female sterilisation also had a similar impact on sex drive. Some participants described men they knew or heard about who experienced impotence or pain when their female partners used contraception. Both women and men worried about these side effects. A male participant described how contraception adversely affects a man’s health through sex:

When a woman is using kulera it is like this: when a man wants to have sex with his wife and they have sex, the effects of the injections [spread to the man]. What happens is that a man does not have chilakolako (a desire for sex) after only having one sexual encounter with his wife who is using injection.

(Chisomo, male, married, age 26, 1 child, FGD)

These beliefs were not limited to men. Some women too shared stories of how contraception affects men sexually

When [having] sex, the man is not able to perform as all his body parts are weak due to family planning. Men say that kulera chemicals disturb their blood [flow] and hormone system. They are not strong enough to perform [sexually] in bed.

(Joyce, female, married, age 25, 0 children, IDI)

Many participants also described a powerful social narrative that women who used modern contraception lost their sexual desirability or appeal to men. Participants reported that men often perceived women who use contraception as lacking ‘sweetness’ or being sexually ‘cold.’ This colloquialism was applied to any type of family planning use, including male condoms and female sterilisation. Several participants, both men and women, described this phenomenon:

The man experiences reduced power (male impotency), because the woman is cold. It is as if you are having sex with a dead person … Because what happens is that when a man is hot, he also needs a woman to be hot. We are able to notice this when a woman starts using kulera.

(Mavuto, male, married, age 26, 1 child, FGD)

Social stigma and marital status

The stigma associated with contraceptive use was linked to women’s stage in the life-course. Unmarried women who used contraception and, at times, married women with multiple children who did not use contraception, were stigmatised.] Contraceptive use among unmarried women was considered a moral issue. Some participants described unmarried women who used contraception as sexually promiscuous. This stigma reinforced the notion that using contraception outside of marriage was shameful.

People will laugh at me if I use family planning. Some will say that I am a prostitute, because I am using the implant while I am not married … You know village life. When you are not married and you are using the implant, people say that you are a prostitute; you have got multiple partners.

(Joyce, female, unmarried, age 25, 0 children, IDI)

Male participants also discussed how unmarried women who used contraception were characterised:

The problem is that when you begin family planning before you have a child, you can start prostitution, because she knows that she cannot conceive … They know that they are safe even if they have multiple sexual partners.

(James, male, married, age 30, 4 children, IDI)

In some cases, young women agreed that contraceptive use outside of marriage was unacceptable. Participants who were still in school reported that female-controlled contraception was rarely discussed and a foreign idea for this particular group. One woman reflected on how the most effective methods of contraception, such as the implant, were specifically not discussed in school:

It is an unusual thing for a girl in school to use the implant. This is fit for married women, but for a girl in school, it is not normal for her to use the implant… Even in the books we read at school, they write, “Use a condom and abstinence” … They did not write that a girl in school should use the implant. Nothing of that sort is written in the books.

(Theresa, female, unmarried, age 19, 0 children, IDI)

While contraception was generally viewed as easily accessible for married women, participants described the barriers that unmarried women faced in obtaining contraception, particularly non-barrier methods. These included both physical access and discriminatory experiences unmarried women encountered at healthcare facilities.

If someone who is in school goes to the clinic and asks to have kulera, it is not easy. When she goes to the clinic and the healthcare workers look at her age, they will ask her, “What do you want?” and when she says that I want to use kulera, they will ask her, “What for at your age?” So, the girls would feel embarrassed. It is not easy for a young girl to use kulera.

(John, male, married, age 33, 3 children, FGD)

In contrast to the stigma unmarried women faced if they used contraception, participants said that married women who had multiple children, and therefore were perceived to not use contraception, might also be stigmatised. Interestingly, these two groups of women were characterised in similar ways. Married women who gave birth frequently were sometimes labelled as sexually promiscuous and were reported to enjoy sex ‘too much’ or unable to control their sexual desires. Some participants thought that women with many children were afraid to use contraception because they believed it would interfere with their sex lives. One woman described how others viewed her before and after she began using contraception:

“Why is she not using family planning methods?” I got worried when women were saying this to me. “Doesn’t she know that there are family planning methods?” Then it pained me, and I made a decision to start using injectables. Things changed; my fellow women started congratulating me about my good child spacing … They were not gossiping … [Before I used family planning], they said, “You like sex. Your fellow women are using injectables. Why are you not using injectables?” This pained me a lot.

(Marha, female, divorced, age 30, 4 children, IDI)

Participants reported that households with appropriately spaced children were highly regarded in their communities. Families were not necessarily considered admirable because they were using contraception (which may or may not be known), but because a small family and/or appropriately spaced children was perceived as smart and modern. Despite the stigma and conflicting messages that women and men received from their peers and community members, participants relied heavily on their social networks for advice about contraception. Many participants reported using a method after a recommendation from a peer and providing recommendations to friends and family.

I told my friends that [my husband and I] agreed that we should start using kulera. My friends were impressed; they too wanted to have it in their families. They asked me what and how I have managed, and they went and discussed it with their husbands. Eventually all my friends are now using kulera, but they have their own methods which they chose.

(Mercy, female, divorced, age 41, 2 children IDI)

Discussion

Study findings suggest that contraceptive decisions were influenced by a complex web of messages that were at times conflicting (e.g. contraception could be seen as both weakening and strengthening to relationships) and the implications of use or non-use of contraception for an individual were context dependent. This is particularly evident in our findings regarding who was seen as an acceptable user of contraception. For example, married women with many children who used contraception were sometimes seen as responsible or modern, while unmarried women were stigmatised and seen as promiscuous. Additionally, a person (such as a spouse) or system (such as a healthcare clinic) that influenced contraceptive could be both a barrier and a facilitator, sometimes in contradictory ways.

Messages about contraception and their implications were moderated by time and life-course stage. Certain milestones were imbued with meaning related to the acceptability of contraception. Before marriage or the birth of a first child, a woman’s family might be a barrier to contraceptive use; however, after having multiple children, those same family members might be key facilitators. Social network studies have identified social influence (i.e. the collective advice of others whether perceived correctly or incorrectly) as a key influence of reproductive health behaviours (Lowe and Moore 2014). Social influence was meaningful in our study, as perceptions of social and gender norms about contraceptive use and decision acted as barriers and facilitators.

We found that men’s roles in contraceptive decision making may be both a barrier and a facilitator of contraceptive use. This was highlighted in findings around social stigma and social support. Social support from spouses can facilitate actions in line with an individual’s desires, but also can be in contradiction. This was evident in the pattern we saw of men seeing themselves as facilitators of contraceptive use (although they recognised other men may be barriers), while women saw men as barriers. Men also often personally identified as supportive of contraception, contrasting themselves with others who were not supportive. Both may reflect shifting norms among men that are not yet fully evident to individuals. Our future work on couples’ joint decision making will explore ways in which such decision making is supportive of family planning use

Concern about side effects is one of the most widely discussed barriers to contraception and is hypothesised to be the most influential in contraceptive decisions (Bongaarts and Bruce 1995; Campbell, Sahin-Hodoglugil, and Potts 2006; Schwandt et al. 2015; Sedgh, Ashford, and Hussain 2016). Our findings also suggest that side effects are an important factor in contraceptive use. However, concerns about side effects were complex and went beyond the physical body of the contraception user and could continue effecting women and men after discontinuation. Family planning programmes and providers should not assume that all women equally privilege side effects. Furthermore, public health campaigns should work to foster positive narratives about contraception, while counteracting negative beliefs (e.g. sex is not ‘sweet’ when women use contraception).

Study findings further complicate understanding of how to intervene on fear of side effects. While women may have been concerned about the physical aspect of side effects, they were also concerned about how side effects would influence their social relationships. For example, prolonged menstruation and amenorrhoea were considered negative side effect of contraception. The overarching message was consistent - that any effect of contraception on menstruation was problematic - but the implications differed. Prolonged menstruation may prevent expected sexual relations and destabilise a relationship, while amenorrhoea was seen as unnatural and a sign of infertility. Given the relative commonality of menstrual side effects associated with frequently used methods in this locality (i.e. injection) (NSO Malawi and ICF 2017), public health programmes need to be attentive to both prolonged menstruation and amenorrhea. Furthermore, information about side effects was almost always a product of hearsay rather than first-hand experiences, as documented elsewhere (Chipeta, Chimwaza, and Kalilani-Phiri 2010; Diamond-Smith, Campbell, and Madan 2012; Schwandt et al. 2015). Women’s fears around side effects were intimately connected to how they perceived the side effects might compromise their relationships and increase their social and economic vulnerability.

Limitations

Participants were recruited from the catchment area of a health clinic that provides a range of contraceptive methods. Our sample may have a larger than typical proportion of current contraceptive users, and participants may have been more aware of contraception because of community programmes and outreach. Additionally, village headmen played a role in recruitment, which may have biased who was included. However, village headmen were asked to identify people with a broad range of perspectives and research assistants ultimately selected participants. Social desirability in what participants shared was also a risk. To minimise this, IDIs and FGDs were conducted in private settings by trained Malawian researchers who lived in the surrounding area. Facilitators/interviewers and participants were also matched by sex, whenever possible.

Implications and conclusions

In Malawi, the discrepancy between availability and use of contraception persists, and may be the result of broad and complex social factors. While unmet need for modern contraception is measured at the individual level, we found that facilitators and barriers to contraception are experienced on a social level. Furthermore, in this study, idiosyncratic relational factors shaped access to and use of contraception and, more broadly, their ability to achieve their reproductive goals. Thus, reducing barriers to access, without attention to the nuanced social and relational lives of men and women, may fall short of addressing the fundamental causes that perpetuate unmet need (Heard, Larsen, and Hozumi 2004).

While men in our study seemed relatively ‘pro-contraception’, pervasive ideas that men will not approve of contraception and that contraception negatively affects their health and sexual experiences persist. In general, we know very little about men’s perceptions and reasons for use/non-use (or supporting use/non-use of contraception), or the characteristics of contraception that men value. Understanding men’s desires and priorities better will ultimately enhance our understanding of unmet need and strategies to address unmet need among both women and men. Our future work will investigate why men use or support specific methods and not others.

Socially shared beliefs that contraception may cause infertility and promiscuity prevent unmarried women from using contraception. Furthermore, social norms about the timing of pregnancy shortly after marriage are significant for childbearing early in life; thus, threats to this norm (i.e. contraception) are viewed cautiously. These socially ingrained and widespread beliefs are difficult to change at the individual-level or by family planning providers alone. Families, schools and community organisations need to be involved, so that change in social norms and expectations occur at the appropriate level.

Reducing significant barriers to contraceptive use can produce dramatic effects on unintended pregnancy and total fertility rates. If all unmet need was met in Malawi, unintended births and unsafe abortions would drop by 87%, and maternal death would decline by more than two-fifths (Guttmacher Institute 2014). By exploring Malawian perspectives on the barriers and facilitators to modern contraception, this study highlights the contradictions surrounding messages about contraception and complicates how public health interventions approach supporting families in using contraception when they do not want a pregnancy.