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. 2026 Sep 14;20:619256. doi: 10.2147/PPA.S619256

Decisional Needs of Young Women (Aged 15–24 Years) in Contraceptive Choice: A Systematic Review

Lewei Tu 1,2,*, Huijie Wu 2,*, Miao Dong 2,*, Ying Xiao 2,✉
PMCID: PMC13588239  PMID: 42761944

Abstract

Background

Despite the wide range of contraceptive options available to women, young women worldwide are at risk of unintended pregnancy. Teenagers aged 15–19 account for 15% of abortions, while young women aged 20–24 represent 26% of abortion cases. This review aimed to identify the decisional needs of young women aged 15–24 years when considering contraceptive options based on the ODSF framework.

Methods

The PRISMA reporting guidelines guided our methodology while we were theoretically directed by the Ottawa Decision Support Framework. Our review included six databases in English and three databases in Chinese, with no publication date limits applied. Two reviewers independently screened citations and performed quality assessment with MMAT while extracting data. Sixteen studies (10 qualitative, 5 quantitative, and 1 mixed-methods) were included. The study results underwent thematic synthesis.

Results

Sixteen studies (10 qualitative, 5 quantitative, and 1 mixed-methods) were included. Six decisional needs were identified: decisional conflict, inadequate knowledge, unrealistic expectations, unclear values, inadequate support and resources, and personal/clinical needs. Inadequate knowledge and inadequate support and resources were the most frequently reported needs. In resource-limited settings, cultural stigma, financial barriers, and limited access to contraceptive services further complicated contraceptive decision-making.

Conclusion

The review identified six decisional needs among young women considering contraceptive options. The findings support the applicability and validity of the Ottawa Decision-Support Framework (ODSF) in the context of young women’s contraceptive decision-making, representing an important theoretical contribution of this review. Healthcare providers and policymakers should improve access to reliable contraceptive information, provide patient-centered and culturally sensitive counseling, and develop tailored decision-support tools. However, the restriction to English- and Chinese-language literature may limit the generalizability of the findings across diverse linguistic and cultural contexts.

Keywords: contraception, decisional needs, decision making, young women, systematic review, ottawa decision‑support framework

Introduction

Unplanned pregnancies present a major health issue worldwide and produce elevated abortion rates particularly among young women. Every year about 73 million induced abortions take place globally, with nearly a third of all pregnancies (29%) and more than half of unplanned pregnancies (61%) end in abortion according to WHO.1 Teenagers aged 15–19 account for 15% of abortions while young women aged 20–24 represent 26% of abortion cases.2 Beyond abortion outcomes, unintended pregnancy during adolescence and young adulthood may have broader and long-term consequences, including disruptions to education, reduced economic opportunities, and adverse effects on psychological well-being.3,4 These far-reaching consequences underscore the importance of addressing reproductive health challenges among young women, who also face limited access to effective contraception, social stigma and cultural barriers.5–8

According to Casey,9 33 million young women between 15–24 have unmet contraceptive needs worldwide while only 59.2% of their contraceptive needs are fulfilled through modern methods which falls below the global average of 75.7%.10 The problem worsens due to the restricted understanding of contraceptive choices coupled with false beliefs about side effects and irregular usage of contraceptives.6,11 Unrealistic beliefs about contraceptive effectiveness paired with a sense of immunity from pregnancy risks lead many young women to use contraceptives inconsistently which results in unintended pregnancies.5,11 The existing difficulties reveal an urgent demand for better educational resources and access to trustworthy contraceptive information.

Young women face increased challenges in contraceptive decision-making because of emotional hurdles alongside social and informational obstacles. Numerous youth women face decisional conflict and anxious uncertainty regarding contraceptive choices because they often lack essential knowledge and support.12–14 The sustained high occurrence of repeat abortions and unintended pregnancies demonstrates a deficiency in decision-support tools designed to meet young women’s specific requirements despite accessible contraceptive options.15,16

The complex process young women face when selecting contraceptives demonstrates the necessity of specialized counseling and psychological support. Knowledge levels combined with worries about side effects and cultural norms as well as socioeconomic status and community beliefs determine their choices.12–14 It is critical to empower young women with information that enables them to make reproductive and sexual health decisions that align with their goals in order to minimize unintended pregnancies and enhance contraceptive use consistency.17

The World Health Organization (WHO),18,19 and other international guidelines20–22 state that informed consent and shared decision-making remain crucial elements for adolescent contraceptive services. Patient-centered care respects individual preferences and values as a core principle and enables people to make autonomous reproductive health decisions. The Person-Centered Contraceptive Care Framework underscores the importance of tailored counseling and decision-support tools to ensure contraceptive solutions match personal needs and preferences.22,23

The Ottawa Decision-Support Framework (ODSF) addresses decision needs of individuals throughout health care delivery. The original 1998 ODSF directed researchers in examining decisional needs and assisted providers in decision-making process and outcome evaluation.24 ODSF is critical to contraceptive decision-making among young women because ODSF aims to identify and address barriers women face when choosing contraceptive methods. It identifies six core decisional needs: ① decisional conflict (uncertainty and anxiety), ② inadequate knowledge (lack of information or misconceptions), ③ unrealistic expectations (misaligned beliefs about outcomes), ④ unclear values (difficulty prioritizing preferences), ⑤ inadequate support and resources (lack of social, financial, or informational support), and ⑥ personal and clinical needs (individual characteristics influencing decisions).25 All components are interconnected and interventions addressing these needs may facilitate informed, value-congruent decision-making and reduce decisional conflict.

The ODSF helps identify obstacles in contraceptive decision-making such as limited contraception knowledge combined with unrealistic effectiveness expectations and inadequate social support. The ODSF enables young women to select their contraceptives autonomously and with full information through customized decision aids and individual-focused counseling that aligns with their reproductive health goals and values.25,26 In this context, high-quality contraceptive decision-making refers to making informed choices that are consistent with individuals’ values, preferences, and reproductive goals. Thus, decision quality is determined not by selecting a specific contraceptive method, but by the extent to which the decision is informed and value-congruent.27,28

While earlier reviews29,30 have addressed factors influencing contraceptive choice and decisional needs among young women, this review focuses specifically on young women aged 15–24 and applies the ODSF to systematically organize and interpret their contraceptive decisional needs. Although the ODSF provides a comprehensive framework for identifying decisional needs, it remains unclear whether existing evidence and interventions adequately address the full range of needs identified by the framework. This review therefore aims to identify and synthesize the decisional needs of young women aged 15–24 within the ODSF framework, thereby informing the development of tailored decision-support interventions.

Methods

Eligibility Criteria

Inclusion Criteria

Study Type: Both qualitative and quantitative studies will be included.

Topic Relevance: Studies must assess patients’ information or decision-making needs, or sources of decisional support regarding contraceptive options.

Participant Population: Studies should include young women aged 15–24 years who are interested in contraceptive methods, or who have used contraceptives before, or who want to start or switch to a new method.

Language: Only primary research papers published in English or Chinese will be included.

Exclusion Criteria

Non-empirical Studies: Reviews or articles without original data will be excluded.

Irrelevant Topics: Studies not specifically focused on contraceptive decision-making or decisional support will be excluded.

Non-target Population: Women outside the target age range, as well as those with specific needs such as postpartum contraception or infertility-related concerns, will be excluded.

Language Limitations: Papers not published in English or Chinese will not be considered.

Information Sources

We adhered to the PRISMA reporting guidelines.31 A comprehensive and systematic search was conducted from the outset across English electronic databases (PubMed, EMBASE, Web of Science, Cochrane Library, PsycINFO, and CINAHL) and Chinese electronic databases (CNKI, Wanfang, and China Biology Medicine disc). No time restrictions were set. We searched databases from their dates of inception through January 09, 2026. Only studies published in English and Chinese were screening. The reference lists of included articles and relevant reviews were also screened.

Search Strategy

We developed a search strategy using keywords and Mesh terms including “contraceptive,” “decisional needs,” and “sources of decisional support.” We did not set limits on publication dates to provide a comprehensive historical view of the literature. The search terms and databases were reviewed by two reviewers independently, with a third reviewer ensuring accuracy. The bibliographies of retrieved articles were manually searched to identify relevant articles for inclusion in this review. The search terms used for this review are outlined in Table 1.

Table 1.

Search Strings

Database CNKI WanFang Chinese Biomedical Literature Database PubMed WOS Embase Cochrane PyscINFO CINAHL
Search strings (contraception OR family planning OR birth control) AND (need OR experience OR information seeking behavior) AND decision AND women (contraception OR family planning OR birth control) AND (need OR experience OR information seeking behavior OR decision) AND women (contraception OR family planning OR birth control) AND (need OR experience OR information seeking behavior OR decision) AND women (Contraception[MESH]OR”Birth ControlContraceptive Methods”[Ab/Title]OR”Contraceptive Method”[Ab/Title]OR”Fertility Control”[Ab/Title]OR”Inhibition of Fertilization”[Ab/Title]OR”Fertilization Inhibition”[Ab/Title]OR”Female Contraception”[Ab/Title]OR”Contraception, Female”[Ab/Title]OR”Contraceptions, Female”[Ab/Title]OR”Female Contraceptions”[Ab/Title]OR”Male Contraception”[Ab/Title]OR”Contraception, Male”[Ab/Title]OR”Contraceptions, Male”[Ab/Title]OR”Male Contraceptions”[Ab/Title]OR”Family Planning Services”[MESH]OR”Family Planning Service”[Ab/Title]OR”Planning Service, Family”[Ab/Title]OR”Planning Services, Family”[Ab/Title]OR”Service, Family Planning”[Ab/Title]OR”Services, Family Planning”[Ab/Title]OR”Family Planning”[Ab/Title]OR”Pregnancy, Planned”[Ab/Title]OR”Planned Pregnancies”[Ab/Title]OR”Pregnancies, Planned”[Ab/Title]OR”Planned Pregnancy”[Ab/Title]OR”Family Planning Programs”[Ab/Title]OR”Family Planning Program”[Ab/Title]OR”Program, Family Planning”[Ab/Title]OR”Programs, Family Planning”[Ab/Title])AND(experience OR emotion* OR feel* OR needs OR attitude* OR opinion* OR management OR demand*)AND(“Decision Making”[MESH]OR”Credit Assignment[Ab/Title]”OR”Assignment, Credit[Ab/Title]”OR”Assignments, Credit[Ab/Title]”OR”Credit Assignments”[Ab/Title]OR”Information Seeking Behavior”[MESH]OR”Behavior, Information Seeking”[Ab/Title]OR”Behaviors, Information Seeking”[Ab/Title]OR”Information Seeking Behaviors”[Ab/Title]OR”Seeking Behavior, Information”[Ab/Title])AND (Female[MESH]) (Contraception OR “Birth Control Contraceptive Methods” OR “Contraceptive Method” OR “Fertility Control” OR “Inhibition of Fertilization” OR “Fertilization Inhibition” OR “Female Contraception” OR “Contraception, Female” OR “Contraceptions, Female” OR “Female Contraceptions” OR “Male Contraception” OR “Contraception, Male “ OR “Contraceptions, Male” OR “Male Contraceptions” OR “Family Planning Services” OR “Family Planning Service” OR “Planning Service, Family” OR “Planning Services, Family” OR “Service, Family Planning” OR “Services, Family Planning” OR “Family Planning” OR “Pregnancy, Planned” OR “Planned Pregnancies” OR “Pregnancies, Planned” OR “Planned Pregnancy” OR “Family Planning Programs” OR “Family Planning Program” OR “Program, Family Planning” OR “Programs, Family Planning”)AND(experience OR emotion* OR feel* OR needs OR attitude* OR opinion* OR management OR demand*)AND(“Decision Making” OR “Credit Assignment” OR “Assignment, Credit” OR “Assignments, Credit” OR “Credit Assignments” OR “Information Seeking Behavior” OR “Behavior,Information Seeking” OR “Behaviors, Information Seeking” OR “Information Seeking Behaviors” OR “Seeking Behavior, Information”)AND Female
Total 3326 135 53 371 309 1846 25 149 333 105
Date of search 2026.1.9 2026.1.9 2026.1.10 2026.1.9 2026.1.10 2026.1.10 2026.1.10 2026.1.10 2026.1.10
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Note: Bold text indicates table titles and column/row headers; all data values are presented in plain text.

Selection Process

References were imported into EndNote (version 21). Then, study identification was conducted in two steps based on inclusion and exclusion criteria. At first, two reviewers (TLW and WHJ) screened titles and abstracts independently, and articles were retained unless both reviewers agreed that they did not meet our inclusion criteria. Second, the two reviewers independently reviewed the full texts of remaining references according to the screening criteria. If there was disagreement between two reviewers, they would discuss to reach an agreement. If not, a third reviewer (XY) was consulted.

Data Collection Process & Data Items

Two reviewers independently extracted data using an extraction form from selected studies. The form included: (i) publication characteristics (first author, year of publication, country), (ii) sample size, (iii) participant characteristics, (iv) design methods and (v) research aims. Following extraction, reviewers compared their data, and discrepancies were resolved through discussion or by consensus with other authors.

Study Risk of Bias Assessment

Two reviewers used the Mixed Methods Appraisal Tool (MMAT) to assess the quality of the included studies. This tool supports analysis of qualitative studies alongside quantitative research including randomized controlled trials and non-randomized studies as well as descriptive research and mixed-methods studies. A complete manual with detailed guidance comes with the MMAT. Two independent reviewers evaluated the methodological quality of the studies and followed PRISMA recommendations while addressing study design quality domains with responses of “Yes,” “No,” or “Can’t tell.”

Synthesis Methods

Our analysis of all selected studies was conducted through thematic synthesis with a data-driven convergent synthesis design.32 The study approach transformed quantitative data such as numerical results from quantitative and mixed methods studies into qualitative codes which were then analysed together with qualitative data including participant quotations and themes from qualitative and mixed methods studies. The thematic synthesis strategy, based on the method by Thomas and Harden.33 This involved 3 stages: (1) line-by-line coding to identify important concepts described in text, (2) creation of descriptive themes by sorting codes into groups related to each other, and (3) creation of analytical themes.

During the coding process, directed content analysis was applied, guided by the Ottawa Decision-Support Framework (ODSF).25 The ODSF’s key decisional needs categories, including decisional conflict, inadequate knowledge, unrealistic expectations, unclear values, inadequate support and resources, complex decision characteristics, and personal and clinical needs, served as the initial coding framework. Relevant data from the included studies were systematically extracted and coded according to these predefined categories.

Results

Study Selection

The search strategy yielded 3,326 references from databases searched. After 148 duplicates were removed, titles and abstracts of the remaining 3,178 records were screened. Of these, 2,850 records were excluded because they were not empirical studies or did not meet inclusion criteria, resulting in the exclusion of 103 articles for full text reading and analysis. After full-text assessment, 14 articles were retained and 89 records excluded. Two additional articles were identified through reading the references of the 14 included articles, for a total of 16 articles included for inclusion. The study selection details are depicted in the provided Figure 1. We excluded studies that focused only on male participants, family members or the perspectives of health professionals. We also excluded studies that focused on specific populations, such as postpartum women or those seeking abortion for medical reasons. However, if a study included relevant data on our target population (young women aged 15–24), we retained it for inclusion to ensure that only the results relating to young women were analysed in the final synthesis.

Figure 1.

A flowchart of study selection process for inclusion in a synthesis. The flowchart illustrates the study selection process for inclusion in a synthesis. It begins with the identification phase, where database searches from sources like PubMed, WOS, Embase, Cochrane Library, PsycINFO, CINAHL, CNKI, WanFang and the Chinese Biomedical Literature Database yielded 3,326 records. No additional records were identified from other sources. In the screening phase, 148 duplicates were removed, leaving 3,178 records screened by title and abstracts. Of these, 3,075 records were excluded due to non-empirical study designs or not meeting inclusion criteria. In the eligibility phase, 103 full-text articles were assessed, with 89 excluded for reasons such as population outside 15 to 24 years, topics not related to contraceptive decision-making, or not published in English or Chinese. The synthesis phase included 14 studies, with 2 additional articles identified from references, resulting in a total of 16 studies included for synthesis.

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Prisma flow diagram of included studies.

Study Characteristics

This systematic review included a total of 16 studies, encompassing both qualitative and quantitative research designs. Among the included studies, 4 were conducted in the United States,34–37 4 in the United Kingdom,38–41 2 in China,42,43 4 in African countries44–47 (including South Africa, Malawi, Kenya, and a multi-country study in Kenya, Nigeria, and Uganda), 1 in Norway,48 and 1 in Sweden49(see Table 2 for details). These studies covered different geographical regions, representing a wide range of cultural and socioeconomic backgrounds. The sample sizes ranged from as few as 12 participants in qualitative studies to over 3,600 participants in quantitative surveys. Most studies focused on young women aged 15 to 24, or those with an average age within this range.

Table 2.

Characteristics of Studies

Reference NO. First Author (year) Country Sample Size Participant Characteristics Design Methods Aims
1 Bharadwaj (2011).41 UK 26 Young women aged 16–27 yrs, majority were under 24 yrs (73.1%). Semi-structured interviews/Qualitative To explore key factors influencing young women when choosing between two methods of emergency contraception (EC).
2 Bhushan (2021).45 Malawi 60 Adolescent girls and young women aged 15–24 yrs Semi-structured interviews/Qualitative To explore the nature of contraceptive conversations among adolescent girls and young women (AGYW) in Malawi. To understand how relationship status and parity influence contraceptive conversations with intimate partners, peers, and older female family members. To identify barriers to contraceptive conversations and their impact on contraceptive decision-making. To provide insights for future sexual and reproductive health interventions targeting AGYW, particularly unmarried and nulliparous individuals
3 Bratlie (2014).48 Norway 359 Young women aged 16–23 yrs, visiting a free sexual health clinic in Oslo, Norway. Cross-sectional survey/Quantitative To investigate awareness and use of long-acting reversible contraceptives (LARCs) in the Norwegian primary care sector. To assess contraceptive usage patterns, knowledge, opinions, and counseling content among young women and GPs in Oslo, Norway. To identify determinants of LARC uptake and barriers to their use among adolescents and young adults.
4 Cheung (2005).38 UK 40 Women aged 16–25 yrs, who were sexually active. In-depth interviews/Qualitative To explore the factors influencing young women’s decision-making regarding highly effective hormonal contraceptives (eg, pills, injections, implants). To understand why women discontinue or inconsistently use hormonal contraceptives, particularly in the context of unwanted side effects. To provide insights for healthcare practitioners to offer more tailored advice and interventions to improve contraceptive use and reduce unintended pregnancies.
5 Cooke-Jackson (2023).37 USA 134 Women aged 18–37 yrs (Mean age: 23.52±3.78 yrs), including 1 transgender woman. An online open-ended questionnaire/Qualitative To explore the contraceptive messages and information-seeking behaviors of young women. To identify the information women wish they had received about contraceptives and the factors influencing their contraceptive decision-making.
6 Falk (2010).49 Sweden 12 Teenagers aged 16–19 who had applied for induced abortion at an out-patient clinic in Linköping, Sweden. In-depth interviews/Qualitative To explore the experiences of teenagers using contraceptives before an unplanned pregnancy. To identify factors that hindered consistent contraceptive use among teenagers. To provide insights for improving contraceptive counseling and access for teenagers to reduce unintended pregnancies and abortions.
7 Free (2005).39 UK 30 Young women aged 16–25 yrs (66.7%were aged 16–22 yrs). In-depth, semi-structured interviews/Qualitative To develop a contextual, integrated, and dynamic model of contraception use. To explore the factors and processes involved in changes in contraception use/non-use over time.To address the limitations of previous research by focusing on the dynamic and contextual nature of contraceptive behavior.
8 Gao Fei (2023)42 China 697 Unmarried women aged 18–29 yrs, who underwent induced abortion, majority were aged 20–24 yrs (52.22%). Cross-sectional survey/Quantitative To investigate the contraceptive knowledge, demand, and reproductive health status of unmarried women undergoing induced abortion in Changzhou. To provide a reference for improving reproductive health education and contraceptive services for this population. To highlight the need for post-abortion care (PAC) services and contraceptive education to reduce repeat abortions and improve reproductive health outcomes.
9 Harrington (2025).46 Kenya 500 Adolescent girls and young women aged 15–20 yrs, sexually active, not pregnant, wishing to avoid pregnancy for ≥6 months. Discrete Choice Experiment/Quantitative To quantify Kenyan adolescent girls’ and young women’s preferences and trade-offs for contraceptive attributes, and to generate evidence for preference-aligned, youth-centered contraceptive services.
10 Hoopes (2016).35 USA 30 Young women aged 14–18 yrs (mean age: 16.2 yrs). One-on-one, semi-structured interviews/Qualitative To explore adolescent women’s attitudes and experiences with long-acting reversible contraceptives (LARCs). To inform the development of adolescent-centered LARC counseling strategies for use in pediatric primary care settings.
11 MacPhail (2007).44 South Africa 3618 Women aged 15–24 yrs who are sexually active (having ever had vaginal or anal sex) and from both urban and rural areas across South Africa. Nationally representative cross-sectional survey/Quantitative To describe the sexual behavior, contraceptive use, and prevalence of pregnancy among young South African women aged 15–24. To identify factors associated with contraceptive use among sexually active young women. To provide data that can inform strategies to encourage greater use of contraception among young women, particularly in the context of HIV prevention.To highlight the importance of integrating family planning and HIV prevention services.
12 Marshall (2018).36 USA 21 Women aged 18–29 yrs (mean age: 22.4 yrs) Semi-structured interviews/Qualitative To assess young women’s decisional needs for choosing a contraceptive method. To identify factors that influence contraceptive decision-making and inform the development of patient-centered interventions to support contraceptive choice. To explore the uncertainty, knowledge gaps, and information needs that young women face when selecting a contraceptive method.
13 Melo (2015).34 USA 21 English-speakingadolescents and young women (aged 14–24 yrs) Semi-structured interviews/Qualitative To explore the contraceptive decision-making processes of adolescent and young women (ages 14–24). To understand the role of peer influence and provider expertise in contraceptive decision-making. To identify factors that influence the choice of contraceptive methods, particularly long-acting reversible contraceptives (LARCs). To provide insights into how young women balance personal concerns with information from peers and providers when choosing a contraceptive method
14 Ouma (2021).47 Kenya, Nigeria, Uganda 171 Young women aged 15–24 yrs, both married and unmarried, from urban and rural areas in Kenya, Nigeria, and Uganda. Focus Group Discussions/Qualitative To explore the challenges that affect contraceptive method decision-making among youth in Kenya, Nigeria, and Uganda. To identify barriers that complicate youth access to the full range of contraceptive methods. To provide insights for program implementers and policymakers to design multi-level interventions to mitigate barriers to contraceptive access for youth.
15 Say (2009).40 UK 127 Young women aged 13–21 yrs (mean age: 16.62 yrs). Cross-sectional survey/Mixed Methods To explore young people’s attitudes towards newer contraceptives and understand the factors influencing their contraceptive choices.
16 Tong Jian (2023)43 China 104 Unmarried women aged 16 to 28 (average age 21.05 ± 1.48 yrs), who underwent induced abortion. Cross-sectional survey/Quantitative To investigate and analyze the contraceptive knowledge, demand, and reproductive tract health status of unmarried women who underwent induced abortion. To provide insights into the need for contraceptive counseling and education to improve reproductive health outcomes for this population. To highlight the importance of contraceptive knowledge and health education for unmarried women to reduce the risks associated with induced abortion.
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Note: Bold text indicates table titles and column/row headers; all data values are presented in plain text.

Ten of included studies used qualitative methods to interview young women through semi-structured interviews, in-depth interviews, and focus group discussions, exploring their contraceptive decision-making processes and the factors that influence these processes. Five studies were quantitative, using one discrete choice experiment and four cross-sectional surveys to evaluate young women’s knowledge, preferences, and behavior regarding contraception. An extra study involved both quantitative and qualitative data and analysis. This combination of methods provides a comprehensive perspective for understanding the decisional-making needs and challenges faced by young women when considering contraceptive options.

Risk of Bias in Studies

Detailed results of the MMAT quality assessments are found in supplementary information (Table 3). Overall, the included qualitative studies generally met the MMAT criteria well. In contrast, the quantitative studies showed greater variability in meeting the criteria, particularly in terms of sample representativeness and the risk of nonresponse bias. For the quantitative studies, the risk of nonresponse bias was notably high in studies of Bratlie48 and MacPhail.44 Additionally, the representativeness of the target population was unclear in studies of Bratlie,48 Gao Fei,42 Harrington46 and Tong Jian.43 Despite these limitations, the included studies provide valuable insights into the decisional needs of young women considering contraceptive options. Ultimately, none of the studies were excluded based on quality assessment. Only minor disagreements took place between the two reviewers. Any disagreements were discussed by the two reviewers to reach a consensus.

Table 3.

Quality Appraisal Results Using the Mixed Methods Appraisal Tool

Screening questions Bharadwaj (2011).41 Bhushan (2021).45 Cheung (2005).38 Cooke-Jackson (2023).37 Falk (2010).49 Free (2005).39 Hoopes (2016).35 Marshall (2018).36 Melo (2015).34 Ouma (2021).47 Bratlie (2014).48 Gao Fei (2023).42 Harrington (2025).46 MacPhail (2007).44 Tong Jian (2023).43 Say (2009).40
S1.Are There Clear Research Questions? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
S2.Do the Collected Data Allow to Address the Research Questions? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Qualitative Studies                                
1.1 Is the Qualitative Approach Appropriate to Answer the Research Question? Y Y Y Y Y Y Y Y Y Y            
1.2 Are the Qualitative Data Collection Methods Adequate to Address the Research Question? Y Y Y Y Y Y Y Y Y Y            
1.3 Are the Findings Adequately Derived from the Data? Y Y Y Y Y Y Y Y Y Y            
1.4 Is the Interpretation of Results Sufficiently Substantiated by Data? Y Y Y Y Y Y Y Y Y Y            
1.5 Is There Coherence between Qualitative Data Sources, Collection, Analysis, and Interpretation? Y Y Y Y Y Y Y Y Y Y            
Quantitative Studies                                
Is the Sampling Strategy Relevant to Address the Research Question?                     Y Y Y Y Y  
Is the Sample Representative of the Target Population?                     CT CT CT Y N  
Are the Measurements Appropriate?                     Y Y Y Y CT  
Is the Risk of Nonresponse Bias Low?                     N Y Y N CT  
Is the Statistical Analysis Appropriate to Answer the Research Question?                     Y Y Y Y Y  
Mixed methods                                
5.1. Is there an adequate rationale for using a mixed methods design to address the research question?                               CT
5.2. Are the different components of the study effectively integrated to answer the research question?                               Y
5.3. Are the outputs of the integration of qualitative and quantitative components adequately interpreted?                               Y
5.4. Are divergences and inconsistencies between quantitative and qualitative results adequately addressed?                               Y
5.5. Do the different components of the study adhere to the quality criteria of each tradition of the methods involved?                               N
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Notes: Yes= Y, No=N, Cannot Tell=CT. Bold text indicates table titles and column/row headers; all data values are presented in plain text.

Results of Syntheses: Type of Decisional Needs

Overall, across all included studies, a total of 48 decision needs were identified, encompassing six types of decision needs within the ODSF framework, except for the “complex decision characteristics” category. Table 4 presents the types of contraceptive-related decisional needs, along with the number of studies, percentages, and corresponding references. Among these, the category of “Inadequate Support and Resources to Make/Implement Decisions” was the most complex and was further subdivided into sub-themes based on the ODSF theoretical framework. The remaining categories were not classified into sub-themes.

Table 4.

Classification of Decisional Needs

Category of Decisional Needs No. of Studies (n=16) % of Studies References
Decisional Conflict 2 12.50 Falk (2010)49/Marshall (2018)36
Inadequate Knowledge 13 81.25 Bharadwaj (2011)41/Bhushan (2021)45/Bratlie (2014)48/Cheung (2005)38/Falk (2010)49/Free (2005)39/Gao Fei (2023)42/Hoopes (2016)35/Marshall (2018)36/Melo (2015)34/ Ouma (2021)47/Say (2009)40/Tong Jian (2023)43
Unrealistic Expectations 4 25.00 Bharadwaj (2011)41/Cooke-Jackson (2023)37/Falk (2010)49/Free (2005)39
Unclear Values 3 18.75 Cheung (2005)38/Free (2005)39/Ouma (2021)47
Inadequate Support & Resources to make/implement decision 11 68.75 Bhushan (2021)45/ Cheung (2005)38/Cooke-Jackson (2023)37/Falk (2010)49/Free (2005)39/Harrington (2025)46/Hoopes (2016)35/MacPhai l(2007)44/ Marshall (2018)36/Melo (2015)34/Ouma (2021)47
Personal & Clinical Needs 3 18.75 MacPhail (2007)44/Marshall (2018)36/Ouma (2021)47
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Note: Bold text indicates table titles and column/row headers; all data values are presented in plain text.

Decisional Conflict

Young women frequently encounter decisional conflict when selecting contraceptive methods, often experiencing feelings of uncertainty, anxiety, and fear.

According to Falk (2010), adolescents commonly report feelings of uncertainty, anxiety, and fear regarding contraceptive use, which can result in non-use or inconsistent use of contraception.49 Similarly, Marshall et al found that young women often felt uncertain and hesitant during the contraceptive decision-making process and perceived it as a difficult task.36 Many participants described difficulties in making decisions, often expressing uncertainty and reluctance due to too many options or lack of understanding of specific methods.

Inadequate Knowledge

This was the most common type mentioned in 13 studies. Young women often have misconceptions about non-barrier contraceptive methods, such as oral contraceptives or injectable contraceptives, believing that these method can lead to infertility or other health problems.38,45 There is a general lack of awareness about the effectiveness, side effects, and proper use of various contraceptive methods,34,36,39,40,42,43,47,49 particularly among adolescents. In addition, many young women have limited understanding of Long-Acting Reversible Contraceptives (LARCs),35,41,48 such as IUDs and implants, which significantly affects their decision-making. These knowledge gaps highlight the need for improved education and accessible information to support informed contraceptive choices. These findings align with the Ottawa Decision-Support Framework’s “Inadequate Knowledge” category.

Unrealistic Expectations

Four of 16 studies (25.00%) reported unrealistic expectations. Young women often hold unrealistic expectations about contraceptive outcomes, including misconceptions about their fertility and the effectiveness of methods. Some believe they are infertile or invulnerable to pregnancy, leading to inconsistent contraceptive use.49 Others overestimate the efficacy of emergency contraceptive pills (ECPs) while underestimating pregnancy risks.41 Additionally, some women perceive themselves as immune to pregnancy risks, believing negative outcomes only affect others.39 These findings align with the Ottawa Decision-Support Framework’s “Unrealistic Expectations” category.

Unclear Values

Three of 16 studies (18.75%) reported unclear values. Young women face conflicting values, such as preferring natural menstruation over hormonal control,38 and vary in prioritizing factors like side effects, duration, and maintenance.39,46,47 This variability leads to unclear decision-making, aligning with the Ottawa Decision-Support Framework’s “Unclear Values” category.

Inadequate Support & Resources

This category was the most frequently identified among all decisional needs, appearing 23 times across 11 studies. Given its prominence, sub-themes were further classified based on the Ottawa Decision-Support Framework (ODSF) to provide a more structured analysis (Table 5). Many young women lack social support from family, partners, and peers in contraceptive decision-making, often due to cultural norms and stigma.35,39,44–47 Reliable information is limited, with many relying on peers or the internet, which may provide incomplete or inaccurate guidance.34,45,47,49 Limited access to health and social services,35,39,47,49 such as long wait times and restricted availability, combined with lack of financial assistance39,46,47 due to high costs, further hinder access to contraceptive services.

Table 5.

Subcategory of Inadequate Support and Resources

Subcategory No. of Studies (n=16) References
5.1 Inadequate perceptions: others’ views/practices: 4 Bhushan (2021)45/Falk (2010)49/ Melo (2015)34/Ouma (2021)47
5.2 Social Pressure 6 Bhushan (2021)45/Free (2005)39/Harrington (2025)46/Hoopes (2016)35/MacPhail (2007)44/Ouma (2021)47
5.3 Difficult Decisional Roles 2 Falk (2010)49/Marshall (2018)36
5.4 Inadequate experience 2 Cheung (2005)38/Free (2005)39
5.8 Inadequate information 1 Cooke-Jackson (2023)37
5.9 Inadequate advice 1 Cooke-Jackson (2023)37
5.12 Inadequate health and social services 4 Falk (2010)49/Free (2005)39/Hoopes (2016)35/Ouma (2021)47
5.13 Inadequate financial assistance 3 Free (2005)39/Harrington (2025)46/Ouma (2021)47
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Note: Bold text indicates table titles and column/row headers; all data values are presented in plain text.

Personal & Clinical Needs

Personal characteristics, such as age and marital status,44,47 as well as clinical factors such as reproductive history and the need to manage menstrual symptoms,36 influence young women’s decisions about contraception.

Discussion

Core Decisional Needs Among Young Women

Our systematic review identified six decisional needs among young women aged 15–24 considering contraceptive options: decisional conflict, inadequate knowledge, unrealistic expectations, unclear values, inadequate support and resources, and personal and clinical needs. These classifications closely align with the Ottawa Decision-Support Framework (ODSF), which delineates important domains that impact health-related decision-making.26 Specifically, our findings support the applicability of the ODSF in the context of contraceptive decision-making for young women, showing that the framework adequately reflects the complex issues they face. For example, the manifestation of inadequate knowledge is common misconceptions about contraceptive effectiveness and side effects—directly corresponds to the ODSF’s emphasis on informational gaps as a barrier to informed choice.50

Young women often report significant levels of decisional conflict and uncertainty when considering contraceptive options. As described by the ODSF,25 this conflict mostly results from lack of information (inadequate knowledge of method efficacy and side effects), value discord (difficulty coordinating one’s own values with method characteristics), and insufficient support. A systematic review51 pointed out that decisional conflict appears when women lack adequate information or feel uncertain about the risks and benefits related to different methods. Additionally, research indicated52 that clinicians’ communication approaches and perceived pressure may worsen decisional conflict by preventing women from freely considering their options. For specific populations, such as women with health problems or postpartum adolescents, additional clinical complexities further intensify this conflict.53,54 The use of decision aids (DAs) that provide comprehensive, balanced information appears to address these gaps, thus decreasing conflict. Decision aids (DAs) were implemented in several studies55–57 to alleviate decisional conflict and facilitate contraceptive decision-making by providing decision support tools that systematically inform patients, clarify their values, and encourage SDM with healthcare professionals. Helping young women overcome knowledge barriers and emotional ambivalence through DS allows them to make well-informed decisions that align with their needs.

This review emphasizes that lack of knowledge about contraception is a significant barrier for young women. Many young women have significant cognitive gaps and misunderstandings about contraceptive methods. They not only lack understanding of long-acting reversible contraceptive measures (LARCs) such as intrauterine devices (IUDs) and subcutaneous implants,41 but also hold misconceptions about non barrier methods such as oral contraceptives that may lead to infertility.45 The direct impact of these cognitive deficiencies is the discontinuation or complete use of contraceptive measures, which increases the risk of unintended pregnancy. This issue is common: studies have shown that Ethiopia has a low level of awareness of emergency contraception,58 and Jordanian adolescents have limited comprehensive knowledge of sexual and reproductive health.59 What is more noteworthy is that misconceptions about contraceptive measures leading to cancer or unethical use still exist, particularly among vulnerable groups.60 Therefore, it is crucial to provide targeted education for young women who lack appropriate contraception knowledge. Schools, healthcare professionals, and public service departments should collaborate to ensure that young women receive accurate information about contraception and adolescence. Spreading knowledge and conducting peer education through social media is an effective way to reach women who have difficulty accessing regular medical services.61,62

Improving education on sexual health and increasing accessibility to youth-friendly health services can help young women learn about and properly use contraceptive methods. The contraceptive decision-making process for young women is often complicated by unclear personal values and information gaps. The ODSF category of unclear values is evident when the wide range of contraceptive options leaves young women feeling overwhelmed and uncertain about which method best suits with their personal and reproductive health goals. A discrete choice experiment in Kenya46 revealed that bleeding pattern was the most prioritized contraceptive attribute among young women and could even outweigh contraception effectiveness in certain trade-off scenarios. This highlights a potential disagreement between personal values (eg, physical autonomy, menstrual normality) and clinical recommendations, which may further result in decisional conflict. A 2022 systematic review63 confirmed that young people hold different contraceptive values, underscoring the necessity of explicitly exploring these values during counseling to effectively meet their specific needs. The necessity of shared decision-making (SDM) in contraceptive counseling is highlighted by these difficulties. SDM provides a structured process to clarify values and align clinical evidence with personal preferences.64 The literatures65,66 underscored the critical role of shared decision-making (SDM) in contraceptive counseling, emphasizing its potential to enhance patient-cantered care and improve contraceptive adherence and satisfaction. The ACOG guideline22 and a 2024 FIGO-ICM joint statement67 both emphasize that prioritizing patient values in shared decision-making (SDM) is necessary for encouraging informed, autonomous contraceptive decisions while improving satisfaction.

Social and cultural factors significantly influence young women’s contraceptive decision-making. In regions such as sub-Saharan Africa and South Asia, premarital sex and contraceptive use are often associated with stigma, leading to reluctance to seek services.47 Cultural norms and social stigma surrounding premarital sex and out-of-wedlock pregnancy strongly influence decisions, with many fearing judgment or social ostracism.41 In addition, religious beliefs and conservative values can act as barriers, especially for adolescents.68 A multinational study of contraceptive use in different cultural contexts found significant differences in use rates.69 The study found that the use of contraception was highest in Western Protestant countries, while the rates were lower in Catholic countries and sub-Saharan Africa. This highlights the profound influence of cultural and religious norms on contraceptive practices. Understanding gender, values, rights and sexuality is therefore essential to improving young people’s access to and use of contraception.70 These cultural differences highlight the need for tailored approaches to contraceptive counseling and education that respect and respond to the unique social and cultural contexts of young women worldwide. By understanding these differences, healthcare professionals and policymakers can better support young women to make informed and autonomous contraceptive decisions.

This review highlights the fact that young women often face issues of insufficient social support and limited access to resources when making contraceptive decisions. Due to a lack of support from partners, family, or medical professionals, many rely on erroneous or partial information from peers or the internet.45,49 Structural barriers, such as high costs, long waiting times, and limited service availability, further impede access.39,47 Financial constraints, particularly among adolescents and youth, compound these challenges, as many lack the financial independence to afford contraceptive methods.71,72 In the USA, initiatives to improve low-income people’s financial access to contraception have been suggested as a way to lower the number of unwanted pregnancies.73 Decision-making is further complicated by inconsistent or biased counseling from medical professionals, especially when it comes to long-acting reversible contraceptives (LARCs) like IUDs and implants.48 Improving service cost, offering objective counseling, and fostering a supportive environment through community-based programs and youth-friendly health initiatives should be the main goals of interventions to address these issues. By removing these obstacles, young women will have access to trustworthy information and services that enable them to make knowledgeable decisions regarding their reproductive health.

Importantly, the social context surrounding contraceptive decision-making warrants greater attention. Partners and other family members may serve as important sources of emotional, informational, and practical support, but they may also influence young women’s preferences and choices through expectations, misconceptions, or social pressure45,74,75 Qualitative evidence among adolescent girls and young women aged 15–24 years indicates that conversations with intimate partners, peers, and older female family members can influence contraceptive decision-making, with partners sometimes providing support for contraceptive use, while family members and peers may provide information that can either support decision-making or reinforce misconceptions.45 Recent qualitative research has similarly highlighted the active role of male partners in contraceptive decision-making, including their provision of emotional and practical support and their influence on contraceptive choices.74 Research among adolescent girls has also identified partners, family members, peers, and other social actors as important influences on contraceptive decision-making.75 In settings where family and interpersonal relationships play an important role in reproductive decision-making, such influences may contribute to value conflicts or decisional uncertainty when personal preferences differ from those of significant others. Therefore, contraceptive counseling should not only provide individual-level information but also, where appropriate and acceptable to the young woman, consider the perspectives and support needs of partners or family members while maintaining the young woman’s autonomy and confidentiality. Such an approach may help strengthen supportive relationships while reducing interpersonal pressures that could compromise informed and value-congruent contraceptive decision-making. These findings76,77 also suggest that the expression and relative importance of specific decisional needs may vary across cultural and social contexts, highlighting the importance of culturally sensitive decision-support approaches.

Given that young women may seek contraceptive information through online platforms, digital interventions may offer a promising and scalable approach to addressing several decisional needs identified in this review.37 Mobile health (mHealth) applications and web-based decision aids may provide accessible and potentially more private avenues for obtaining contraceptive information and decision support, particularly for young women who experience social stigma or difficulties accessing youth-friendly services.51,55–57 Existing evidence suggests that technology-based contraceptive decision aids can improve contraceptive knowledge and self-efficacy and may support contraceptive use and continuation.51 Mobile messaging and online educational interventions have also been explored as potential approaches to supporting contraceptive information and decision-making among young women61,62.Within the ODSF framework, these approaches may address multiple decisional needs by providing accurate and tailored information to address inadequate knowledge, facilitating consideration of personal preferences and values to address unclear values, and providing accessible avenues for decision support to address inadequate support and resources.51,56,57 By providing balanced information and facilitating consideration of personal preferences and values, digital decision aids may have the potential to reduce uncertainty and decisional conflict, although evidence regarding their effects on specific decision-making outcomes remains limited.51 Nevertheless, further research is needed to evaluate the effectiveness, cost-effectiveness, privacy, and cultural adaptability of digital interventions across diverse settings, particularly low- and middle-income countries, as well as their optimal integration with in-person counseling to ensure equitable access to contraceptive care.

Implications for Policy and Practice

The six decisional needs identified and classified in Table 4 provide a structured evidence base for developing targeted interventions. Our findings highlight important gaps in decision support for young women choosing contraceptive methods. Policymakers should consider incorporating evidence-based digital platforms and peer-led programs into youth-friendly contraceptive services to improve access to reliable information and decision support. School curricula and public health campaigns need to adopt evidence-based sexual health education to address unrealistic expectations and decisional conflicts identified in our review.

Healthcare providers need to transition from providing basic information to delivering comprehensive and unbiased contraceptive counseling. ODSF framework-based decision support tools facilitate value clarification and expectation management regarding contraceptive side effects and efficacy. Our review identifies substantial obstacles in support and resource availability which necessitate policy measures including subsidized contraceptive options and better access to youth-oriented services. Training programs for healthcare professionals must focus on culturally sensitive counseling that considers personal and clinical factors affecting contraceptive choices. By addressing each of these six needs—from improving knowledge and managing expectations, to clarifying values and strengthening support systems—healthcare systems can move beyond one-size-fits-all approaches and enable young women to make informed, autonomous contraceptive decisions that align with their personal values and reproductive goals.

Strengths

The strength of the review is based on Ottawa Decision Support Framework, providing a comprehensive theoretical structure for analysing decisional needs. Methodologically, we adhered rigorously to PRISMA guidelines, employing two independent reviewers screening and data extraction. Our search strategy was comprehensive, including six English databases and three Chinese databases. Systematic quality assessment using the Mixed Methods Appraisal Tool ensured transparent assessment of study quality, while the thematic synthesis approach combined data-driven and theory-driven analysis to produce robust findings with clear guidance for practice.

Limitations and Future Research Directions

There are some limitations with this systematic review that should be considered when interpreting these findings. By only searching English and Chinese language databases and articles, important evidence published in other languages may have been missed, particularly from regions such as Latin America and Southern Europe, where cultural contexts surrounding contraceptive decision-making may differ substantially. This limits the generalizability and widens the gap between research findings and applicability to various contexts outside of Western, English-speaking settings. Future research should work to source literature that was published in other languages and represents a wider variety of cultures.

Furthermore, the geographical distribution of the included studies is skewed toward Western, Chinese, and select African settings, with limited representation from South Asian countries (eg, India and Bangladesh) and Latin America—regions that bear a substantial burden of unintended pregnancies. This underrepresentation reflects the available literature identified through our search strategy rather than an intentional exclusion, but it nonetheless constrains the generalizability of our findings to these high-burden settings. Future research should prioritize primary studies in these underrepresented regions to better capture the decisional needs of young women in diverse cultural and socioeconomic contexts.

Additionally, some quantitative studies included in this systematic review had limitations in sample representativeness and potential non-response bias, which may affect the robustness and generalizability of the synthesized findings. Moreover, most of the included quantitative studies employed cross-sectional survey designs, and experimental studies or intervention trials that could provide more rigorous evidence regarding the effectiveness of different decision-support strategies remain scarce in the current evidence base—a gap that reflects the current state of the literature rather than a limitation of our review methodology perse. Consequently, findings supported primarily by studies with methodological limitations should be interpreted cautiously, and policy recommendations based on these findings should be implemented with careful evaluation and ongoing monitoring. As this review used thematic synthesis and directed content analysis rather than statistical pooling of effect estimates, conventional weighting procedures and statistical sensitivity analyses were not applied. Future studies should aim to have more rigorous sampling methods as well as plans to mitigate a high non-response rate, and should incorporate more longitudinal and intervention study designs to better evaluate decision-support strategies.

Due to this review being a secondary analysis of the current literature, it is limited by lack of depth that primary research provides. Future primary research should work to build on the findings discovered using mixed methods to confirm, clarify, and expand on these results. Studies with more diverse samples and methodological rigor will enhance our understanding of contraceptive decision-making needs across different populations and better inform support for young women.

Conclusion

The review identified six decisional needs among young women aged 15–24 years: decisional conflict, inadequate knowledge, unrealistic expectations, unclear values, inadequate support and resources, and personal and clinical needs. Among these, inadequate knowledge and inadequate support and resources were the most consistently identified and prominent needs across the included studies. By applying the Ottawa Decision-Support Framework, this review provides a structured understanding of the decisional needs of young women considering contraceptive options. The findings support the applicability and validity of the ODSF in the context of young women’s contraceptive decision-making, representing an important theoretical contribution of this review. To address these needs, healthcare providers and policymakers should improve access to reliable contraceptive information, provide patient-centered and culturally sensitive counseling, and develop tailored decision-support tools, including accessible digital approaches where appropriate. Policy priorities may differ by setting, with greater emphasis on addressing counseling and decision-making challenges in high-income settings and improving access, affordability, and youth-friendly services in low- and middle-income settings. These strategies may help young women make informed and autonomous contraceptive decisions that align with their values and preferences.

Acknowledgments

The authors would like to thank all the researchers whose work was included in this systematic review. We are grateful for their contributions to the field of contraceptive decision-making and reproductive health.

Registration and Protocol

We registered our protocol in PROSPERO a prior (registration #CRD42025640749).

Abbreviations

WHO, World Health Organization; ODSF, Ottawa Decision-Support Framework; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; MMAT, Mixed Methods Appraisal Tool; LARCs, Long-Acting Reversible Contraceptives; IUDs, Intrauterine Devices; ECPs, Emergency Contraceptive Pills; Das, Decision Aids; SRH, Sexual and Reproductive Health; SDM, Shared Decision-Making; ACOG, American College of Obstetricians and Gynecologists; FIGO, International Federation of Gynecology and Obstetrics; ICM, International Confederation of Midwives.

Data Sharing Statement

The data supporting the findings of this study are provided in tabular format within the manuscript itself. Besides, the analytic code and other materials used in this review are available from the corresponding author upon reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data supporting the findings of this study are provided in tabular format within the manuscript itself. Besides, the analytic code and other materials used in this review are available from the corresponding author upon reasonable request.

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