Relationship between women’s decision-making power over their own health care and use of modern contraception in the Democratic Republic of the Congo: a cross-sectional secondary data analysis

In sub-Saharan Africa, the use of modern contraception (MC) is a critical part of many maternal health interventions that aim to reduce maternal mortality rates associated with unintended, high-risk pregnancies [1]. Additionally, using MC to increase the length of interpregnancy intervals can improve perinatal health outcomes by reducing the risk of low birthweight and premature birth [1]. However, as of 2013, only eight percent of non-pregnant women aged 15–49 in the Democratic Republic of the Congo (DRC) reported using MC [2]. This represents a less than two percent increase from 2007 [3]. Furthermore, this is very low, even in comparison to other countries in sub-Saharan Africa such as Ghana and Kenya, where prevalence rates of MC use are 22% and 53%, respectively [4, 5]. The National Strategic Plan for Family Planning in DRC aims to increase the prevalence of MC use to 19.0% by 2020 [6]. Progress towards this goal has been made, particularly in the capital city, Kinshasa, where the prevalence of MC use among women aged 15–49 has increased from 18.5% in 2013 to 26.7% in 2017 [7, 8]. In the conflict-affected eastern regions of the DRC, low prevalence of MC use has been attributed to a lack of availability of family planning methods [9]. Previous studies have shown that MC tends to be utilized by women in conflict-affected areas of the DRC when it is available to them [9, 10]. Additionally, there are a variety of sociocultural barriers to accessing contraception in the DRC, including religious beliefs that God should determine the number of children that a woman bears [11, 12]. Previous studies have also found that factors such as wealth, education level, and urban–rural residence are important determinants of MC use [13‐15]. That said, further investigation into the reasons for the current climate of contraceptive use in the DRC is warranted.

Women’s general participation in decision-making has been found to be an important factor in increasing the use of MC [13, 15, 17]. However, these studies measured women’s decision-making using a composite variable [13, 15, 17]. Therefore, the specific relationship between women’s decision-making power over their own healthcare and the use of MC has been minimally explored. Two studies in Nigeria found that women who have a say in decisions regarding their own health care are more likely to use MC than women who have no say [14, 18]. Interestingly, a study of young women in Bangladesh found that women who make health care decisions jointly with their partner are more likely to use MC than women who make health care decisions alone [19]. Furthermore, in the DRC, women who report using a modern method of contraception commonly state that support from their partner was a key determinant in their use [11, 12]. These findings support the model of relational autonomy, which emphasizes the importance of having social supports in decisions regarding reproductive health care [20].

Therefore, though women’s participation in reproductive health care decisions has been observed in a few studies to be important in MC use, it is unclear whether autonomous decision-making versus joint decision-making regarding women’s health care is more strongly associated with MC use [20]. Additionally, whether or not a woman participates jointly in decisions about MC may have implications for the type of MC used [21].

Previous literature has investigated the association between decision-making and the use of MC [13‐15, 17‐19, 21]. However, no study in the DRC has compared the relationship between women having independent, joint or no say over their own health care and current use of MC. Further research is needed to better understand the role of health care decision-making power in an effort to contribute to the reproductive health of women in the DRC. Thus, our primary objective was to investigate the relationship between Congolese women’s decision-making power over their own health care and current use of MC. It was hypothesized that women’s participation, and in particular joint participation with their partner, in decisions about their health care would be associated with an increased likelihood of using MC. Furthermore, among current users of MC, our secondary objective was to examine the association between women’s decision-making power over their own health care and the method of MC used.

This study examined the association between Congolese women’s decision-making power over their own health care and current use of MC. Results are consistent with previous findings from Nigeria which suggest that women’s participation in health care decision-making is important in increasing the use of MC [14, 18]. However, contrary to our expectation, women who made health care decisions alone, as opposed to those who made decisions jointly with their husband/partner, were more likely to use MC. This contradicts the previous finding that relational autonomy, as determined by joint participation in health care decisions, is important in increasing the use of MC [19, 20].

While not the primary focus of our study, we observed that women who participated jointly with their partner in decisions about how their partner’s earnings were used were more likely to use MC compared to women who had no say. Since a large proportion of the health system in the DRC is financed by out-of-pocket expenses, jointly deciding to invest in contraception may be important [32, 33]. Additionally, the role of financial decision-making in contraceptive use has likely become more important in recent years due to increasing interest in the use of contraceptive implants. A study in Kinshasa found that from 2013 to 2017, the proportion of MC users with long-acting reversible contraception increased from 10.8% to 40.0% [7, 8]. This was almost exclusively due to increased use of the implant [7, 8]. However, with cost being reported as a major barrier to Congolese women using contraceptive implants [11], joint decision-making about contraception may be more important from a financial rather than a health care standpoint.

In addition to decision-making, there were other variables that were statistically significantly associated with current use of MC in this study population. For example, women with secondary or higher levels of education were more likely to use MC than women with no education. This relationship between education level and use of MC is consistent with previous findings and supports the idea that women with higher levels of education have a better understanding of health and are more assertive about their needs [13‐15, 20]. Additionally, consistent with previous literature, wealth was found to be an important determinant of MC use [13‐15]. This is likely because Congolese individuals are often required to pay out-of-pocket for contraception, which, as described above, is likely a major barrier to contraceptive use given that a high proportion of the population lives below the poverty line [11, 32, 33]. Moreover, women in urban areas were more likely to use MC than women in rural regions, which may suggest that women in urban areas have better access to reproductive health care services.

In 1981, the Primary Health Care (PHC) strategy was enacted in the DRC, which states that, among other services, family planning must be available at primary healthcare centers [6]. Furthermore, in 2008, the National Policy for Reproductive Health (RH) was revised to normalize family planning services and make them accessible in rural and urban regions [6]. However, implementation of these services at health facilities has been challenging [6]. Family planning arguably only came into the government’s agenda in a meaningful way in 2012 when the Permanent Multisectoral Technical Committee (CTMP) began developing a National Strategic Plan for Family Planning, which was released in February 2014 [34]. Additionally, at the 2013 International Conference on Family Planning, the DRC was confirmed as a member of the global Family Planning 2020 (FP2020) partnership to increase MC access for women and girls [35]. This also brought light to the funds that were allotted by the government to MC in 2013 [34]. However, these funds are not a fixed budget item for the Ministry of Health, and turnover in the government means that commitment to funding family planning is not guaranteed for upcoming years [34]. Therefore, in order to ensure the availability and accessibility of MC across the DRC, there needs to be continued financial contributions from the government and improvements in service delivery through the coordination of various family planning organizations [33, 34].

Despite these efforts, there are still numerous sociocultural barriers to contraceptive use, particularly for women. Out of 160 countries, the DRC ranks 152 in the Gender Inequality Index and this inequality is exemplified in the limited decision-making control that many women have [22, 36]. Additionally, a study in Kinshasa found that men often feel that contraception cannot be used because God creates a natural order and this must be respected [11]. A study in rural DRC also found that many individuals feel that their community idealizes having many children as children are God’s gift [12]. These religious factors, as well as cultural factors, may lead to communities viewing family planning unfavourably [12]. Other common reasons for having a negative attitude towards MC use include beliefs that it promotes prostitution and causes sterility [12]. Awareness raising to overcome misperceptions about MC and gender sensitization are both needed to increase contraception uptake at the community level. Activities to increase MC use and improve gender equality will contribute to Sustainable Development Goals (SDG) 5.6 and 3.1 by helping to increase access to sexual and reproductive health and rights and reduce maternal mortality [16].

Finally, among current users of MC, no association was found between health care decision-making power and method of MC used. To our knowledge, the only other published study in sub-Saharan Africa to investigate the relationship between health care decision-making power and method of MC used found that Zambian women who made health care decisions jointly with their partner were more likely to use long-acting and permanent contraceptive methods than Zambian women who did not make joint decisions [21]. This suggests that the permanence of the method may also be important to consider. Further studies should investigate the relationship between women’s decision-making power and method of MC used in a more granular way.

Interestingly, other variables, such as province of residence, were significantly associated with the method of MC used in the current study. For example, women in Nord-Kivu and Sud-Kivu were significantly more likely to use female methods of MC than women in Kinshasa. These two provinces are located in eastern DRC which has been affected by armed conflict over the last two decades [9]. Therefore, higher rates of female modern contraceptive use may be a result of the concentration of humanitarian aid in these areas [37]. This is particularly likely given that aid organizations may aim to provide a range of contraceptive methods, including IUDs and implants, which are highly utilized [9, 38]. Additionally, older women were found to be more likely to use female methods of MC than younger women. This may be because some female methods of contraception, such as the IUD and implant, are long-acting. Long-acting methods may be preferred by older women because their need to space or limit births may be greater.

A major strength of this study was that the data were collected at the population level and therefore are more generalizable in the DRC. Additionally, there was a high response rate, with 99% of women agreeing to partake in the survey [2]. High response rates in DHS surveys have been attributed to the thorough training of staff and supervisors, the short time frame between obtaining household lists and conducting the survey, and the high levels of cooperation commonly seen in developing countries as opposed to developed countries [39]. The survey also contained a variety of questions on demographic, health and social factors, which allowed for adequate assessment of known confounders [2]. However, the study has some notable limitations. Firstly, the cross-sectional nature of the study does not allow for determination of a temporal relationship between health care decision-making power and use of MC. Nevertheless, it is unlikely that the use of contraception influenced women’s decision-making power over their own health care [40]. Secondly, there is the possibility of measurement error in the exposure variable because of the crude nature of the question asked in the survey questionnaire. In patriarchal societies, women may report that a joint decision was made even when they were forced to agree with the decision of their partner [41]. Thirdly, women in the first six weeks postpartum are not in need of contraception, but they were unable to be selectively removed from the analysis [42]. However, due to the large size of the study population, these women are unlikely to have significantly biased the results. Fourthly, there is the possibility of interviewer bias and social desirability bias given that sensitive questions were asked in face-to-face interviews. However, local interviewers were extensively trained and measures were taken to ensure that women answered questions privately, which likely minimized the effects of these biases [2]. Finally, while it is recognized that the 2013–14 DHS data may not represent present day conditions, it is the most recently conducted household survey in DRC.

This study adds to the body of literature investigating the relationship between women’s decision-making power and use of MC in the DRC. Specifically, our results suggest that women who make decisions about their health care alone are more likely to use MC. Additionally, we observed that women who engage in joint decision-making with their partner about their partner’s earnings may be more likely to use MC. These findings have two main implications for programs aimed at increasing the use of MC in the DRC. Firstly, interventions promoting women’s autonomy and right to independently make decisions regarding their own bodies may aid in increasing use of MC. This is also important in working towards the SDGs of good health and gender equality [16, 20]. Secondly, programs should consider implementing interventions aimed at improving the ability of Congolese women to negotiate with their partner about how his earnings are spent. Further research is needed to qualitatively assess the relationship between different domains of decision-making in relation to MC use. Specifically, given the societal and cultural barriers to MC use, qualitative research is needed to understand the perspectives of men, women and couples on how decisions regarding MC are, or should be, made. Doing so may provide additional guidance on how to most effectively deliver interventions that enable women to negotiate for the use of MC.