Family planning in refugee settings: findings and actions from a multi-country study

A household survey based on family planning section of the CDC Reproductive Health Assessment Toolkit for Conflict-Affected Women was used to gather data on family planning-related knowledge, attitudes, and behavior among WRA [20]. Sampling frames for Cox’s Bazar, Amman, and Kuala Lumpur were generated through UNCHR’s ProGres database and registered mobile numbers. The remaining sites relied on spatial sampling.

Female interviewers were recruited from the host community. Female participants were asked to provide verbal consent and the surveys were administered in the refugees’ dominant languages. No identifying characteristics of respondents were recorded during data collection. All collected data were entered by the study supervisors, cleaned, and analyzed using CSPro, SAS, or SPSS. For this article, the WRC and staff from the University of Michigan Institute for Social Research merged, cleaned, and re-analyzed the six country datasets using SPSS.

Facility assessments were conducted to examine service availability, quality of services, and provider perspectives. Facilities were selected by UNHCR and its partners based on the level of care provided and included government- and UNHCR partner-run facilities. Broadly, facility assessments examined staffing, training, method mix, and capacity to meet infection prevention standards. The assessment was conducted using an adapted health facility checklist with a scoring grid; a short interview with providers (or staff in charge) in their primary language; and an observation of family planning consultations. Study supervisors entered the data into an Excel database for analysis.

In-depth interviews were conducted among men and women and included refugee community leaders, imams, and health volunteers. The guides were developed by WRC and UNHCR and translated and reviewed in each site. The interviews were conducted in the local language through an interpreter. The questions sought to learn about challenges and barriers to increasing contraceptive uptake within the refugee community. Respondents were purposively selected by UNHCR and partners based on interviewees’ presumed knowledge of the community and/or their constituents if they were leaders.

FGDs were held with refugee women, men, adolescent girls, and adolescent boys to gather qualitative data on attitudes towards and barriers to contraceptive uptake. The FGDs were conducted in the local languages by a facilitator of the same gender of the group, and audio recorded. The study supervisors transcribed, translated, and analyzed the data per site.

All health facilities assessed were supported by UNHCR, and included government referral hospitals and NGO clinics. In Amman, Eastleigh, and Kuala Lumpur, both government and NGO health facilities were assessed. In Cox’s Bazar, Ali Addeh, and Nakivale, facilities were run by national and international NGOs.

For quantitative analysis, responses from 2,733 refugee women were included. We used four outcome measures: awareness, ever use, current use, and unmet need for family planning methods. All of these outcomes are measured as a dichotomy, yes (coded 1) versus no (coded 0). Our explanatory measures were women’s age, marital status, education, and location of refuge as a respondent’s background characteristics. Age and marital status are important proximate determinants of fertility, and hence, for contraceptive use [21‐24]. Similarly, education is one of the determinants of contraceptive awareness, use, and unmet need [25‐29]. Thus, we explored whether there was any association between these background characteristics and outcomes. We also controlled for site of refuge as the association between explanatory and outcome measures.

First, we describe the sample using simple descriptive tools such as frequencies and percentages. Second, we examine associations between various outcome measures by women’s background measures (Table 3). We then provide distribution of outcome measures of each modern and traditional method by women’s background characteristics (Table 4). Finally, as the bi-variate results may mislead conclusions due to confounding from other factors, we use multivariate analysis to explain the net effects of various background characteristics on outcomes of interest. As all four outcome measures are dichotomous in nature, we used binary logistic regression as the multivariate tool. Results are provided in Table 5 and described below.

Among the women surveyed, 38.7% reported that they ever used any modern method of family planning (Table 3). These results also suggest that adolescents were significantly less likely to report ever use of any modern method compared to older women. Among adolescents, 10.1% reported that they ever used any modern method compared to 42.9% of adults. More married women (48.0%) were likely to report ever use of modern contraceptives compared to other (unmarried) women (16.1%). Significantly greater proportions (43.6%) of women who ever attended school reported that they ever used any modern method compared to 33.8% among those who never attended school.

By site of refuge, significantly greater proportions (48.5%) of women in Cox’s Bazar reported ever use of any modern method compared to women in other sites. In contrast, a small proportion (9.6%) of women from Ali Addeh reported that they ever used any modern method. Ever use of specific modern and traditional methods by age, marital status, school attendance, and site of refuge are provided in Table 4.

By method, one-fourth of women (24.2%) reported ever using the pill. This was followed by injectables (19.8%), male condoms (10.9%), and withdrawal (10.8%); a traditional method. Ever use of specific methods also varied by site. While 49.3% of women in Cox’s Bazar reported that they ever used injectables, 42.0% reported that they ever used the pill. These methods were less common in other sites including Ali Addeh and Amman. Similarly, ever use of other methods also varied by site.

Multivariate results show adolescents were 79.3% (odds ratio = 0.207; p < .001) less likely to report ever use of any modern method compared to adult women, net of other factors (Table 5). Married women were nearly six times (odds ratio = 5.641; p < .001) more likely to report ever use of any modern method compared to women who were not currently married. Women who ever attended school were nearly two times (odds ratio = 1.990; p < .001) more likely to report ever use of any modern method compared to women who never attended school.

Altogether, one in five women (19.9%) reported that they were currently using any modern method (Table 3). Bivariate results suggest that more adult women (22.2%) were currently using any modern method compared to 4.0% of adolescents. Significantly greater proportions of married women (26.2%) were currently using any modern method to avoid or delay pregnancy compared to other currently unmarried women. As expected, women who attended school were significantly more likely to report current use of any modern method. The distribution of current use of modern and traditional methods is provided in Table 4.

Among women reporting current use of any modern method, 8.1% of women were currently using injectables followed by pills (6.1%), male condoms (3.9%), and withdrawal (3.8%). Current use of specific methods also varied by site.

Results in Table 5 suggest that adolescents were significantly less likely (odds ratio = 0.327; p < .001) to report current use of any modern method compared to adults, adjusting for all other factors. Married women were more than 13 times (odds ratio = 13.438; p < .001) more likely to currently use any modern method compared to currently not married women, controlling for all other factors. Similarly, net of other factors, women who ever attended school were two times (odds ratio = 1.990; p < .001) more likely to report current use of any modern method compared to women who never attended school. By site of refuge, women living in all other sites were significantly less likely to report current use of any modern contraceptives compared to those living in Cox’s Bazar.

We examined unmet need³ for family planning among women in the six refugee settings. Overall, 6.7% of women reported unmet need for family planning. These are women who reported not wanting more children and are currently not using any modern method to stop or delay pregnancy.

From Table 3, 4% of adolescents compared to 7.1% adults reported unmet need for family planning. Similarly, 8.8% of currently married women reported an unmet need compared to 1.5% of currently not married women. A greater proportion (7.7%) of women who never attended school reported an unmet need compared to 5.8% of those who ever attended school. This scenario also varied by site.

Facility assessments showed limited availability of certain methods. In Ali Addeh, Eastleigh, Kuala Lumpur, and Cox’s Bazar, all assessed facilities were offering at least three short-term methods (primarily male condoms, pills, and injectables); assessed facilities in Nakivale and Amman were not (Table 6).

Stock outs of oral contraceptives were reported in Nakivale and Ali Addeh, the latter stemming from shortages at the regional level. In Amman, UNHCR’s two partners were not providing any family planning method, one citing religious reasons. However, the Ministry of Health (MoH) was providing free contraceptives to Iraqi refugees and encouraging them to access public services. Three public health facilities and one private NGO clinic provided more than three short-term methods. In Ali Addeh, Amman, and Kuala Lumpur, inadequate numbers of service centers or staff providing family planning were also barriers to availability.

Findings varied in terms of availability of long-acting and permanent methods (Table 6). In Eastleigh, all three visited facilities were offering implants and the intrauterine device (IUD), and two of three performed tubal ligation and vasectomy. In Amman, UNHCR’s partners did not provide any such methods; no assessed facility in Ali Addeh and Nakivale provided these methods.

In terms of emergency contraception (EC), only Ali Addeh and Eastleigh had the commodity available in all assessed facilities. In Amman, a prescription was necessary to obtain EC from pharmacies and UNHCR partner facilities. In all contexts where EC was available, it was primarily in the context of clinical care for survivors of sexual assault and not as a part of family planning programs (Table 6).

Community reports of contraceptive availability also differed by setting. In Ali Addeh, Kuala Lumpur, and Cox’s Bazar, FGD participants reported that they could obtain contraceptives from government facilities and/or NGO clinics. In Kuala Lumpur and Cox’s Bazar, participants reported accessing contraceptives from community health workers (CHWs). However, in reality, many Burmese refugees in Kuala Lumpur reported purchasing contraceptives—especially oral contraceptives—in pharmacies, or illegally, from Burmese shops. Similarly in Amman, while contraceptives were available and free at public health facilities, many Iraqis reportedly obtained them at pharmacies. In Nakivale, despite partner efforts to maintain roughly 25 condom dispensers in the settlement, adolescent girls who exchanged sex for money reported frequently finding them empty.

In Kuala Lumpur, costs of services, transport, and concerns of being detained—especially for unregistered refugees—were major barriers in refugees’ ability to seek services. Misinformation that was raised among the Burmese in Kuala Lumpur and Congolese in Nakivale was that modern methods can cause birth defects in future children and infertility in women after cessation.

Participants also reported that they were aware of the benefits of planning families despite limited information, education, and communication (IEC) materials and varying degrees of opposition to use. In terms of religious-based resistance, among the Somalis in Eastleigh and Ali Addeh; the Muslim and Christian Burmese in Kuala Lumpur; and the Muslim, Catholic, and Pentecostal communities in Nakivale; religious teaching was cited as a major factor discouraging the use of modern methods. Somalis in Eastleigh, however, noted that exclusive breastfeeding and other natural methods of child spacing were, in fact, encouraged by religion. The Burmese acknowledged that their religion allowed for the use of contraceptives to protect the health of the mother and to adapt to the challenges of displacement. Religion was not reported as a major barrier by Iraqis in Amman, and in Cox’s Bazar, religious leaders were supportive of the concept of planning families. In fact, in Cox’s Bazar, FGD participants acknowledged decreasing resistance to family planning in the community.

In Nakivale, adolescents were hesitant to seek contraceptives from the health facility, as family planning consultations took place in the maternity ward. While gender-based violence programs offered EC to survivors of sexual assault, family planning providers, especially in Nakivale, reportedly disapproved of making EC available for non-sexual assault cases, citing that it could promote promiscuity. In Cox’s Bazar, facility assessments revealed that unmarried adolescents could not receive contraceptives from the camp clinics since commodity distribution is reported to the government. They could only receive condoms through the camp HIV programs.

When asked about available family planning services in FGDs, women—with the exception of those in Cox’s Bazar—noted issues pertaining to the lack of adherence to standard precautions, lack of cleanliness, long wait times, limited options for privacy, and lack of confidentiality as factors that impacted their willingness to obtain contraceptives from health facilities. In Amman, women reported accessing contraceptives from pharmacies rather than for free from public health facilities due to long wait times and unhygienic practices. Likewise in Eastleigh, the lack of privacy and long wait times in public facilities drove women to private clinics. In Nakivale, consultation times were inconvenient for women undertaking domestic chores and too short for adequate counseling. Hours were also not conducive to client needs, leading women to seek services at pharmacies and private health facilities.

Facility assessments also attested to varied levels of quality across facilities and settings. In terms of the challenges reported by FGD participants, on average, facilities in Kuala Lumpur and Ali Addeh showed better adherence to infection prevention standards, while those in Eastleigh fared worse. Facility assessments further showed that in Amman, the government referral clinics were overcrowded. However, most facilities demonstrated strong capacity to meet infection prevention standards. In Eastleigh, the assessed public facility reported more challenges with longer wait times and lack of adequate privacy compared to the two private facilities. In Cox’s Bazar, higher standards of privacy and confidentiality were observed in camp clinics compared to government clinics. In Ali Addeh, facility staff reported that wait times for consultations were hours, and the distance from the health center to the farthest parts of the camp was two kilometers.

Facility assessments also examined the strength of the referral system. A system existed in Eastleigh to provide clients with referrals for contraception; however, referrals were not followed-up. Whereas in Cox’s Bazar, among facilities that were not providing certain long-acting or permanent methods, referrals from the camp clinics were relatively strong. Follow-up was better reported among camp clinics compared to government clinics. Community volunteers were also responsible for individual follow-up through home visits. In Amman, where UNHCR’s partners did not offer any contraceptives, one of the two facilities provided educational materials and information about facilities that provided family planning. In Ali Addeh and Nakivale, where no assessed facility provided any long-acting or permanent methods, no functioning referral system was in place.

In terms of staffing, the assessed facilities in Eastleigh had adequate staff to provide family planning services. In Cox’s Bazar, Kuala Lumpur, and Nakivale, high caseloads were observed, leading to consultations that were too short in duration for informed decision-making and limited privacy. A government clinic in Kuala Lumpur, favored by the Burmese refugees for perceived quality and access to interpretaters, was reportedly stretched, with providers alluding to the need for refresher trainings. In Nakivale, midwives were particularly overstretched since they dealt with antenatal care, post-natal care, family planning, and deliveries. All providers in Nakivale reported gaps in their skills and requested refresher trainings, as well as trainings on long-acting methods and new contraceptive technologies. Among public facilities providing family planning in Amman, staff had received extensive training in modern methods. Nevertheless, the need for routine refresher trainings was observed in all sites. In Ali Addeh, the midwife provided family planning services and counseling, and expressed the need for follow-up training. The staff reported the facility’s ability to provide comprehensive family planning services to the community to be at 30%.

The household study findings show that awareness, ever use, current use, and unmet need for family planning varied by age, marital status, school attendance, and site of refuge. Regarding awareness, ever use, and current use, adult women aged 20–49 years were significantly more likely to be aware, to have ever used, or are currently using a modern method as compared to adolescent girls aged 15–19 years, net of other factors. Similar differences were also found between married women and women who were currently not married. As demonstrated in other studies, education played a large role in awareness, ever use, and current use: women who attended some level of schooling were at least twice as likely to be aware, have ever used, or were currently using a modern method [25‐29].

In terms of contributions towards awareness, FGD participants reported receiving family planning information from home visits as an appropriate and well-received channel (Amman). Participants in other settings identified the most appropriate avenues to receive information through CHWs, family planning field workers, NGOs, leaders from the community, women’s organizations (Ali Addeh), and religious leaders (Eastleigh). In Nakivale, RH sessions (without contraceptive distribution) reportedly took place after school.

Marital status was the only individual background factor that influenced unmet need. Married women were more likely to report unmet need compared to those who were not currently married, based on how this indicator was defined.

In terms of site of refuge, due to the types of existing programs, it is not surprising that women in Cox’s Bazar reported significantly higher current use of modern methods as compared to women in the other five settings, controlling for age, marital status, and education. Unmet need was reportedly high in Nakivale where the qualitative methods used in this study showed limited accessibility, although the household survey did not find significant differences in unmet need by age and education.

Since the purpose of the assessment was to improve programming, UNHCR, WRC, and partners developed short- and longer-term recommendations based on the findings that have been summarized in country-specific, self-published reports [13‐19]. Recommendations in particular focused on ensuring availability of long-acting methods—which has been documented to be increasingly acceptable and feasible in humanitarian settings, including among the populations encompassed in the study—and EC to enhance method mix [4, 30]. They further focused on increasing accessibility of contraceptives for adolescents; as well as making service quality improvements around adherence to standard precautions, cleanliness, wait times, and privacy; strengthening mechanisms for follow-up; and addressing staffing challenges. Recommendations were based on documented good practices and existing guidance, taking into account feasibility, as well as priority concerns as shared by the communities [31]. Countries addressed gaps by integrating some or all of the setting-specific recommendations into country work plans. In 2015, UNHCR and the WRC followed-up on the implementation of recommendations, through a self-reported questionnaire to UNHCR country offices delivered and received via email. Five of six countries responded (all but Kenya), with the most progress reported in Djibouti, which has prioritized family planning. While the settings represented different displacement contexts—camps, settlements, and urban areas—many of the activities undertaken appeared similar due to common challenges.

Limitations to the study include insufficient time, as not all teams were able to implement the suggested 12 FGDs or visit all tertiary level facilities accessed by refugees. Sampling posed challenges, especially in urban settings, due to limited accuracy of registration lists and recorded cell phone numbers. The self-reported nature of the survey is a limitation; the survey also did not capture method switching and discontinuation. A lack of privacy and the sensitive nature of the topic may have created reporting bias in the survey, especially in Cox’s Bazar, Eastleigh, and Nakivale. Social desirability bias of respondents, particularly among unmarried women and adolescent girls, was perceived to exist, especially in Amman, Ali Addeh, and Eastleigh.