Women’s empowerment, intrahousehold influences, and health system design on modern contraceptive use in rural Mali: a multilevel analysis of cross-sectional survey data

Despite needing methods to avoid unwanted pregnancies and safely space births, many women around the globe are unable to obtain modern contraception (for example, condoms, implants, etc.) particularly in middle and western Africa. In Mali, less than one in six women aged 15 to 49 years use modern contraception. In order to help design strategies to increase use, we need to understand what factors support women to use contraception in settings where access to healthcare is poor. In December 2016 and January 2017, we surveyed 14,032 women in Bankass, rural Mali, and asked them about themselves and their use of reproductive health services, among other topics. Less than five percent used modern contraception at the time of the survey. In a statistical regression analysis, we determined that women who were involved in decisions pertaining to her own health, visiting her relatives, and household spending were more likely to use contraception than those who were not, as were women who had any education and any paid work. Living with another woman in the household who used contraception meant that a woman was three times more likely to use herself. We also found that the further a woman lived from a health center, the less likely she was to use, even within 5 kilometers. When designing and rolling out targeted strategies to expand access to contraception, we ought to consider these elements related to women’s empowerment, intimate relationships, and the broader health system.

Ensuring access to contraception and women’s family planning needs are met with modern methods is essential to meeting the Sustainable Development Goals related to universal access to reproductive healthcare, gender equality, and the empowerment of women and girls. Among all women of reproductive age globally, the use of modern contraception has increased only marginally between 2000 and 2019 from 42.0 to 44.3%, with the greatest unmet need persisting in middle and western Africa [1]. In Mali, only 15% of women aged 15–49 years used modern contraception at the time of the last Demographic and Health Survey (DHS) in 2018 [2].

Mali’s total fertility rate is among the highest in the world. Women have an average of 6.3 children, with women in rural areas having almost two more children than those in urban areas (6.8 versus 4.9 children per woman) [2]. Although fertility has declined in Mali since 1987 when the average was 7.1 children per woman, certain regions today have fertility rates as high as the 30 year old national average [2]. Despite national policy and law promoting sexual and reproductive health and rights, more than one in five reproductive-aged women in Mali report an unmet need for family planning, including one quarter of women in union and over half of sexually active women not in union [2].

A number of structural barriers may inhibit or delay access to contraception and other basic healthcare services within Mali’s decentralized, pluralistic, fee-for-service healthcare system. Family planning services are theoretically integrated into all levels of public sector care in Mali: national, regional, district, health catchment area, and community. In some communities greater than 5 km from a primary health center (PHC), community health workers (CHW) are stationed in fixed community health posts to provide counseling, services and referral, including for family planning, to patients who seek care and pay the fees for service. However, direct and indirect costs to care, including distance, are well-established barriers to timely, appropriate healthcare across a variety of settings [3‐8]. Furthermore, service delivery at all levels of care in Mali suffers from a shortage and inequitable distribution of the health workforce, inadequate clinical mentoring and supervision, and poor infrastructure and frequent stock-outs, which undermine quality of care and patient confidence. Major system-wide reforms in Mali to improve access to care are were announced in February 2019 and expected to take full effect by 2022, including removing user fees for contraceptives and maternal and child health, strengthening the CHW cadre, and increasing national budget allocations to health.

Beyond barriers related to health system design and implementation, women in this context may be further hindered in fulfilling their contraceptive needs due to infringements on their empowerment, defined here as the expansion in people’s ability to make strategic life choices through resources, agency, and achievements [9]. Socio-economic disadvantages such as poor access to formal education and the paid labor force, constraints on physical mobility, limited decision-making power, and gender norms and attitudes have been shown to limit women’s ability to exercise contraceptive choices in settings across sub-Saharan Africa [10‐17]. The expansion in women’s ability to make strategic choices related to reproduction in such a prevailing context may be influenced by household composition, familial relationships, and decision-making dynamics. In South Asian settings where extended family ties are strong, intrafamilial influences, such as spousal communications and interactions with mothers-in-law, may play an important role in women’s contraceptive use [18, 19]. In rural Mali, where women in union typically live with their husband’s extended family and 40% are in a polygynous arrangement [2], the role, autonomy, and contraceptive use status of their female household members may expand women’s access to contraceptive choice.

Mali recently developed a renewed five-year national strategic plan for family planning, with the ambitious goal of increasing female modern contraceptive use to 30% by 2023 [20]. Building on the experiences and lessons learned in implementing the previous 5-year plan (2014–2018), the renewed plan for family planning is based on five strategic pillars: demand generation; availability and access to services; supply chain management; an enabling political environment and financing; and monitoring and supervision. In order to achieve this new goal, Mali must attain a rapid growth rate in contraceptive use comparable only to that achieved by Sierra Leone in the West African region [20]. Further elucidating how health system design and women’s realities influence modern contraceptive use helps to determine how such ambitious plans should be operationalized in order to improve access.

In this study, we aim to: (1) describe modern contraceptive use among women of reproductive age in the under-studied, high fertility, rural Malian context of the Bankass district, including methods and procurement among users; (2) explore descriptively and visually household and village composition of reproductive-aged women and their use of modern contraception; and (3) identify predictors of modern contraceptive use in this context where utilization is exceptionally low. We use a multilevel modeling approach using detailed household survey data, including geolocated measures of distance, to assess influences on women’s modern contraceptive use at the individual, household, community, and health system levels. We include ‘direct’ measures of women’s empowerment (decision-making and mobility in the public domain), as well as indirect socio-economic sources of empowerment (education and paid labor force participation). We explore the role of intimate female social networks by assessing how living in a household with another woman who uses modern contraception influences adoption. Determining what structural barriers to dismantle and social relationships to leverage in order to expand contraceptive access is key to meeting national and international goals for women’s wellness, health, and survival.

Our study in seven health catchment areas of the Bankass district in the Mopti region of Mali found a modern contraceptive prevalence below 5%. This is similar to, but even lower than the 8.7% regional average in 2018 (an increase from 2.7% in 2012–2013 [23]), despite over a third of all women in Mopti desiring family planning [2]. Another study in the Youwarou district of Mopti found 8.8% of non-pregnant, reproductive-aged women visiting PHCs used modern contraception [29]. The injectable contraceptive was the most common method used in our study population, followed by the implant, which were also the two most common in the 2018 DHS (34% and 44%, respectively) [2]. Anecdotally, there is a preference for these methods in our context due to their long-acting and discrete nature. We may have had underreporting of traditional methods, although the DHS also reports that less than 1% of all contraceptive users used traditional methods [2].

Such low modern contraceptive prevalence may be partly explained by the services available. Within a global context of shortages and inequitable distribution of human resources for health, approximately 37% of doctors, nurses, and midwives in Mali work in rural areas where three quarters of the population resides [20]. Where healthcare workers are available in Mali’s rural areas, distance, quality, and cost create barriers to basic health services [8]; contraceptive options can be limited and stock-outs frequent. Yet, despite chronically poor service availability and accessibility across our entire study area, some women—and even some pairings of women within single households—used modern contraception. Distilling individual, household, community, and health system level factors associated with contraceptive use in this context helps to inform the design of strategies to reduce unmet need for contraception where access is at its absolute worst.

We found that women who played any role in decision-making, who had any formal education, and participated in any paid labor, were more likely to use modern contraception. In addition, a greater percentage of households that had at least one modern contraceptive user included any reproductive-aged woman in decision-making, compared to households that had no users (37% versus 29%). We found unexpected results related to women’s mobility, where women with some mobility were less likely to use modern contraception than those who had none. Our findings on the association between women’s education and contraceptive use are consistent with other studies from sub-Saharan Africa [10‐12, 17]. The evidence base for the role of women’s empowerment, as measured by decision-making and mobility, on contraceptive use is mixed and dominated by research conducted in South Asia [17, 18, 26, 30]. Our results suggest that having any involvement in decision-making related to healthcare, visiting relatives, or household purchasing more adequately captured women’s capabilities to make strategic choices related to contraceptive use in this context than having freedom of movement to the marketplace, health center, women’s group, or outside the village. It may be that having ever been or been alone to these places does not reflect a woman’s physical autonomy in this context, but rather their availability or distribution. Alternatively, it may be that having recently (rather than ever) been to these places—as mobility is so dependent on age or phase of life [30]—would be a more appropriate predictor of current contraceptive use.

Living in the same household as another woman who used modern contraception was strongly associated with an individual’s uptake in our study. Our findings contribute to the broader healthcare utilization literature on the importance of engaging social networks including in Mali [31, 32], by illustrating the power of intimate intrahousehold female relations—among cowives, and among mothers and their daughters—in influencing contraceptive use. One woman’s ‘functioning achievement’ [9] in accessing modern contraception that she desires may transform the intrahousehold context in which another woman makes a strategic life choice to use. These findings, taken together with education, paid labor, and decision-making, suggest that utilizing contraceptive services in this poor access, low use context may have required considerable assertiveness on the part of women. Strategies to expand women’s ability to make contraceptive choices might engage direct axes of empowerment, sources of empowerment, and the settings for empowerment [33]—decision-making, education and paid labor, and intrahousehold female relations, in this context.

Health systems must be designed to meet women most of the way. Distance to nearest public sector health facility, where 85% of contraceptive users procured their method, was a strong predictor of modern contraceptive use. Compared to women closest to a health center, those who lived between 2 and 5 km were half as likely to use modern contraception, and those between 5 and 10 km were a third as likely. A growing body of literature suggests that even relatively short distances from health facilities are associated with adverse health outcomes [34]; however, the 5 km cut-off continues to dominate research, policy, and practice [7]. Although CHWs offered family planning counseling and services in some villages 5 km or more from a PHC at the time of the survey, only condoms and the OCP were offered and women were referred to the more distant health centers for other methods. CHW capabilities to deliver a range of specific health interventions and contribute to health outcomes, including contraceptive use, is well established [35]—when CHW programmes are appropriately designed and implemented, and supported by health system enablers [36]. In our study setting, CHWs services were accessible only to patients who initiated their own care-seeking from the fixed community health post, and who paid a fee for service—a practice known to hinder utilization across settings and interventions. Our findings suggest that this conventional approach to CHW service delivery is insufficient to increase contraceptive use. Home visits by CHWs have shown particular promise as an alternative approach to community-based contraceptive service delivery [37, 38]

Finally, variation in modern contraceptive prevalence and methods between PHC catchment areas and the parameter estimates for PHC catchment areas in the regression model suggest that the availability and quality of contraceptive services differed in important ways between the seven neighboring PHCs in the Bankass district. The intracluster correlation coefficients (ICC) in the multilevel model indicated that the local village-cluster environment and the family compound environment within a given village-cluster played a role in contraceptive use in addition to the individual, household, and health catchment area fixed effects. We note that the two catchment areas with the highest prevalence of modern contraceptive use were the smallest in terms of population and tended to be wealthier, and anecdotally, are better connected to societal resources through tourism.

Our study was subject to some important limitations. First, we were unable to measure unmet need for contraception and thus analyzed use among all women of reproductive age. We were unable to exclude women intending to become pregnant at the time of the survey, as respondents did not report this data. Furthermore, while we used the current WHO definition of a modern contraceptive method, we note that women may not encounter the same barriers to using fertility awareness based methods, such as LAM and the standard days methods, as they do for methods procured at a health facility e.g., distance. Given the small number of users in the sample population, we were unable to perform subgroup analyses on users of specific methods or method types. We did not have geolocation data for contraceptive procurement sites other than the PHCs and district referral hospital, and were therefore unable to measure distance to these other locations. Although we assessed relative poverty on contraceptive use, wealth quintiles may be less meaningful in a context where absolute poverty is so widespread. Over three quarters (77.4%) of our sample fell in the poorest wealth quintile relative to a nationally representative sample, and only 5.5% were in Mali’s top two quintiles [2]. Furthermore, small holder wealth in a context like West Africa is difficult to measure as it is accumulated through shifting and diversifying sources (e.g., productive assets, land, labor, remittances, social networks, etc.). Due to seasonality and social desirability bias, we may have underestimated the prevalence of food insecurity. Finally, although we consider the inclusion of empowerment measures a strength of our study on contraceptive use in sub-Saharan Africa, we acknowledge that these measures are “simple windows into complex realities” and thus inherently limited [9]. However, it is likely that our measure of decision-making would underestimate the actual agency women exercise over resources and choice, which may also be exerted through informal or subtle negotiation.

Our multilevel modeling technique allowed us to appropriately model the nested structure of individuals within households within family compounds within communities, and to assess the influences of higher level factors on individual level outcomes. Although women with missing outcome data were different in some observable characteristics, the percentage of missing data was very low (0.4%) and our complete case regression analysis included 95% of women in the sample; therefore, this should not have impacted our results. Finally, by using precise geolocation data at the household and facility levels, our study was able to examine household distance to health center as a predictor of modern contraceptive use and to explore how users were grouped together at the community level. This sets our research apart from much of the multilevel research on the use of reproductive health services that relies on DHS data.

Women’s decision-making, education, and paid labor force participation, as well as living in a household nearer to a health center and with another women who used modern contraception, were associated with use in this poor access environment. In designing and implementing strategies to expand access to contraception, policymakers and practitioners should consider these axes, sources, and settings for underlying female empowerment. Relevant to the design of accessible and effective community health systems more broadly, our findings suggest that distance to facility is an important barrier to care even within a 5 km radius, and that care available from a fixed community health post on a fee-for-service basis is insufficient to increase utilization.