Knowledge, Attitude and Practices of family planning
Results from a Knowledge, Attitude and Practices survey conducted by Marie Stopes Sierra Leone in 2013.
The critical scale of maternal mortality and overall low levels of family planning use in Sierra Leone highlight an urgent need to better understand knowledge, attitude and practices of family planning in Sierra Leone.
This briefing disseminates key findings from a survey exploring progress in this area, in order to provide health planners and health providers with data which will help them to adapt and target family planning services.
The 2013 Sierra Leone Demographic and Health Survey[i] preliminary report shows that modern family planning use in Sierra Leone remains low, with 16% of married women reporting using a modern method of family planning in 2013. This is despite the fact that this is over double reported use in 2008[ii].
These low adoption rates are amongst the many interrelated causes behind dramatically high maternal mortality rates in the country, and have broader significant impact for maternal health.
Beyond the numbers, there is a need to explore in more depth Sierra Leoneans’ knowledge, attitudes and practices of family planning, as well as the barriers preventing the adoption of these services.
This research briefing presents findings from a knowledge, attitude and practices survey[iii] commissioned by Marie Stopes Sierra Leone (MSSL) and conducted in 2013.
Key findings from the survey
Capturing family planning knowledge, attitude and practices
The purpose of this knowledge, attitude and practice (KAP) survey was to enable health providers working in Sierra Leone to understand progress with regard to knowledge, attitude and practices of family planning, as well as existing barriers to family planning utilisation, in 13 districts.
It was commissioned in November 2013 by MSSL, with a view of providing up-to-date data to guide its work and that of others and to further strengthen progress in the area of family planning.
The survey was conducted in 300 enumeration areas across all 13 districts.
Twenty nine trained local researchers interviewed a total of 3,000 respondents in 3,000 households, using a structured questionnaire.
The data collected have generated rich insights into respondents’ fertility; knowledge, attitude and use of family planning; knowledge and practice of abortion; and marketing approaches.
Key findings are summarised below.
About survey respondents
The majority of respondents were women, although there were variations in the proportion of male and female respondents across districts.
Overall, respondents were relatively young, with ages ranging from 15 and 35 years old.
There was a relatively high proportion of respondents who reported having attained secondary education, and most respondents reported being students or unemployed, followed by being employed in sales and retail sectors or agriculture, and lastly by manual and professional, technical or managerial work.
Findings on fertility
Women in several districts reported having fallen pregnant through situations others than choice. Their proportion reaches 33% in Bonthe and Western Rural, and 27% in Bo.
The overwhelming majority (95%) of respondents said they were sexually active, and about three in five of sexually active respondents reported their last sexual encounter was within a month to the survey.
On average, a female respondent reported becoming sexually active at least one year before her male counterpart, at age 17 against 18 for males. In addition, around half of all sexually active female respondents surveyed had their first sexual experience at the age of 16, compared to 17 for males.
On average, female respondents had experienced childbirth three times, and on average two children per respondent survived.
The pregnancy status of female respondents varied considerably between districts. In several districts, most women who were pregnant at the time of the survey experienced pregnancy as a personal choice.
However, respondents in Bonthe (33%), Western Rural (33%) and Bo (27%) got pregnant through situations other than choice.
This may point at factors such as existing unmet need for modern family planning.
On family planning
Despite good knowledge of modern contraceptive methods, only 45% of respondents were using contraception at the time of the survey, and there were important disparities in contraceptive uptake across districts.
Respondents displayed good levels of knowledge of modern contraceptive methods, less so of traditional family planning methods.
Despite existing knowledge, just over 45% of respondents mentioned they were using a contraceptive method at the time of the survey.
Preference was given to contraceptive pills, injectables and implants (almost 87% of all methods reported by female respondents), whereas traditional methods were barely in use.
The survey showed important disparities in levels of family planning use across districts, with contraceptive uptakes above 50% in Pujehun, Western Urban and Bombali, against 30% to 40% in Port Loko, Kenema and Koinadugu.
Higher education levels often meant higher contraceptive use, and so did being single or unmarried but living with a partner.
The vast majority of respondents reporting using contraception to control childbirth (85% of females and 78% of males), followed by to reduce poverty.
Significant reasons for non-use amongst respondents who were not using contraceptives included wanting to have a child (25%), breastfeeding (16%) and not having sex at the time of the survey (10%).
It was also reported that contraceptive use can be perceived to be associated with bad or promiscuous behaviour by the broader community.
Marie Stopes was cited as the main provider of modern contraceptive methods, with respectively approximately 77% and 64% of women reporting accessing IUD and implants from MSSL.
On the other hand, government facilities were not identified as lead providers and private sector providers lagged even further behind except in the area of male condoms provision.
Despite being illegal, abortion is a reality for women in Sierra Leone, with 15% reporting having experienced it and many reported experiencing complications.
Most respondents considered abortion to be an option for terminating an unwanted pregnancy, but three in every ten respondents said that even unwanted pregnancies should be continued.
Many respondents believed that abortion is expensive, represents a religious sin and can affect health negatively. Age (e.g. teenage pregnancy) and marital status (e.g. unmarried woman) were not believed to justify abortions, unlike being aware of health risks for the mother or the child.
The subject of abortion was perceived as secret and personal, and over 15% of women admitted to have aborted a pregnancy.
A range of modern abortion methods were cited, with the most known being surgery (45%), while traditional methods were less widely cited, with herbs or roots infusion being the most popular in this category (25%).
Most respondents went to public hospitals (26%) and health centres/health posts (16%) for post abortion services, although some mentioned MSSL (15%).
Very few reported seeking the service from the back market (6%). The decision to select a given place for post abortion care appeared to be primarily informed by cost considerations (31%), followed by recommendation (25.5%), convenient location (20%) and reputation (18%).
Complications among respondents who reported receiving post abortion care were widespread but varied between facilities: this was 44% among respondents who received post abortion services at a Marie Stopes facility; 53% those who had attended pharmacies and 73% among those who reportedly attended a private clinic.
Exposure to marketing
Electronic media and the radio were found to be effective tools to reach the population and can be used for family planning communications and messaging.
The survey also provided data on critical marketing elements with regards to MSSL’s programmes visibility and service provision, which can be of use to other health providers.
It found that MSSL is well known to the population that it provides services to, with almost 80% of respondents knowing MSSL at the time of the survey. Main channels of information included friends or neighbours (64%), outreach (48%) and the radio (46%).
In addition, family planning was largely recognised as the flagship service provided by MSSL, and MSSL was appreciated for providing high quality services (47%).
The survey also found that electronic media are more effective than print media in reaching the population, and that the radio is the most popular media reported.
Health providers in Sierra Leone should:
- Differentiate their client targeting strategies in order to respond to variations in family planning rates across districts. Districts with lower adoption rates should benefit from increased sensitisation in order to improve coverage in the future.
- Explore the reasons why contraceptive usage is lower among married women as opposed to single women and unmarried women in partnerships. This is key in order to guide future strategies to increase adoption rates among this population.
- Look into how they can support more women with post abortion services. Despite the illegality of abortion, this practice does exist, and there is a real need to reach out for and help women who undergo abortions in this context.
[i] Statistics Sierra Leone, Measure DHS, & ICF Macro. (2014). Demographic and Health Survey 2013: Preliminary Report. Freetown & Rockville: SSL, MEASURE DHS, & ICF Macro.
[ii] Evidence for Action. (2014). MamaYe Facts and Figures on the Sierra Leone Demographic and Health Survey 2013. London: Evidence for Action
[iii] Marie Stopes Sierra Leone (2014) Knowledge, Attitude and Practices of family planning in 13 districts of Sierra Leone.Evidence for Action. (2014). Research briefing: Knowledge, Attitude and Practices of family planning in 13 districts of Sierra Leone. London: Evidence for Action.