Introduction

The uncontrolled population in developing regions over the last decade has brought family planning and the advocacy for modern contraception to the forefront of the global agenda. Modern contraceptive methods (MCM) as defined by Hubacher et.al. refers to technological products or medical procedures that affect natural reproduction. They can be classified as short-acting reversible contraception (SARC), long-acting reversible contraception (LARC), or permanent methods [1]. Access to modern contraception is now recognized as a universal human right that significantly improves maternal and child health status, reduces poverty, and enables women’s economic participation [2]. Despite the investment in family planning through the initiation of policy and programs and subsequent gains in contraceptive uptake, approximately 210 million women of reproductive age residing in low-middle income countries (LMICs) still report an unmet need for contraception. This is due to limited access to contraceptive services both geographically and financially, poor quality of services, lacking agency and decision-making on reproductive health and misconceptions regarding the use and side-effects of contraceptive methods [3, 4].

Within Asia, Pakistan, with its annual growth rate of 2.5, has already exceeded South Asia’s average growth rate of 1.2% and is forecasted to catapult to 403 million inhabitants by 2050 [5, 6].

Pakistan initiated commitment to improving maternal and child health in 1994 through the launch of the Lady Health Worker Program—the flagship Family Planning program. Since the program’s launch, the country has become a member of the global family planning community and a signatory to FP 2023 commitments envisioning the empowerment of women and young couples by achieving a balance between family size and resources. A recent development in this context is the introduction of the Costed Implementation Plan (CIP) by the Sindh government under the FP2020-30 initiative [7] which holds the potential to expedite advancements towards achieving the desired modern contraceptive prevalence rate (mCPR) targets. The CIP was developed to mark out a strategic multi-year roadmap to achieve family planning goals. The country also remains committed to the fulfilment of the SDG goals (particularly Goal 3 Health and well-being) with a firm stance on ensuring comprehensive access to family planning resources, services, and commodities. Diverse initiatives have been initiated within the country in collaboration with international and domestic non-governmental organizations, with sustained support from National, Provincial, and District governments.

Despite these efforts and commitments, utilization of family planning services and uptake of contraception have been low as reflected in a marked by a country-wide CPR of 34%, and 25% of unmet need for MCM [8–10]. Within Sindh, the second most populous largest province of Pakistan Sindh reports, contraceptive use is only at 28.9%, of which 25% is attributed to MCMs use [5]. A review of the local literature on family planning and contraception reveals limited method choice, specifically for modern methods; social stigma attached to birth control; family and societal disapproval; and lack of knowledge of the importance of birth spacing and maternal health as have been as persistent demand side barriers [11]. On the supply side, irregular supply of contraceptive methods, poor attitude and competency of healthcare providers and limited coverage and outreach of family planning services, have been reported as significant factors that negate uptake [11–13]. These low rates of uptake, of any type of contraceptive methods, are dangerously manifested in the country’s high fertility rate of 3.56 births per woman, combined with a maternal mortality rate of 186/100,000 livebirths and under-5 mortality rate of 63.3 deaths/ 1000 live births [14, 15]. Besides mortality, concomitantly high rates of early marriages of girls before 18 years of age, unintended pregnancies and resulting abortions, estimated at annual rate of 50 per 1000 women [16] coupled with socio-cultural and patriarchal barriers, present a concerning picture of the sexual and reproductive health and overall well-being of women and young girls in the country.

The reality and magnitude of these manifestations placed against the country’s continued sub-national and national efforts towards family planning and enhancing contraceptive uptake, require an assessment into why there is a disconnect and more importantly, what is not working. This is an important gap that provides the rationale for this study as it attempts to uncover and study various predictors in the voluntary uptake of modern contraception, specific to the context of Pakistan that can explain and strategically address this gap.

Methods and materials

This was a cross-sectional study with face-to-face interviews of married women of reproductive age at household level, using a structured questionnaire, as the pregnancies in Pakistan primarily occur following marriage [17]. This survey was conducted in two districts of the Sindh province, Matiari and Badin (Fig 1).

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Fig 1. *Study Sites–Badin and Matiari districts of province Sindh, Pakistan.

*Map developed on ArcGIS, available here for proper citation of base map: https://support.esri.com/en-us/knowledge-base/faq-what-is-the-correct-way-to-cite-an-arcgis-online-ba-000012040#:~:text=To%20reference%20the%20use%20of,Scale. Compatible with our CC-BY 4.0 license.

https://doi.org/10.1371/journal.pgph.0002419.g001

The selection of districts was based on propensity matching score further details could be obtained from protocol paper [18]. PSM is a statistical method to create a propensity score for participants based on the variables of interests or covariates among the districts. PSM also reduces the confounding biases in observational studies thereby decreasing challenges in comparison of the respondents from two population [19]. In this research, the matching process involved a sampling frame that included 23 districts within the Sindh province, utilizing data from the Multiple Indicator Cluster Survey (MICS) conducted in 2018 [5]. Data was extracted on all relevant program indicators, including the study population’s mCPR, antenatal and postnatal care services, facility births, and socio-economic and demographic status. Detailed PSM scores found in the supporting information file (S1 Table). The final district selection was approved by the Director General (DG) Health Sindh and project lead consultative meetings.

Results

From the total sample size of 1,760, 96% (n = 1,684) of MWRA were interviewed. There was a high response rate of 96%, as projected in the interview-based studies at the household level.

Sociodemographic characteristics of MWRA

In terms of sociodemographic characteristics in Table 1, the mean age of the study participants was 32.3years, with a standard deviation (SD) of 7.1 years. Among respondents, 27.0% (n = 453) had formal education. The average number of children per woman was 4.0± 2.0, and the average number of members living in the household was 7.2 ± 2.7.

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Table 1. Socio demographic characteristics of MWRA(n = 1,684).

https://doi.org/10.1371/journal.pgph.0002419.t001

Current use of contraceptives

Table 2 showed that from a total of 1,684 married women, 76.2% (n = 1255) reported that ever heard of at least one contraceptive method to delay pregnancy.

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Table 2. Current use of contraceptives reported by MWRA (n = 1,684).

https://doi.org/10.1371/journal.pgph.0002419.t002

The contraceptive prevalence rate was 27.4% (n = 462) in the sampled population. Furthermore, the overall use of modern contraceptive methods was observed to be slightly lower at 26.1% (n = 441). Among different methods, the most common short-term methods reported by the respondents were condoms (n = 87; 5.1%) followed by pills (n = 83; 5.0%) and injectables (n = 63; 3.7%). Moreover, the lactation amenorrhea method (LAM) use was reported by 6 women. However, one woman reported the use of standard days methods (SDM). Out of all the long-acting reversible contraceptive methods respondent’s reported using implants (n = 41; 2.4%) and IUDs (n = 12; 0.7%). Among irreversible/permanent methods of contraception, (n = 109; 6.5%) reported female sterilization and only one respondent reported male sterilization method use.

The prevalence of traditional methods was less than two percent amongst all surveyed women (n = 22; 1.3%). Among such practices, 1.1% (n = 19) of observations were recorded for the withdrawal method, which was found to be the most common, followed by the rhythm method (n = 3; 0.1%). Additionally, distribution of modern contraceptive methods among socio demographic characteristics attached as supporting information file (S2 Table).

Predictors for use of modern contraceptive methods (MCM)

Table 3 shows the univariate and multivariate analysis of the predictors associated with the use of modern contraceptives.

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Table 3. Predictors for use of modern contraceptive method (MCM) among Married Women of Reproductive age (MWRA- 15-49years).

https://doi.org/10.1371/journal.pgph.0002419.t003

Univariate analysis.

The odds of using contraceptives among women with more than four children were four times higher than those with only one child (OR: 3.73; 95%CI: 2.27–6.14). The likelihood of use of contraceptives was two times higher for women aged 35–39 years compared to women aged below 19 years (OR: 2.55; 95%CI: 1.34–4.85). Women who had completed middle-level education were at least twice as likely to use modern contraceptives to delay pregnancy than those without education (OR: 1.62; 95%CI: 0.97–2.73). Similarly, husbands who had completed their middle-level education were at least two times more likely to use contraceptives compared to those who were uneducated (OR: 1.87; 95%CI: 1.20–2.93). The odds of modern contraceptive use among women who belonged to the rich wealth index were two times higher than women in the poorest wealth index category (OR: 1.722; 95%CI: 1.051–2.00).

Women who were using health facilities for maternal health services showed a significant increase in the odds of using contraceptives in their postpartum period compared to women who were not using health facilities. Mothers who sought antenatal care services had higher odds of adopting modern contraceptive methods (OR: 1.25; 95%CI: 0.956–1.77) as compared to those who did not have ANC visits. Similarly, mothers who had visited health facilities four or more times for ANC visits were 1.25 times more likely to use contraceptives in their postpartum period than those who had visited less than four times during their pregnancy.

Moreover, mothers who delivered by skilled birth attendant showed higher odds of using contraceptives than those who delivered at home (OR: 1.30; 95%CI: 0.99–1.79). The odds of use of contraceptives amongst women with cesarean birth were 1.4 times the odds of use of contraceptives amongst women who had either normal or assisted vaginal delivery (0R: 1.40; 95%CI: 1.04–1.88). Women who had a postnatal care also showed higher odds of using postpartum contraceptives than those who did not (OR: 1.33; 95%CI: 1.00–1.75). Lady Health Worker visits after delivery and for PNC were associated with a significant increase in the odds of the use of contraception (OR: 2.028; 95%CI: 1.56–2.62). Similarly, family planning counseling during antenatal care visits also showed a significant increase in the odds of the use of postpartum contraceptives compared to those who had not received any counseling (OR: 1.60; 95%CI: 0.74–3.44).

Multivariate analysis.

The multivariate logistic model shows that women with four or more children are four times more likely to use contraceptives than those with only one child (AOR: 5.23; 95%CI: 2.78–9.84). Compared to the bivariate model, after controlling for other covariates, the odds of use of contraceptives were significantly higher among women who had completed primary education compared to uneducated women (AOR: 1.73; 95%CI: 1.26–2.36). The odds ratio remained significant for husbands who had attended middle level education in the multivariate model (AOR: 1.69; 95%CI: 1.03–2.76). The odds of a postnatal care of the mother were 1.4 times higher amongst mothers who had used contraceptives (AOR: 1.46; 95%CI: 1.09–2.05) as well as women who were visited by the Lady Health Worker in their postnatal period and were counseled on family planning (AOR: 1.83; 95%CI: 1.38–2.42).

Discussion

This study assessed predictors for opting for voluntary modern contraceptive methods amongst women of reproductive age in Sindh. This was achieved through univariate and multivariate analysis for specific variables, including knowledge, practices, access, and use of reproductive and maternal health services. The results showed the number of children, mother’s education, husband’s education, postnatal care visits of mother, and LHW counseling for family planning as part of the PNC visit; were the most accurate predictors of modern contraceptive methods. These results provide valuable insights into designing family planning programs that are well-suited to the local context with its unique and challenging socio-cultural and patriarchal dynamics.

The study noted that the average number of living children was at least four children per MWRA; women with more than four children were more likely to use modern contraceptives. This showed a significant inclination of the sample population towards limiting their pregnancy rather than spacing between desired pregnancies, particularly in women aged more than 35 years for which majority of them opted for sterilization, a surgical procedure. Younger respondents, on the other hand, tended to prefer short-acting methods like condoms, pills, and injections. The desire for uptake of contraception by both younger and mature women as revealed in this study, is coherent with findings from studies conducted in Pakistan. A cross sectional study conducted on women’s decision-making autonomy as a facilitating factor for contraceptive uptake highlights women’s increasing acceptance and demand for contraceptive methods to avert unwanted pregnancies [13].

Despite this awareness and desire for contraceptive methods, the utilization of long-acting reversible contraceptives (LARC), such as intrauterine devices (IUDs) and implants, was not widely observed in this study. This finding is supported by a mixed methods study on reasons for low uptake on widely available modern contraceptive methods conducted in Pakistan. The study reported that married women of reproductive age perceive that long-acting methods are less effective and have severe and fatalistic side-effects, that could potentially reduce their fertility [25].

Conversely, contraception needs related to desire for spacing are predicted to be greater among younger women; however, the results show the reverse whereby contraceptive use amongst younger women was lower. This dilemma of high need but low use discerned in our results can be explained by findings from the literature. Studies on barriers to uptake in family planning and socio-demographic determinants of unmet need in Pakistan emphasize that younger women and couples are less likely to have a discussion about use of contraception due to a lack of knowledge, couple communication gaps in the initial years of marriage, and societal pressure to have children which leaves them, especially younger girls, less motivated to consider timely uptake of contraception [9, 12, 26]. Additionally, the prevalence of contraceptive use amongst respondents was almost similar to that reported in the national and regional statistical records [8]. The current study has further highlighted gaps between the awareness and practice of modern contraceptive methods. Though majority of the participants were aware of contraceptive methods, this did not translate into practice. Other studies conducted in Pakistan attribute this gap mainly to socio-cultural and societal barriers [25, 27].

Another significant element contributing to narrowing the gap between knowledge and application is the accessibility of contraceptive methods along with their consistent availability. The uninterrupted provision of these methods plays a pivotal role in addressing the issue of unmet needs and fostering the adoption of MCMs [28]. The importance of availability is emphasized as a major predictor of contraception usage in a quantitative study undertaken in Karachi, Pakistan. The study iterates that a lack of contraceptive commodities leads to high rates of discontinuation and reduced effectiveness of contraception and more broadly family planning efforts [10].

Moreover, other negative attitudes and misconceptions, including fear of side effects and a preference for a male baby, continue to contribute to low uptake of contraceptives. This is echoed in various qualitative and mixed methods studies conducted on family planning in Pakistan that reiterate the desire for a son, specifically in rural areas, as a key hinderance to uptake of contraception. These studies also link the lack of community knowledge and awareness of contraception with myths and ill-founded suspicions regarding side effects of contraception, including death, that continue to be spread through social communication networks within local neighborhoods and communities [9, 29–32].

Interestingly, the study found that amongst subgroups in the sample population, the contraceptive prevalence rate was higher amongst women falling within the rich quintile. This finding is similar to other studies, both in the local and global literature, that explore and validate a strong positive association between increasing level of wealth quintile and increased ease of access to FP information and contraceptive services as well as sustained use of MCMs [33, 34].

Interestingly, women educated at the primary level were more likely to opt for modern contraceptive methods than women who had attained comparatively higher education as opposed to previous studies [31, 34]. Furthermore, in univariate analysis, contraceptive use showed an increase with increasing levels of males’ education. These findings are compounded by the literature that describes a comprehensive range of studies on family planning that emphasize the role of male engagement in improving uptake, specifically through (i) enabling male partners / spousal support for adopting a contraceptive method and (ii) involving their female partners in decisions regarding family size, reproductive health, and use of an MCM [26, 35–38].

This study’s most important finding was identifying postnatal care (PNC) as the most significant predictor for opting for family planning. Respondents who sought PNC were more likely to use modern contraceptive methods. Evidence in the literature has endorsed that postnatal counseling before discharge significantly improves motivation for and practice of contraceptive uptake [25, 28–30]. This study also observed that Lady Health Worker’s counselling delivered during a PNC visit increased the likelihood of family planning utilization. The probable cause of this finding can be linked to the preference of the local community for Lady Health Workers to discuss family planning matters on a one-to-one basis at the household level while maintaining confidentiality [39]. Moreover, Lady Health Workers also provide family planning commodities like condoms and pills during their routine visits. Consistent with our results, referral to a health care facility through LHW also increases postpartum utilization of family planning. Therefore, the Lady Health Worker Program strongly influences women’s fertility choices and their use of sexual and reproductive health care services [30, 40].

Our study population reported a lower prevalence of family planning counseling received during ANC visit. At the same time, these visits still influenced positive behaviors towards modern contraceptive methods. In addition to this, family planning exposure was seen to be associated with subsequent antenatal care visits, a higher number of deliveries performed by skilled professionals, and a greater chance of delivery at a health facility [41]. Earlier studies have shown a positive relationship between the delivery of high-quality antenatal family planning counseling services and increased contraceptive use [4, 42].

Another study conducted in a similar setting as our study sites, concluded that in communities where a higher proportion of women received quality antenatal care with an explanation of the importance of postpartum family planning and where discussion of birth spacing was more common, there was significantly higher contraceptive use particularly for LARCs [41, 43]. In light of these findings, this study recommends integrating family planning with maternal, newborn, and child health services and using community engagement as a key mechanism of service delivery. In that, these integrated services can be delivered through ongoing antenatal and postnatal care visits conducted by well-trained Lady Health Workers that incorporate a renewed focus on providing family planning counselling, information, referral and services for women, young couples as well as men [44–47].

These studies were short-term funded programs highlighting the need for sustainable programs and scaling up existing resources. Thus, multiple determinants then affect contraceptive uptake in the context of Sindh, and strategically addressing these are imperative in improving MCM prevalence rates.

Addressing these determinants requires an inter-sectoral approach that integrates various local, regional and national sectors such as policymaking, programming, education, health and development. By building evidence for predictors that affect contraceptive uptake, this study provides an important basis for informing, rethinking, and strengthening the current public health agenda and policies that focus on improving access, availability, quality and affordability of contraceptive services, specifically to a greater proportion of high-risk populations within the country.

Conclusion

According to the aim of this study to assess predictors associated with the uptake of MCMs in rural Sindh, this study showed that the voluntary uptake of modern contraceptive methods is higher in women receiving antenatal care, postnatal care at facility and skilled-based delivery, family planning counseling Lady Health Workers visits after delivery. Education was also seen as an important predictor as the odds of use of contraceptives were significantly higher amongst women with primary education as compared to women with no education.

The findings also revealed that existing family size is an important predictor of uptake, in that, women with four or more children are more likely to use contraceptives than those with one child. The main purpose of using MCMs is for limiting pregnancies rather than maintaining birth-spacing and utilization increases with age. This is an important finding that can be used to inform behavioral change interventions to improve outcomes.

Supporting information

Acknowledgments

We extend our appreciation to the Department of Health and the Population Welfare Department of the Sindh Government for their essential partnership in project implementation. Our sincere gratitude is directed towards the study participants, whose involvement and input are highly valued. Additionally, we acknowledge the dedicated district-based personnel for their consistent assistance throughout project activities, playing a crucial role in the effective achievement of this initiative.