Background

Ensuring access to modern contraceptive methods for women is a key to securing not only the health and well-being of women, but also the health and development of communities [1]. The World Health Organization (WHO) have recognized that tailored reproductive services are not only critical to improving the health of women, but also a human right. Currently, about 214 million women have an unmet need for modern contraceptives [2]. Over 85 million mistimed or unwanted pregnancies occur each year worldwide, which leads to high rates of induced abortions and maternal morbidity and mortality [3]. The European Action Plan for Sexual and Reproductive Health emphasizes the importance of improving access to contraceptive services of disadvantaged groups, such as immigrants [4]. Nonetheless, studies from Europe suggest that immigrant and refugee women have higher rates of unintended pregnancy and abortion than non-immigrant women [5–9], raising concerns about their access to quality contraceptive education and healthcare [10, 11]. Unfair differences in access to reproductive health services within and between groups are defined by the World Health Organization (WHO) as inequity [7].

Research undertaken in Scandinavia suggests that immigrant women seek induced abortion in higher numbers than would be expected given their proportion of the population [8, 11, 12]. A registry-based study in Norway found a pregnancy termination rate of 30.2 per 1000 women per year among refugees compared with a 16.7 per 1000 women per year rate among non-migrants [10]. Another study in Norway found that 25% of women seeking abortion were immigrants from non-Western countries [11]. Immigrant women are vulnerable to unintended pregnancies owing to their limited knowledge about and access to services for contraception and family planning [8, 12, 13]. Furthermore, the underutilization of contraceptives does not only result in unintended pregnancies and abortion, it also restricts women’s ability to achieve educational and economic goals [14]. Reproductive rights include the right of women to decide how many children they want to have, full access to family planning information and services [15]. Facilitating access to contraception for women has the potential benefit of improving maternal health [16] by lowering the annual number of unintended pregnancies.

The Norwegian healthcare system is predominantly public and everyone is entitled to have a general practitioner (GP) who can prescribe contraceptives and insert implants and intrauterine devices (IUDs). There is co-payment for the GP visit, while midwives and nurses can also prescribe contraceptives. Unlike GPs, the visits to midwives and nurses are free of charge. Contraceptive methods are subsidized partly or wholly for women under the age of 22 while older women must pay the full cost of the method. The utilization of reproductive services depends on language proficiency, and comprehension of information received about the health system. Doctor-patient interaction patterns, and language and cultural differences between immigrants and health providers are critical in immigrant’s access to services [17].

An estimated 43,000 Somali immigrants live in Norway, thus constituting the largest non-Western immigrants in the country. Somalia is an East-African country with a population of 12 million and it has the lowest contraceptive prevalence rate in the world of <10% [18]. Understanding and utilization of modern contraceptives is low amongst Somali women, including those who desire to avert pregnancy [19]. Somali women’s fertility rate is 6.4, which exceeds fertility rate in sub-Saharan Africa (5.1) and the world (2.5). This is partly reflected in the high maternal mortality rate of Somalia (732 per 100,000), which is much high than the average in sub-Saharan Africa (84.5 per 100,000) [20]. Total Fertility rate of Somali women in Norway is 4.40 [21], which is much higher than the total fertility rate in Norway of 1.78. Religious misperceptions, cultural factors, and a lack of knowledge regarding modern contraceptives prevent both Somali women and men from accepting and accessing contraceptive health services [22]. Large families are valued in Somali culture, and therefore there is a social pressure for women to bear more children [23].

Somali immigrants may bring their beliefs and attitudes toward contraception with them during migration. For instance, the main reasons for Somali immigrant women in Finland not using contraception were reported to be religious objections and issues related to gender roles [24]. This mirrors the rationale of women in Somalia, where using contraceptives with the intention to limit the number of children is considered to be against Islamic values and Somali traditions [22], further highlighting that the culture of immigrant’s country of origin may shape their contraceptive use regardless of availability of the methods. Nevertheless, cultural traditions, religious misperceptions and social norms are not static but, rather, a dynamic process that changes with the circumstances that surround it [25]. Migration to a new country, exposure to different social context, and improved educational levels can influence traditions and cultural beliefs of individuals, which in turn play a key role in reshaping a community’s norms, behaviors, and values [25].

A number of studies in Norway reported a low utilization of modern contraception among immigrant women [10, 11, 26]. However, none of these studies have explored reasons underlying immigrant women’s underutilization of modern contraception. This study thus, provides the first qualitative study on the barriers and facilitators to modern contraception among Somali immigrant women in Norway.

Methods

Data collection

The participants were interviewed one on one in Somali language, either at their homes or at a selected place of their choice. Data were collected using an interview guide but questions were asked to women in a convenient way, and the order of the questions varied from interview to interview. The interview started with open-ended questions to collect participants’ demographic characteristics as shown in Table 1. The participants were offered the opportunity to share detailed information of their experiences and opinions about contraception utilization of Somali women [27, 28]. The unstructured interview technique allowed women to go beyond the actual questions and to talk freely about the contraception methods to highlight additional issues of concern, which allowed for the exploration of unanticipated themes. Thus, the participants presented not only their personal experiences but also the experience of their acquaintances and friends. The interview guide covered several themes: (1) community norms and communication regarding family planning (2); knowledge and attitudes toward modern contraceptives (3); reasons for usage or non-usage of modern contraceptives; and (4) factors that prevent Somali women from utilizing modern contraception. Lastly, the acceptable means of increasing access and utilization of contraception were explored through women’s perspectives. The interviews lasted for 45 to 60 minutes. All the interviews were audio-recorded with consent. The second author, who is a Somali ethnic female with extensive experience in qualitative data collection, carried out the interviews, together with the first author. Recruitment and interviews continued until researchers became convinced that no new information was emerging from the additional interviews, that is, when saturation was achieved.

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Table 1. Characteristics of study participants.

https://doi.org/10.1371/journal.pone.0229916.t001

Results

As shown in Table 1, majority of study participants have been living in Norway for an average (± standard deviation) of 17.9 ± 7.8 years. After the analysis, four main categories emerged from the data. Two of these categories represented barriers to contraception use, while the other two have represented facilitators to contraception use. These categories were summarized in Table 2.

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Table 2. Themes and subthemes.

https://doi.org/10.1371/journal.pone.0229916.t002

System related barriers

In this paper, system related barriers refer to users’ inability to access relevant contraceptive information and services mainly due to system related factors.

Socio-cultural barriers

Socio-cultural barriers refer to factors that impede women’s utilization of modern contraceptives for religious believes, social norms, social pressure, husband not in favor of using it and so on.

System based facilitators

Community based facilitators

Discussion

This study explored barriers and facilitators to contraception use among Somali immigrant women in Oslo, Norway. The study found that Somali women in Norway do not have their contraceptive needs met. System-related barriers, including the lack of appropriate information about the safety and accessibility of modern contraception, were among the barriers to contraceptive use. This finding may explain why immigrant and refugee women in Europe have higher rates of unintended pregnancy and abortion than non-immigrant women [5–9]. Many Somali women are skeptical about the modern contraception, which they associate with cancer, vitamin deficiency and infertility. This skepticism can be considered a direct consequence of a lack of appropriate information about modern contraception. Information provision requires a cultural understanding between immigrant women and health providers, with a culturally competent interpreter in place. Moreover, it may not be easy for many Somali women to discuss contraception and sexual health with a male doctor or through a male interpreter [32], which may limit their ability to discuss all their concerns with the male provider, and this compromises their right to take informed decisions. Training health providers for provision of appropriate and culturally tailored information about contraceptives is required to increase the contraception uptake of Somali immigrant women.

The study shows socio-cultural barriers mainly religious misperceptions that influence the decision of many Somali women in Norway to use contraception. This finding is in-line with prior finding among Muslim women in Africa whereby 66% of women’s decisions toward contraception is influenced by religion [33]. In Norway, this finding is unexpected given the fact that Somali immigrant women interact with many other Muslim communities that are knowledgeable about Islam and its position in family planning. Predominantly oral society, there are plenty of religious myths that thrive amongst them. For example, Somalis believe that female genital mutilation (FGM) is obligated by Islam, while many Muslim communities in Norway are not only totally unfamiliar with the practice, but also considered it un-Islamic. A study in USA found very low uptake of contraceptives among Somali women which was associated with religious beliefs [34]. However, in most Muslim countries, Imams support the use of modern contraception [35]. A study in Nigeria found that the exposure to family planning messages from religious leaders increased modern contraceptive use among Muslim women [33]. Campaigns against FGM in Norway have long used religious leaders as agent of change, which led to attitude change toward the practice among Somali immigrants [36]. Given the influential positions of religious leaders, the strategies to increase contraceptive uptake should engage religious leaders in advocacy work.

In this study, male partner’s resistance to family planning was another hurdle to contraception use. Participants of this study reported that there is a concern among women that if a woman fail to reproduce as many children as her husband wants, the husband is likely to abandon her to another woman who is willing to meet his fertility demand. A study in Tanzania reported that women using contraception against the wishes of the husbands could lead to violence or divorce of the woman [37], which support the Somali women’s concern. Our earlier quantitative study found that 20% of Somali women in Oslo have never discussed contraception with their husbands [31]. In a study on FGM amongst Somalis in Sweden asking men and women separately about potential perpetrators of FGM, men claimed that the practice is encouraged by women while women reported the contrary; after being brought together to discuss the issue and it became clear they had never discussed the issue. Similar situation may be true that Somali women and men do not discuss the contraception use; women may believe that men would not allow contraception use, while otherwise could be true with men. Nonetheless, Somalis are patriarchal society where men determines most of the family issues. A prior study of Somali women in Finland argued that if Somali men were educated about the importance of family planning, there might be a transformation of values and perceptions about birth control [24]. In sub-Saharan African, the majority of women considered modern contraception acceptable, but they require the permission of their partners before they actually adopted a modern method [38]. Consistent with this, a participant in our study suggested that there are many Somali women in Norway whose personal conviction is insufficient to ensure the uptake of modern contraceptive methods. Male involvement in family planning can increase uptake and continuation of contraceptive use by improving spousal communication [24, 38]. Therefore, any intervention to increase contraception use among Somali women in Oslo should educate women and men equally about family planning, and promote partner communication regarding contraceptive methods.

Participants have presented their views about facilitators to contraception use including participation of religious leaders in awareness creation campaigns. Many Somali women perceive contraception as against their religious teaching. This could be because some prominent Somali Imams speak against modern contraception. Contrastingly, in Arabic speaking Muslim countries such as Jordan, 82% of male religious leaders and 98% of female religious leaders believe that Islam encourages family planning [35]. Similarly, Muslim nations have actively engaged Islamic scholars to advocate for maternal and child health, including modern contraception [39, 40]. Study participants suggested that awareness campaigns aimed to change the perception of Somali immigrant women and men towards contraception should engage religious leaders in awareness programs. This engagement should go hand in hand with building capacity to enhance religious leaders’ knowledge on family planning methods.

Finally, participants think that empowering Somali women in decision making and autonomy for the decisions affecting their health and wellbeing is the most important factor affecting their contraceptive use. Women’s empowerment is defined as ‘the expansion of people’s ability to make strategic life choices in a context where this ability was previously denied to them’ [41] which is an important aspect affecting family planning and reproductive health outcomes of women. Empowering women through essential resources such as education and employment was associated with lower fertility, longer birth intervals and lower rates of unintended pregnancy [42]. While improving reproductive health rights of women is receiving growing attention in Norway [16], the barriers to contraception that Somali immigrant women experience are similar to barriers reported among women in different parts of Africa. Norwegian government efforts to promote reproductive health and rights of women should ensure that women’s individual resources such as education and employment are strengthened. Such efforts should enable women to make an informed contraceptive choice, which is consistent with their personal values, needs and beliefs.

This study had several limitations. The purposeful selection of study sample does not ensure that these populations were in fact representative of all Somali women in Norway. Moreover, study participants were women who have lived in Norway for a mean 17 years. Therefore, newly arrived women might have experienced different barriers that are not mentioned here. However, there are studies that investigated barriers to contraceptives among the Somali community, both in Somalia [22] and Somali immigrants in the West, which found similar results [43]. Despite these limitations, the result of this study contribute to the existing body of knowledge on utilization of contraception services among immigrant communities in Western countries. The findings demonstrate that, despite the availability and the equal access of contraceptive methods to all women in Norway, predominantly socio-cultural barriers impede Somali women’s contraceptive usage. The study findings underline that the availability of contraceptive methods in isolation is insufficient to ensure uptake amongst immigrant Somali women. Socio-cultural factors, such as the social pressure of having many children, men’s attitude toward contraception and religious misperceptions toward modern contraceptives, must be addressed.

Conclusion

Family planning is affected by many factors operating at the level of the individual, family, peer group, community, institution, and policy environment. Eliminating the barriers preventing immigrant women from receiving modern contraception has important public health implications, including decreasing unplanned pregnancies and induced abortions. Participants had a good understanding of the importance of contraceptive methods for the health of the mother and the child. Although the majority had good knowledge of modern contraception and had experienced using it, they made it clear that Somali women face barriers to access. In order to successfully meet women's modern contraceptive needs, policy makers, health providers and civil society organizations should consider the barriers, and implement the facilitators reported by this study. Steps that we suggest include: the provision of appropriate health information on contraception to women, especially in early years of their arrival in the country; subsidy on contraceptive methods; encouraging partner communication in family planning; training health providers to improve their multicultural competence; and engaging religious leaders in advocacy work. Moreover, broader research is recommended that assesses the barriers at each level (individual, family, peer group, community, institutional, and the policy environment) to determine which interventions are best suited to increase Somali immigrant women’s contraception use. While health providers and policy makers should address system related barriers, civil society and community organizations should promote women’s empowerment and encourage partner’s discussion on family planning to counteract community based barriers. Further, given the influential positions of religious leaders, the strategies to increase contraceptive uptake should engage religious leaders in advocacy work. Finally, women’s low level of decision making power within families is a major barrier in contraception utilization affecting the health and development of immigrant women and thus, it should be addressed through multiple fronts.

Acknowledgments

We thank Norwegian Women’s Public Health Association who owns the project, and Vera Minja for helping research team on administrative work. We also thank Bernadette Kumar and Berit Austveg for commenting the study proposal.