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      Family Planning in the Democratic Republic of the Congo: Encouraging Momentum, Formidable Challenges

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          Abstract

          Formidable challenges: uncertain political situation, cultural norms favoring high fertility, a thin patchwork of service delivery institutions, logistical issues in a vast country with weak infrastructure, and low capacity of the population to pay for contraceptive services. Encouraging progress: increasing government and donor support, openness to progressive service delivery policies, innovative programming including robust social marketing and initiatives with nursing schools and the military, strong collaboration among stakeholders, high unmet need suggesting strong latent demand for family planning, and an increasingly balanced method mix including long-acting methods.

          Abstract

          Formidable challenges: uncertain political situation, cultural norms favoring high fertility, a thin patchwork of service delivery institutions, logistical issues in a vast country with weak infrastructure, and low capacity of the population to pay for contraceptive services. Encouraging progress: increasing government and donor support, openness to progressive service delivery policies, innovative programming including robust social marketing and initiatives with nursing schools and the military, strong collaboration among stakeholders, high unmet need suggesting strong latent demand for family planning, and an increasingly balanced method mix including long-acting methods.

          Abstract

          Momentum for family planning in the Democratic Republic of the Congo (DRC) is evident in multiple ways: strong political will, increasing donor support, a growing number of implementing organizations, innovative family planning programming, and a cohesive family planning stakeholder group. Between 2013 and 2017, the modern contraceptive prevalence rate (mCPR) in the capital city of Kinshasa increased from 18.5% to 26.7% among married women, but as of 2013–14, it was only 7.8% at the national level. The National Multisectoral Strategic Plan for Family Planning: 2014–2020 calls for achieving an mCPR of 19.0% by 2020, an ambitious goal in light of formidable challenges to family planning in the DRC. Of the 16,465 health facilities reporting to the national health information system in 2017, only 40% offer family planning services. Key challenges include uncertainty over the political situation, difficulties of ensuring access to family planning services in a vast country with a weak transportation infrastructure, funding shortfalls for procuring adequate quantities of contraceptives, weak contraceptive logistics and supply chain management, strong cultural norms that favor large families, and low capacity of the population to pay for contraceptive services. This article describes promising initiatives designed to address these barriers, consistent with the World Health Organization's framework for health systems strengthening. For example, the national family planning coordinating mechanism is being replicated at the provincial level to oversee the expansion of family planning service delivery. Promising initiatives are being implemented to improve the supply and quality of services and generate demand for family planning, including social marketing of subsidized contraceptives at both traditional and non-traditional channels and strengthening of services in military health facilities. To expand contraceptive access, family planning is being institutionalized in nursing schools, allowing students to operate as community-based distributors. While major challenges remain, significant progress in family planning has been made in the DRC, which should be judged not in comparison with sub-Saharan African countries with high mCPR and mature programs, but rather with those starting from much further behind.

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          Most cited references13

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          Contraceptive method skew and shifts in method mix in low- and middle-income countries.

          Method mix-the percentage distribution of contraceptive users in a given country, by method-is one measure that reflects the availability of a range of contraceptive methods. A skewed method mix-one in which 50% or more of contraceptive users rely on a single method-could be cause for concern as a sign of insufficiency of alternative methods or provider bias. Shifts in method mix are important to individual countries, donors and scholars studying contraceptive dynamics.
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            Barriers to modern contraceptive use in rural areas in DRC.

            Recent research in the Democratic Republic of Congo (DRC) has shown that over a quarter of women have an unmet need for family planning and that modern contraceptive use is three times higher among urban than rural women. This study focuses on the reasons behind the choices of married men and women to use contraception or not. What are the barriers that have led to low levels of modern contraceptive use among women and men in DRC rural areas? The research team conducted 24 focus groups among women (non-users of any method, users of traditional methods and users of modern methods) and husbands (of non-users or users of traditional methods) in six health zones of three geographically dispersed provinces. The key barriers that emerged were poor spousal communication, sociocultural norms (especially the husband's role as primary decision-maker and the desire for a large family), fear of side-effects and a lack of knowledge. Despite these barriers, many women in the study indicated that they were open to adopting a modern family planning method in the future. These findings imply that programming must address mutual comprehension and decision-making among rural men and women alike in order to trigger positive changes in behaviour and perceptions relating to contraceptive use.
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              Barriers to Modern Contraceptive Use in Kinshasa, DRC

              Recent research from Kinshasa, DRC, has shown that only one in five married women uses modern contraception; over one quarter have an unmet need for family planning; and almost 400 health facilities across Kinshasa report that they provide modern contraception. This study addresses the question: with reasonable physical access and relatively high unmet need, why is modern contraceptive prevalence so low? To this end, the research team conducted 6 focus groups of women (non-users of any method, users of traditional methods, and users of modern methods) and 4 of husbands (of users of traditional methods and in non-user unions) in health zones with relatively strong physical access to FP services. Five key barriers emerged from the focus group discussions: fear of side effects (especially sterility), costs of the method, sociocultural norms (especially the dominant position of the male in family decision-making), pressure from family members to avoid modern contraception, and lack of information/misinformation. These findings are very similar to those from 12 other studies of sociocultural barriers to family planning in sub-Saharan Africa. Moreover, they have strong programmatic implications for the training of FP workers to counsel future clients and for the content of behavior change communication interventions.
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                Author and article information

                Journal
                Glob Health Sci Pract
                Glob Health Sci Pract
                ghsp
                ghsp
                Global Health: Science and Practice
                Global Health: Science and Practice
                2169-575X
                21 March 2018
                21 March 2018
                : 6
                : 1
                : 40-54
                Affiliations
                [a ]Government of the Democratic Republic of the Congo (DRC) , Advisor to the Prime Minister , Kinshasa, DRC.
                [b ]Tulane International LLC , Kinshasa, DRC.
                [c ]United States Agency for International Development/DRC , Kinshasa, DRC.
                [d ]United Nations Population Fund , Kinshasa, DRC.
                [e ]Programme National de Santé de l'Adolescent, Ministry of Health , Kinshasa, DRC.
                [f ]Programme National la Santé de la Reproduction , Kinshasa, DRC.
                [g ]The Bill & Melinda Gates Foundation , Seattle, WA, USA.
                [h ]Tulane School of Public Health and Tropical Medicine , New Orleans, LA, USA.
                Author notes
                Correspondence to Jane T Bertrand ( bertrand@ 123456tulane.edu ).
                Article
                GHSP-D-17-00346
                10.9745/GHSP-D-17-00346
                5878077
                29602865
                8028f17c-a368-4c43-9f21-8ea4bea70813
                © Kwete et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://doi.org/10.9745/GHSP-D-17-00346

                History
                : 6 September 2017
                : 9 January 2018
                Categories
                Programmatic Reviews & Analyses

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