Where are Women Getting Contraceptives in Conflict-Affected Settings?: Analysis of Demographic and Health Survey Data From 30 African Countries

Abstract

Background: Most populations affected by conflict still lack adequate reproductive health (RH) care. This study examined the association between conflict and modern contraceptive use, unmet need, and provision in 30 sub-Saharan African (SSA) countries. Objectives were to compare outcomes in conflict-affected, post-conflict and non-affected countries, and quantify the effect of conflict status on where women sourced their contraception. Methods: We used Demographic and Health Survey datasets to estimate our primary outcome of contraceptive use, within which we examined unmet need and type of contraceptive used. To examine where women accessed care, we categorised health services into public and non-public sectors. We classified countries as non-conflict, conflict-affected, or post-conflict using Uppsala criteria. Bivariate and multivariable logistic regression models were used to examine the association between outcomes and conflict. Findings: Among 344,394 women, unmet need was 53∙9%, 64∙3% and 66∙0% in non-, conflict-affected, and post-conflict settings, respectively. Use of modern contraceptives was 15∙1% overall, highest in non-conflict (21∙3%) and lowest in conflict-affected countries (10∙5%). Women in conflict-affected countries had 2∙35 times higher adjusted odds (95%CI 2∙10-2∙62) of seeking contraceptive services in the non-public sector than women in non-conflict affected countries. Interpretation: Contraceptive prevalence in conflict-affected SSA countries was low with a skew toward short-acting methods in conflict-affected countries. Women in conflict areas were more likely to seek services in the non-public sector. MCPR could potentially be increased through engagement with non-public sector entities, as women are already accessing contraceptive services there. Funding Information: Funding for this work came from MSD, through MSD for Mothers. Declaration of Interests: None declared. Ethics Approval Statement: Informed consent and ethical approval is obtained in every country the DHS is conducted. Ethical approval for this analysis was obtained from the London School of Hygiene and Tropical Medicine ethics committee.