In this country comparative study, the focus was on the prevalence and determinants of unmet need for FP among women in Gambia and Mozambique. Being located in two different regions in sub-Saharan Africa, these two countries share similar demographic and population health characteristics such as life expectancy, fertility rates, and maternal and child mortality rates. Our analysis indicates that unmet need for FP is similar in these two countries, with a slightly lower prevalence in Gambia (17.86%) than Mozambique (20.79%) and in comparison, with previous studies in Nigeria, 16.1% [20] and Ethiopia, 37.5% [21]. As estimated by the World Bank in 2016, the per capita health expenditure in Mozambique stands at $19.21 which is very close to that of Gambia, $20.93. However, meeting the reproductive health needs of Mozambique’s larger population presents a more sizeable task. In both of the countries, low coverage of FP remains a public health challenge because of the low use of contraception [22] and lack of adequate healthcare workers and healthcare infrastructure [23]. For this study, information on healthcare workforce and infrastructure—two important indicators for better coverage of FP services—was not available. However, region specific analysis showed that urban women in Mozambique had a noticeably lower prevalence of having unmet need for FP. Rural regions generally underperform in health-related indicators, and our analysis suggests that the urban–rural gap is also a matter of concern for Mozambique.
Several similarities were observed between these two countries in terms of the sociodemographic factors associated with unmet need as well as type of occupation and access to electronic media. In both countries, women having employment in white collar professions (e.g. technical/managerial) had lower likelihood of reporting unmet need of FP. In general, type of occupation reflects women’s socioeconomic status with professional jobs being more conducive to better health status and awareness [24]. This finding suggests that women without employment are at higher odds of having unmet need for FP, and therefore, deserve special attention from FP program designers. Although socioeconomic status is recognized as a key predictor of using FP services [25,26,27,28], our analysis did not find any significant association with wealth and educational status. Education plays a positive role on health knowledge and awareness which lead to better self-efficacy and practice [29, 30]. A study in the sub national region of Ethiopia also showed no association between education and unmet need for family planning [7]. Similarly, better financial situations act as an enabling factor for using health services, and therefore women living in wealthier households are believed to enjoy better access to contraception [31]. Despite these known positive roles, the insensitivity of education and wealth status results in this study can imply that the main causes of unmet need may lie outside the demand side factors and are rooted in supply side factors. Further studies are necessary to explore the mechanisms behind these irregularities.
Having access to electronic media showed an inverse association with unmet need for FP in Mozambique. This finding is line with several studies conducted in sub-Saharan African countries. The Nigeria Demographic and Health Survey (2013) revealed that women who had access to mass media messages had higher likelihood of using FP services [28]. Lack of access to mass media was found to be associated with higher level of unmet need for spacing and limiting births among women in Ethiopia [21]. Mass media platforms function as potential sources of health communication on various issues including sexual and reproductive health, thereby increasing exposure to information with the capacity to influence the knowledge and practice of seeking FP services. Concrete data on the content of the messages received through electronic media and whether they were relevant to FP was not available; this type of information could provide better context to inform our understanding of the association. FP communication through mass media [32] and social networking (including friends, family members, and media sources) [33] were shown to have beneficial effects on the use of FP. Based on these reports, it seems beneficial for family planning programs to utilize mass media as a knowledge mobilization tool for FP communication in Mozambique. For example, a recent study in Ghana revealed a high level of misconceptions about intrauterine devices among women that prevented use of the device for family planning [34]. Other countries experiencing low uptake of IUDs as contraception may benefit from mass media education dispelling myths and increasing successful FP approaches. Interestingly, no significant effect of media access was observed for Gambia; this requires further exploration.
Lastly, this study revealed women in female headed households and women who had experienced abortion were less likely to have unmet need for FP. A possible explanation for the first finding is that women in female headed households are more likely to be aware of the need for FP services, or enjoy a better FP-friendly environment than those who live in male headed households. For women who had a history of abortion, the likelihood of using FP is expected to be higher due the knowledge and awareness gained through their experience.
There are several limitations to report regarding the present analysis. Contraceptive use is a complex behaviour and can be influenced by a wide range of factors such as lack of awareness and knowledge, personal belief and attitude towards the technology, fear of side-effects, as well as inconvenience/unsuitability [35]. Individual behaviour itself is shaped and influenced by various sociocultural and environmental factors which are essential for a deeper understanding of the causes of non-use of FP services. As such, the subject matter is more qualitative in nature and requires in-depth investigation which is not possible through quantitative analysis. As this study was based on secondary data, authors had no control over the design of the study and were not able to choose variables in terms of their demonstrated association with unmet need for FP. Nonetheless, the findings provide valuable information for further qualitative research on this topic. Data collection took place in 2013 and 2011 for Gambia and Mozambique respectively, therefore, the prevalence estimates may not reflect the present scenario. Information on unmet need were self-reported, and thus remain subject to reporting bias/error. The surveys were cross-sectional, which means the outcome and explanatory variables were measured at the same time, and therefore cannot guarantee any causality of the associations.