This study examined the association between Congolese women’s decision-making power over their own health care and current use of MC. Results are consistent with previous findings from Nigeria which suggest that women’s participation in health care decision-making is important in increasing the use of MC [14, 18]. However, contrary to our expectation, women who made health care decisions alone, as opposed to those who made decisions jointly with their husband/partner, were more likely to use MC. This contradicts the previous finding that relational autonomy, as determined by joint participation in health care decisions, is important in increasing the use of MC [19, 20].
While not the primary focus of our study, we observed that women who participated jointly with their partner in decisions about how their partner’s earnings were used were more likely to use MC compared to women who had no say. Since a large proportion of the health system in the DRC is financed by out-of-pocket expenses, jointly deciding to invest in contraception may be important [32, 33]. Additionally, the role of financial decision-making in contraceptive use has likely become more important in recent years due to increasing interest in the use of contraceptive implants. A study in Kinshasa found that from 2013 to 2017, the proportion of MC users with long-acting reversible contraception increased from 10.8% to 40.0% [7, 8]. This was almost exclusively due to increased use of the implant [7, 8]. However, with cost being reported as a major barrier to Congolese women using contraceptive implants [11], joint decision-making about contraception may be more important from a financial rather than a health care standpoint.
In addition to decision-making, there were other variables that were statistically significantly associated with current use of MC in this study population. For example, women with secondary or higher levels of education were more likely to use MC than women with no education. This relationship between education level and use of MC is consistent with previous findings and supports the idea that women with higher levels of education have a better understanding of health and are more assertive about their needs [13,14,15, 20]. Additionally, consistent with previous literature, wealth was found to be an important determinant of MC use [13,14,15]. This is likely because Congolese individuals are often required to pay out-of-pocket for contraception, which, as described above, is likely a major barrier to contraceptive use given that a high proportion of the population lives below the poverty line [11, 32, 33]. Moreover, women in urban areas were more likely to use MC than women in rural regions, which may suggest that women in urban areas have better access to reproductive health care services.
In 1981, the Primary Health Care (PHC) strategy was enacted in the DRC, which states that, among other services, family planning must be available at primary healthcare centers [6]. Furthermore, in 2008, the National Policy for Reproductive Health (RH) was revised to normalize family planning services and make them accessible in rural and urban regions [6]. However, implementation of these services at health facilities has been challenging [6]. Family planning arguably only came into the government’s agenda in a meaningful way in 2012 when the Permanent Multisectoral Technical Committee (CTMP) began developing a National Strategic Plan for Family Planning, which was released in February 2014 [34]. Additionally, at the 2013 International Conference on Family Planning, the DRC was confirmed as a member of the global Family Planning 2020 (FP2020) partnership to increase MC access for women and girls [35]. This also brought light to the funds that were allotted by the government to MC in 2013 [34]. However, these funds are not a fixed budget item for the Ministry of Health, and turnover in the government means that commitment to funding family planning is not guaranteed for upcoming years [34]. Therefore, in order to ensure the availability and accessibility of MC across the DRC, there needs to be continued financial contributions from the government and improvements in service delivery through the coordination of various family planning organizations [33, 34].
Despite these efforts, there are still numerous sociocultural barriers to contraceptive use, particularly for women. Out of 160 countries, the DRC ranks 152 in the Gender Inequality Index and this inequality is exemplified in the limited decision-making control that many women have [22, 36]. Additionally, a study in Kinshasa found that men often feel that contraception cannot be used because God creates a natural order and this must be respected [11]. A study in rural DRC also found that many individuals feel that their community idealizes having many children as children are God’s gift [12]. These religious factors, as well as cultural factors, may lead to communities viewing family planning unfavourably [12]. Other common reasons for having a negative attitude towards MC use include beliefs that it promotes prostitution and causes sterility [12]. Awareness raising to overcome misperceptions about MC and gender sensitization are both needed to increase contraception uptake at the community level. Activities to increase MC use and improve gender equality will contribute to Sustainable Development Goals (SDG) 5.6 and 3.1 by helping to increase access to sexual and reproductive health and rights and reduce maternal mortality [16].
Finally, among current users of MC, no association was found between health care decision-making power and method of MC used. To our knowledge, the only other published study in sub-Saharan Africa to investigate the relationship between health care decision-making power and method of MC used found that Zambian women who made health care decisions jointly with their partner were more likely to use long-acting and permanent contraceptive methods than Zambian women who did not make joint decisions [21]. This suggests that the permanence of the method may also be important to consider. Further studies should investigate the relationship between women’s decision-making power and method of MC used in a more granular way.
Interestingly, other variables, such as province of residence, were significantly associated with the method of MC used in the current study. For example, women in Nord-Kivu and Sud-Kivu were significantly more likely to use female methods of MC than women in Kinshasa. These two provinces are located in eastern DRC which has been affected by armed conflict over the last two decades [9]. Therefore, higher rates of female modern contraceptive use may be a result of the concentration of humanitarian aid in these areas [37]. This is particularly likely given that aid organizations may aim to provide a range of contraceptive methods, including IUDs and implants, which are highly utilized [9, 38]. Additionally, older women were found to be more likely to use female methods of MC than younger women. This may be because some female methods of contraception, such as the IUD and implant, are long-acting. Long-acting methods may be preferred by older women because their need to space or limit births may be greater.
