CHAPTER 2

LITERATURE REVIEW

This chapter offers an overview of the literature, which is most

pertinent to our study. A literature review is a systematic and critical evaluation of existing

research on a particular topic (Poth 2023). It serves as the cornerstone of scholarly inquiry by

providing a comprehensive overview of the current state of knowledge, identifying research

gaps, and establishing a theoretical framework for subsequent research. By synthesizing previous

findings, a literature review illuminates the context within which new research is positioned,

enabling researchers to build upon existing knowledge and contribute meaningfully to the

academic discourse. Essentially, it is an indispensable tool for scholars to situate their work

within the broader field of study and to demonstrate a thorough understanding of the relevant

literature.

Various resources of literature such as international journals, research

papers, PubMed and Medscape have been consulted to find out the relevant

literature and the most significant ones are shared below.

A hospital-based cross-sectional study was conducted, involving data collection from 251

participants using both quantitative and qualitative methods. The study highlighted that only

27.5% of women of reproductive age who attended Hoima Regional Referral Hospital had

utilized family planning services. This low rate was alarming and reflected a broader trend

observed in Uganda, where high rates of unwanted pregnancies and maternal mortality were

prevalent due to inadequate uptake of family planning services. Several factors significantly

influenced the utilization of these services. The education level of women showed a strong
association with their likelihood of using family planning services, while the perceived

competence of health workers also played a crucial role. The findings underscored the pressing

need for policies that promoted girls' education and enhanced the training

of health workers(Solomon).

Another study employed a cross-sectional design to examine the clients of Lady Health Workers

(LHWs) using a quantitative approach to collect data. The respondents were married female

household members aged 15 to 49 years who had previously utilized LHW services. The study

was conducted in Lahore district, with a sample of 398 households selected through probability

sampling using a proportional systematic random selection method. The findings revealed that

several factors influenced the utilization of family planning services provided by LHWs at the

community level. These factors predominantly included the attitudes and skills of LHWs when

delivering family planning services, as perceived by the beneficiaries. The study further

concluded that LHWs' ability to communicate effectively while maintaining confidentiality and

fostering a trustworthy relationship was directly linked to the uptake of their family planning

services. This association was particularly significant in the context of Pakistani society, where

matters related to family planning are considered private and not openly discussed(Din and

Jabeennazi 2022).

A secondary analysis of the Pakistan Demographic and Health Survey 2019 data was conducted.

The dataset included 15,143 women sampled proportionally from various provinces, including

Gilgit-Baltistan and Azad Jammu and Kashmir. The unit of analysis was women from the

individual survey dataset. Factors such as age, type of residence (rural or urban), division,

education level, and language were evaluated to assess access to family planning and
contraception services. The results indicated an increasing prevalence of contraceptive use with

age, particularly among women aged 35–39 compared to those aged 15–19. While the majority

of participants were aware of contraception, its practical application was significantly lower.

Clear inequalities in usage were observed, with contraceptive prevalence higher in urban areas

compared to rural ones and varying across provinces. Punjab had the highest rate of

contraceptive use, while Baluchistan had the lowest. Additionally, contraception use was notably

lower among women without formal education compared to those with higher education

levels(Khan, Asif et al. 2024).

Using a convenience sampling technique, a descriptive study was conducted. Data were

collected from 250 married women of reproductive age from the Rawalpindi and Neelum Valley

regions in Pakistan through the distribution of adapted questionnaires. Convenience sampling

was chosen for its cost-effectiveness, efficiency, and ease of use. The results revealed that

contraceptive self-efficacy (CSE), contraceptive knowledge, and spousal communication

positively influenced the adoption of modern contraceptive methods for family planning (FP)

practices. Higher levels of CSE among women were found to motivate them to adopt modern

contraceptive methods for FP. Additionally, it encouraged women to overcome barriers that

limited their access to FP services. CSE also enabled women to recognize the significance of FP

practices in maintaining appropriate intervals between childbirths(Shah, Lee et al. 2021).

(Naz, Siddiqui et al. 2024) conducted an exploratory study using a sample of 13,331 women,

excluding pregnant and sexually inactive married women aged 15–49. The dataset was cross-

sectional. Exploratory analysis was employed to examine patterns of contraceptive knowledge,

types of contraceptive utilization, and intentions to use contraceptives among the participants.
The findings revealed a significant trend between women's age and contraceptive behavior: as

women aged, their likelihood of using contraceptives decreased. Women over 40 years of age

were found to have lower fecundity and took longer to conceive compared to younger women.

Additionally, women entering menopause, who can no longer conceive, often perceived a

reduced need for contraception. Conversely, some studies indicated that as women approached

the later stages of their reproductive years, they became more inclined to use contraceptives to

prevent unintended pregnancies.

A qualitative and explanatory study was conducted in rural communities of Islamabad,

Pakistan, to explore the factors influencing the utilization of long-acting reversible contraception

(LARC) among married couples. Data were collected through in-depth interviews with 16

married couples, purposively selected based on their contraceptive use history.

The analysis revealed that respondents lacked functional knowledge of family planning and

modern contraceptives and held misconceptions about the side effects of LARCs. Decisions

regarding contraceptive use were influenced by individual preferences and reproductive events.

The opinions of husbands and family members, particularly mothers-in-law, played a crucial role

in the choice to use LARCs. Experiences of closely spaced, unintended, or mistimed pregnancies

often motivated couples to initiate discussions on family planning and contraceptive use. Inter-

spousal communication varied among the couples; those with an unmet need for limiting family

size demonstrated better communication compared to others. These couples also had aligned

views about their desired family size and intentions to use contraceptives. Religious beliefs

further influenced decisions regarding contraceptive use. The study highlighted the importance

of male partners in family planning decisions, emphasizing their role in preventing unintended
pregnancies and improving service delivery programs. It also identified challenges faced by

married couples, particularly men, in understanding family planning and contraceptive use. The

findings revealed limited male participation in family planning decisions and a lack of targeted

programs and interventions for men in Pakistan(Sarfraz, Hamid et al. 2023).

An exploratory descriptive qualitative study was conducted to investigate the factors influencing

family planning literacy among women of childbearing age in the rural Lake Zone of Tanzania.

Respondents were purposively selected for inclusion in the study, and data were primarily

collected through focus group discussions.

The findings revealed a range of factors that affected women’s family planning literacy, which in

turn limited their use of modern family planning methods. Addressing these factors was deemed

essential to improving the effective utilization of modern family planning methods among

women. Raising the general literacy level of women in rural areas through targeted campaigns

aimed at enhancing their education was identified as a critical step in enabling them to

understand family planning messages from various sources. Additionally, efforts to integrate

family planning education with religious teachings were highlighted as an important strategy to

address social dilemmas that discouraged women and their male partners from adopting family

planning practices. Strengthening these initiatives was recommended to promote broader

acceptance and adoption of family planning in the region(Kassim and Ndumbaro 2022).

An explanatory sequential mixed-methods study was conducted by (Hakizimana and Odjidja

2021) in Burundi. A total of 530 women in union were interviewed using a structured and pre-

tested questionnaire. Subsequently, 11 focus group discussions were held with community

members, including married men and women, as well as administrative and religious leaders.
The study revealed that knowledge of contraceptive methods was high, with 94.3% of

respondents able to name at least one modern contraceptive method, whereas utilization

remained low at 22.6%. These findings aligned with the Burundi Demographic and Health

Survey (BDHS), which indicated that 97% of men and women were aware of at least one

contraceptive method, but only 29% were using any family planning method at the time of the

survey. Fear of perceived side effects emerged as the primary factor influencing the low

utilization of family planning methods. Many women discontinued the use of modern

contraceptives after experiencing unpleasant side effects, which significantly impacted overall

utilization rates. (Hakizimana and Odjidja 2021)

A community-based cross-sectional survey was conducted among 577 randomly selected

currently married women of reproductive age in selected rural districts of Eastern Ethiopia. Data

were collected using a pretested, interviewer-administered questionnaire that gathered

information on women’s sociodemographic characteristics, knowledge of contraception,

reproductive history, contraceptive use and fertility desires, couple communication, and

decision-making regarding family planning. The study revealed that modern family planning

(FP) utilization in the study area was very low, despite universal knowledge of modern

contraceptive methods within the community. The overall modern FP utilization rate among the

participants was found to be 18.4%. Women who were knowledgeable about modern FP

methods were approximately seventeen times more likely to use modern FP methods compared

to women who lacked knowledge of any type of modern contraceptive. Additionally, the

husband’s perspective and approval of modern contraceptive methods had an independent and

significant effect on their utilization (Mulatu, Sintayehu et al. 2020).

purposive sampling method. A total of 150 females who had utilized healthcare services at

primary health care centers in Al-Najaf City between September 7, 2018, and February 16, 2019,

were included in the study. Data was collected using a questionnaire. Descriptive and inferential

statistical analyses were conducted to analyze the collected data. The study results showed that

the majority of participants were aged between 30 and 37 years (42.0%), with a marriage

duration of 6 to 11 years (44.0%). Regarding the number of children, more than half of the

sample had 3 to 5 children (49.3%). The most common level of education was higher secondary

school (28.0%), and the majority of participants were homemakers (70.7%) residing in urban

areas. The most commonly used contraceptives were pills and IUDs, primarily due to their ease

of use and lack of procedural requirements, as well as perceived knowledge. A significant

relationship was found between knowledge, attitude, and the utilization of family planning

methods. Some demographic factors, such as level of education and place of residence, had an

impact on knowledge and attitudes towards family planning(Hussain and Lefta 2020).

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Hakizimana, S. and E. N. Odjidja (2021). "Beyond knowledge acquisition: factors influencing family
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