title: Motivations and Constraints to Family Planning: A Qualitative Study in Rwanda's Southern Kayonza District.
abstract: BACKGROUND
  While Rwanda has achieved impressive gains in contraceptive coverage, unmet need for family planning is high, and barriers to accessing quality reproductive health services remain. Few studies in Rwanda have qualitatively investigated factors that contribute to family planning use, barriers to care, and quality of services from the community perspective.
  
  
  METHODS
  We undertook a qualitative study of community perceptions of reproductive health and family planning in Rwanda's southern Kayonza district, which has the country's highest total fertility rate. From October 2011 to December 2012, we conducted interviews with randomly selected male and female community members (n = 96), community health workers (n = 48), and health facility nurses (n = 15), representing all 8 health centers' catchment areas in the overall catchment area of the district's Rwinkwavu Hospital. We then carried out a directed content analysis to identify key themes and triangulate findings across methods and informant groups.
  
  
  RESULTS
  Key themes emerged across interviews surrounding: (1) fertility beliefs: participants recognized the benefits of family planning but often desired larger families for cultural and historical reasons; (2) social pressures and gender roles: young and unmarried women faced significant stigma and husbands exerted decision-making power, but many husbands did not have a good understanding of family planning because they perceived it as a woman's matter; (3) barriers to accessing high-quality services: out-of-pocket costs, stock-outs, limited method choice, and long waiting times but short consultations at facilities were common complaints; (4) side effects: poor management and rumors and fears of side effects affected contraceptive use. These themes recurred throughout many participant narratives and influenced reproductive health decision making, including enrollment and retention in family planning programs.
  
  
  CONCLUSIONS
  As Rwanda continues to refine its family planning policies and programs, it will be critical to address community perceptions around fertility and desired family size, health worker shortages, and stock-outs, as well as to engage men and boys, improve training and mentorship of health workers to provide quality services, and clarify and enforce national policies about payment for services at the local level.
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Didi Bertrand
authors.initials: DB
authors.lastname: Farmer
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Leslie
authors.initials: L
authors.lastname: Berman
authors.affiliation: London School of Hygiene and Tropical Medicine, Centre for Global Mental Health, London, UK.
authors.forename: Grace
authors.initials: G
authors.lastname: Ryan
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Lameck
authors.initials: L
authors.lastname: Habumugisha
authors.affiliation: National University of Rwanda School of Public Health, Kigali, Rwanda.
authors.forename: Paulin
authors.initials: P
authors.lastname: Basinga
authors.affiliation: Partners In Health, Boston, MA, USA.
authors.forename: Cameron
authors.initials: C
authors.lastname: Nutt
authors.affiliation: Rwinkwavu District Hospital, Rwinkwavu, Rwanda.
authors.forename: Francois
authors.initials: F
authors.lastname: Kamali
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Elias
authors.initials: E
authors.lastname: Ngizwenayo
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Jacklin
authors.initials: J
authors.lastname: St Fleur
authors.affiliation: Partners In Health-Inshuti Mu Buzima, Rwinkwavu, Rwanda.
authors.forename: Peter
authors.initials: P
authors.lastname: Niyigena
authors.affiliation: Ministry of Health (Rwanda), Kigali, Rwanda.
authors.forename: Fidele
authors.initials: F
authors.lastname: Ngabo
authors.affiliation: Partners In Health, Boston, MA, USA Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Farmer
authors.affiliation: Partners In Health, Boston, MA, USA Brigham and Women's Hospital, Division of Global Health Equity, Boston, MA, USA Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Rich
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health; D002648:Child; D003268:Contraception Behavior; D003469:Culture; D005193:Family Planning Services / Q000706:statistics & numerical data*; D005260:Female; D005783:Gender Identity; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation; D036301:Qualitative Research; D012111:Residence Characteristics; D012432:Rwanda; D012736:Sex Education; D055815:Young Adult