title: Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi.
abstract: Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere.
  
  
  
  We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7).
  
  
  
  Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services.
  
  
  
  Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.
authors.affiliation: Partners In Health-Lesotho, House No. 233, Maseru West Cnr Lancers and Caldwell Rd., Maseru, Lesotho.
authors.forename: M
authors.initials: M
authors.lastname: Ndayizigiye
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, USA.
authors.forename: M C Smith
authors.initials: MC
authors.lastname: Fawzi
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, USA.
authors.forename: C Thompson
authors.initials: CT
authors.lastname: Lively
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave., Boston, MA, USA. norma_ware@hms.harvard.edu.
authors.forename: N C
authors.initials: NC
authors.lastname: Ware
mesh_terms: D000293:Adolescent; D000328:Adult; D002063:Burundi; D003150:Community Health Workers; D003219:Confidentiality; D003268:Contraception Behavior / Q000706:statistics & numerical data*; D003270:Contraceptive Agents; D005193:Family Planning Services / Q000941:ethics / Q000706:statistics & numerical data*; D005260:Female; D017144:Focus Groups; D019538:Health Care Surveys; D006801:Humans; D007407:Interviews as Topic; D008875:Middle Aged; D012068:Religion and Medicine; D012424:Rural Population; D055815:Young Adult
chemical_list: D003270:Contraceptive Agents
keywords: Africa; Contraceptives; Family Planning; Fertility; Rural Burundi